Thermoregulation of the Extremely Low Birth Weight Neonate

The birth of an extremely low birth weight (ELBW) neonate is complex because of their immaturity. Respiratory and hemodynamic stabilization often takes precedence in the immediate delivery period. While establishing effective breathing and circulation is vital to the survival of the neonate, it is crucial to understand that other adverse outcomes can occur during the resuscitation and transport of the ELBW neonate. Impaired thermoregulation is one of the most detrimental adverse outcomes during the golden hour period and later in the neonatal intensive care unit. Hypothermia is an independent risk factor for increased morbidity and mortality and can impact multiple body systems, making management even more challenging. This article discusses the physiology of thermoregulation while exploring interventions to maintain normothermia in the ELBW neonate, ultimately improving long-term outcomes.

Survival and Neurodevelopmental Outcome of Extremely-Low-Birth-Weight Infants at One Year of Age-A Prospective, Descriptive Study

OBJECTIVES

To study the survival rates at discharge and neurodevelopmental outcome at 1 y of corrected age (CA) of extremely-low-birth-weight ELBW neonates.

METHODS

This prospective, descriptive study was conducted in a tertiary care level III extramural NICU of a teaching hospital. Forty-nine extremely-low-birth-weight (ELBW) neonates were enrolled in the study from July 2017 to June 2018. Baseline demographic data, morbidities during NICU stay, and survival at discharge for the enrolled neonates were recorded. The enrolled infants were followed up to 1 y of CA at three-monthly intervals. During the follow-up, anthropometry, developmental screening by Denver Developmental Screening Test (DDST), and tone assessment by Amiel-Tison scale were done. Developmental Assessment Scale for Indian Infants (DASII) was administered at CA of 12 mo.

RESULTS

Thirty-seven (75.5%) neonates survived to discharge. Survival rate of neonates with birth weight > 750 g and with gestational age ≥ 26 wk was 90.2% and 85.7%, respectively. Amongst those < 750 g or < 26 wk (n = 8), none survived. Abnormal developmental quotient (DQ < 70%) was seen in 6 infants out of 33 infants (18.1%) followed at 1 y of CA.

CONCLUSION

Overall, 3/4^th of ELBW infants survived to discharge and 80% of those who were followed up at 1 y of CA had normal neurodevelopmental outcome. However, survival rates of neonates born at < 26 wk and/or with birth weight < 750 g  were less and needs to be improved.

Instrumental dead space: A glass ceiling for extremely low birth weight preterm infants? A dead space washout bench study

BACKGROUND

When ventilating extremely low birth weight infants, clinicians face the problem of instrumental dead space, which is often larger than tidal volume. Hence, aggressive ventilation is necessary to achieve CO₂ removal. Continuous tracheal gas insufflation can wash out CO₂ from dead space and might also have an impact on O₂ and water vapor transport. The objective of this bench study is to test the impact of instrumental dead space on the transport of CO₂ , O₂ , and water vapor and the ability of continuous tracheal gas insufflation to remedy this problem during small tidal volume ventilation.

METHODS

A test-lung located in an incubator at 37°C was ventilated with pressure levels needed to reach different tidal volumes from 1.5 to 5 mL. End-tidal CO₂ at the test-lung exit, O₂ concentration, and relative humidity in the test-lung were measured for each tidal volume with and without a 0.2 L/min continuous tracheal gas insufflation flow.

RESULTS

CO₂ clearance was improved by continuous tracheal gas insufflation allowing a 28%-44% of tidal volume reduction. With continuous tracheal gas insufflation, time to reach desired O₂ concentration was reduced from 20% to 80% and relative humidity was restored. These results are inversely related to tidal volume and are particularly critical below 3 mL.

CONCLUSION

For the smallest tidal volumes, reduction of instrumental dead space seems mandatory for CO₂ , O₂ , and water vapor transfer. Continuous tracheal gas insufflation improved CO₂ clearance, time to reach desired O₂ concentration and humidification of airways and, thus, may be an option to protect lung development.

Humidity during high-frequency oscillatory ventilation compared to intermittent positive pressure ventilation in extremely preterm neonates: An in vitro and in vivo observational study

BACKGROUND

Inappropriate humidification of inspired gas during mechanical ventilation can impair lung development in extremely low birthweight (ELBW) infants. Humidification depends on multiple factors, such as the heater-humidifier device used, type of ventilation, and environmental factors. Few studies have examined inspired gas humidification in these infants, especially during high-frequency oscillatory ventilation (HFOV). Our objective was to compare humidity during HFOV and intermittent positive pressure ventilation (IPPV), in vitro and in vivo.

METHODS

In vitro and in vivo studies used the same ventilator during both HFOV and IPPV. The bench study used a neonatal test lung and two heater-humidifiers with their specific circuits; the in vivo study prospectively included preterm infants born before 28 weeks of gestation.

RESULTS

On bench testing, mean absolute (AH) and relative (RH) humidity values were significantly lower during HFOV than IPPV (RH = 79.4 ± 8.1% vs. 89.0 ± 6.2%, p < 0.001). Regardless of the ventilatory mode, mean RH significantly differed between the two heater-humidifiers (89.6 ± 6.7% vs 78.7 ± 6.8%, p = 0.003). The in vivo study included 10 neonates (mean ± SD gestational age: 25.7 ± 0.9 weeks and birthweight: 624.4 ± 96.1 g). Mean RH during HFOV was significantly lower than during IPPV (74.6 ± 5.7% vs. 83.0 ± 6.7%, p = 0.004).

CONCLUSION

RH was significantly lower during HFOV than IPPV, both in vitro and in vivo. The type of heater-humidifier also influenced humidification. More systematic measurements of humidity of inspired gas, especially during HFOV, should be considered to optimize humidification and consequently lung protection in ELBW infants.

Golden Hour Education, Standardization, and Team Dynamics: A Literature Review

The "golden hour" is the critically important first 60 minutes in an extremely low birth weight neonate's life that can impact both short- and long-term outcomes. The golden hour concept involves several competing stabilization priorities that should be conducted systematically by highly specialized health care providers in both the hospital and transport settings for improvement in patient outcomes. Current literature supports utilizing an experienced team in the golden hour process to improve patient outcomes through standardization, improved efficiency, and positive team dynamics. Although a variety of teaching methods exist to train individuals in the care of extremely low birth weight infants, the literature supports the incorporation of low- or high-fidelity simulation-based training. In addition, initial and ongoing educational requirements of individuals caring for a golden hour-eligible infant in the immediate post-delivery phase, as well as ongoing care in the days and weeks to follow, are justified. Instituting standard golden hour educational requirements on an ongoing basis provides improved efficiency in team function and patient outcomes. The goal of this literature review was to determine whether implementation of golden hour response teams in both the inpatient and transport setting has shown improved outcomes and should be considered for neonatal intensive care units admitting or transporting golden hour eligible infants.

Multivariable Predictive Models of Death or Neurodevelopmental Impairment Among Extremely Low Birth Weight Infants Using Heart Rate Characteristics

OBJECTIVE

We hypothesized that a cumulative heart rate characteristics (HRC) index in real-time throughout the neonatal intensive care unit (NICU) hospitalization, alone or combined with birth demographics and clinical characteristics, can predict a composite outcome of death or neurodevelopmental impairment (NDI).

STUDY DESIGN

We performed a retrospective analysis using data from extremely low birth weight infants who were monitored for HRC during neonatal intensive care. Surviving infants were assessed for NDI at 18-22 months of age. Multivariable predictive modeling of subsequent death or NDI using logistic regression, cross-validation with repeats, and step-wise feature elimination was performed each postnatal day through day 60.

RESULTS

Among the 598 study participants, infants with the composite outcome of death or moderate-to-severe NDI had higher mean HRC scores during their stay in the NICU (3.1 ± 1.8 vs 1.3 ± 0.8; P < .001). Predictive models for subsequent death or NDI were consistently higher when the cumulative mean HRC score was included as a predictor variable. A parsimonious model including birth weight, sex, ventilatory status, and cumulative mean HRC score had a cross-validated receiver-operator characteristic curve as high as 0.84 on days 4, 5, 6, and 8 and as low as 0.78 on days 50-52 and 56-58 to predict subsequent death or NDI.

CONCLUSIONS

In extremely low birth weight infants, higher mean HRC scores throughout their stay in the NICU were associated with a higher risk of the composite outcome of death or NDI.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00307333.

Prematurity is a critical risk factor for respiratory failure after early inguinal hernia repair under general anesthesia

INTRODUCTION

The purpose of this study was to determine the earliest timing of inguinal hernia repair under general anesthesia with minimized risk for respiratory complications during postoperative course.

METHODS

We performed a monocentric analysis of patient records of premature and full-term infants undergoing inguinal hernia repair between 2009 and 2016. In addition to demographic and medical parameters, preexisting conditions and the perioperative course were recorded.

RESULTS

The study included 499 infants (preterm n = 285; full term n = 214). The number of subsequently ventilated patients was particularly high among preterm infants with bronchopulmonary dysplasia, up to 45.3% (p < 0.001). Less than 10% of subsequent ventilation occurred in preterm infants after 45 weeks of postmenstrual age at the time of surgery or in patients with a body weight of more than 4,100 g. Preterm infants with a bronchopulmonary dysplasia had an increased risk of apneas (p < 0.05). Only 10% of the preterm babies with postoperative apneas weighed more than 3,600 g at the time of surgery or were older than 44 weeks of postmenstrual age.

CONCLUSION

Our data indicate that after the 45th week of postmenstrual age and a weight above 4,100 g, the risk for respiratory failure after general anesthesia seems to be significantly decreased in preterm infants.

Ultrasound-Guided Peripherally Inserted Central Catheter Placement in Extremely Low Birth Weight Neonates

Extremely low birth weight (ELBW), <1,000 g, neonates require central venous access for their growth, development, and survival. Peripherally inserted central catheters (PICCs) provide such access and reduce the risks associated with other types of central venous catheters. While the use of ultrasound (US) to guide PICC placement further reduces these risks, this technology has not been integrated into neonatal practice. The purpose of this case study is to describe US-guided PICC placement in 2 ELBW neonates. PICCs were placed in 2 patients weighing 505 g and 800 g, respectively, utilizing US guidance where the practitioner was unable to identify veins using traditional methods (e.g., palpation, landmarks, transillumination, or infrared device). PICC placement utilizing US guidance in ELBW neonates is a safe and effective technique that improves outcomes, prevents complications, and promotes vessel preservation in this vulnerable population. It is essential that this technique is integrated into neonatal practice.

Peritoneal dialysis in very low and extremely low birthweight infants: A pooled analysis

BACKGROUND

Peritoneal dialysis (PD) represents an important therapeutic option in neonatal acute kidney injury (AKI), although evidence regarding its effects in preterm neonates remains unclear. The present study aims to evaluate the feasibility of PD in very low birthweight (VLBW) and extremely low birthweight (ELBW) infants and clarify the association of catheter choice with clinical outcomes.

METHODS

Medline, Scopus, Web of Science, Clinicaltrials.gov and CENTRAL databases were systematically searched from inception to 15 January 2021. Studies reporting individual participant data of VLBW and ELBW infants treated with PD were selected.

RESULTS

Overall, 20 studies were included comprising 101 patients. Catheter-related complications were significantly more frequent among ELBW infants (odds ratio: 5.18, 95% confidence intervals (CI): 1.23-29.09). After inverse probability treatment weighting, compared to drainage catheters, death risk was significantly lower with the use of PD (hazard ratio: 0.42, 95% CI: 0.19-0.90) but not vascular catheters (hazard ratio: 0.58, 95% CI: 0.28-1.20). Similarly, kidney function loss was significantly lower only with the implementation of PD catheters (hazard ratio: 0.44, 95% CI: 0.21-0.94).

CONCLUSIONS

PD is a feasible kidney replacement therapy modality in VLBW and ELBW infants with AKI. The use of drainage catheters may be linked to significantly worse kidney recovery and overall survival rates, compared to PD catheters. Future cohorts should confirm the most appropriate catheter type and contribute to the standardisation of PD procedures.

The concomitant use of vancomycin and piperacillin-tazobactam is associated with acute kidney injury (AKI) in extremely low birth weight infants (ELBW)

BACKGROUND

Late-onset sepsis is common in extremely low birth weight (ELBW) infants, and it leads to the use of antibiotics to cover resistant organisms, which can be nephrotoxic. Here we have investigated the role of vancomycin plus piperacillin-tazobactam on the rate of acute kidney injury (AKI).

METHODS

In a retrospective case-control study, medical records of all ELBW infants who were admitted to our Neonatal Intensive Care Unit (NICU) with late onset sepsis who were prescribed vancomycin plus piperacillin-tazobactam were reviewed for demographics, clinical characteristics, use of potential nephrotoxic medications and outcomes.

RESULTS

During the study period, 264 patients were admitted, of whom 28.4%(75/264) received vancomycin plus piperacillin-tazobactam and were matched with 64 controls. There were no differences in gestational age or birth weight between cases and controls [688±160 vs. 689±162 grams (p = 0.99), and 24.7±1.8 vs. 24.7±1.6 weeks (p = 0.99) respectively]. There was no difference in the rate of sepsis between cases and controls [76%(55/72) vs. 64%(41/64) respectively, p = 0.11]. Infants exposed to vancomycin plus piperacillin-tazobactam had a higher percentage of concomitant use of vasopressors and amphotericin. To adjust for confounders, a logistic regression analysis was conducted with AKI as the dependent variable. Use of vasopressors and vancomycin plus piperacillin-tazobactam were the only risk factors associated with AKI with an adjusted OR (95%CI) of 4.08 (1.90-8.74), p <  0.001; and 2.87 (1.26-6.53), p = 0.01 respectively.

CONCLUSION

The use of vancomycin plus piperacillin-tazobactam in ELBW infants is associated with an increased risk for AKI.

Extremely low birthweight neonates with phenylketonuria require special dietary management

AIM

Extremely low birthweight (ELBW) neonates require a high protein intake, but this can be challenging in the very rare cases when they also have phenylketonuria (PKU). This is due to a lack of suitable parenteral nutrition or enteral formula. Our aim was to analyse tolerance to phenylalanine in these infants.

MATERIAL

There are approximately 110 000 children born in the Czech Republic each year. A neonatal screening programme from 2005 to 2020 found that 320 neonates had PKU, including 30 premature neonates with a birth weight of less than 2500 g.

RESULTS

This study focused on three neonates who were born with ELBWs of 720, 740 and 950 g, respectively. Phenylalanine levels normalised in ELBW neonates with PKU within 1 week of the introduction of low-phenylalanine parenteral or enteral nutrition. The tolerance to phenylalanine was very high (70-110 mg/kg) in the first months of life, due to a rapid weight gain, but significantly decreased during infancy.

CONCLUSION

Extremely low birthweight neonates with PKU need special dietary management. Regular assessments of phenylalanine are necessary during the first weeks of life to allow prompt dietary adjustments that reflect rapid weight gain and transitory high tolerance to phenylalanine.

Parental presence after significant procedures and medical events in the neonatal intensive care unit

PURPOSE

Very low birth weight (VLBW) and extremely preterm (EPT) infants typically experience multiple significant medical events, while in the neonatal intensive care unit (NICU), we aimed to identify how major medical and procedural events were associated with parental presence in this patient population.

MATERIALS AND METHODS

We retrospectively identified VLBW/EPT neonates at a single center and determined parental presence in the first 60 days of hospitalization based on routine documentation in the electronic medical record. The presence on each day was regressed on medical events and procedures occurring within the previous day using mixed-effects logistic regression.

RESULTS

The analysis included 174 infants contributing 8750 days (observations), including 6061 days (69%) with parental presence, and 607 days (7%) with major medical events or procedures. The occurrence of a medical event or procedure within the past day increased the odds of parental presence by 28% (odds ratio: 1.28; 95% confidence interval: 1.04, 1.57; p = .018). Further analysis found this association was limited to severe (versus moderate) events and procedures, and was absent when considering events over the past week (versus the past day).

CONCLUSIONS

Major medical events or procedures are associated with increased parental presence in the NICU. Future studies are needed to determine how interventions around the time of major medical events can support parental presence in the NICU and involvement in the child's care.

Enablers and barriers for enteral feeding with mother`s own milk in preterm very low birth weight infants in a tertiary care neonatal intensive care unit

BACKGROUND

The management of lactation in preterm mothers is a real challenge for Neonatal Intensive Care Unit (NICU) care, providers. The study aimed to evaluate the enablers and barriers for enteral feeding with mothers` own milk (MOM) in preterm very low birth weight (VLBW) infants in a tertiary care neonatal unit.

METHODS

This prospective observational study took place at a tertiary level NICU of a high-risk obstetric unit in a private hospital. All VLBW infants and mothers were incorporated into the study. Data on enablers and barriers were gathered from mother-baby dyads at the time of birth, at the end of the 7th day, and then weekly till the discharge of the baby from the unit.

RESULTS

We studied 87 mother-baby dyads. Mean (SD) maternal age, gestation age and birth weight were 29.3 (4.7) years, 30.8 (2.0) weeks, and 1196 (196) grams respectively. We categorized our data into 2 groups based on outcome estimates done during the entire hospital stay or pre-discharge (48 hours before the discharge). On comparison of perinatal and post-natal factors, the enablers were maternal dwelling from the rural locality, number of milk expression son day 1 after the birth, number of night expressions in the first week postnatally, and MOM volume till day 3, day 7, and 2 weeks postnatally. The enablers of MOM in the pre-discharge group were the number of expressions in the first 3 days, the number of night expressions in week 1, mother`s visit, and the number of maternal visits on day 1 to NICU and MOM volume expressed from day 1 until the second week after birth. The main barriers for MOM (48 hours pre-discharge) were extremely low birth weight (ELBW) and intrauterine growth-restricted infants (IUGR).

CONCLUSIONS

ELBW infants and IUGR infants are susceptible to low MOM feeding. The total of milk expressions in the first 3 days, number of night expressions in the first week, maternal visits on day 1 and the average MOM amount in the first 2 weeks are enablers for MOM feeding.

Developing a Small Baby Program for the Extremely Low Birth Weight: The Wee CARE Team

The Children's Hospital at Providence (TCHaP) is a hospital within a hospital, in the heart of Alaska's biggest city, Anchorage. TCHaP admits up to 60 extremely low birth weight (ELBW) neonates per year. The ELBW population, although small in number, contributes disproportionately to rates of death or serious morbidities. Nationally, ELBW is defined as a neonate born at a gestational age between 22 and 29 weeks. In 2014, only 38 percent of neonates born in Alaska <28 weeks survived without experiencing major morbidities. For those born <26 weeks, morbidity-free survival dropped to 25 percent. Discussions were held among NICU nursing leaders, clinical nurses, and physicians about current co-morbidities and potentially best practices to improve outcomes. Subsequently, the group decided to develop best practices for managing the care of the ELBW, which started by organizing a group of specialists. This group at TCHaP is called the Wee CARE team.

More than Just a Fad: Building and Maintaining a Small Baby Program

Survival rate for preterm infants has improved significantly in the last decade because of advancements in care provided by NICUs. Yet, a large proportion of extremely low birth weight (ELBW) infants continue to be at risk of being discharged home from NICUs with long-term co-morbidities. Several centers have introduced and described the concept of a focused program on the care of micro-preemies and demonstrated improved processes as well as outcomes utilizing a continuous improvement approach with adoption of standardized guidelines, checklists, and shared team values. The journey and effort that it takes to develop and sustain such a program have been described less. This article discusses the process of building a Small Baby Program using a change model framework, how the organization and staff bought into the concept, as well as the accomplishments and challenges experienced during the last 3 years as the program continues to evolve and grow.

Recombinant tissue-type plasminogen activator treatment in an extremely low birth weight infant

Tissue plasminogen activator can effectively treat clinical thrombosis in premature infants 11 hours after birth.

Primary anastomosis as a valid alternative for extremely low birth weight infants with spontaneous intestinal perforation

The aim was to assess the results of primary anastomosis (PA) compared to enterostomy (ES) in infants with spontaneous intestinal perforation (SIP) and a weight below 1000 g. Between 2014 and 2016, enterostomy was routinely carried out on extremely low birth weight (ELBW) patients with SIP. From 2016 until 2019, all patients underwent anastomosis without stoma formation. We compared outcome and complications in both groups. Forty-two patients with a median gestational age of 24.3 weeks and a birth weight of 640 g with SIP were included. Thirty patients underwent PA; ES was performed in 12 patients. Overall in-hospital mortality was 11.9% (PA: 13.3%, ES: 8.3%). Reoperations due to complications became necessary in 10/30 patients with PA and 4/12 patients with ES. Length of stay was 110.5 days in the PA group and 124 days in the ES group. Median weight at discharge was higher in the PA group (PA: 2258 g, ES: 1880 g, p = .036).Conclusion: Primary anastomosis is a feasible treatment option for SIP in infants < 1000 g and may have a positive impact on weight gain and length of hospitalization. However, further studies on selection criteria for PA are necessary. What is Known: • Enterostomy (ES) and primary anastomosis (PA) are feasible treatment options in preterm infants with spontaneous intestinal perforation (SIP). • Stomal complications or failure to thrive due to poor food utilization can pose significant problems. What is New: • Primary anastomosis in case of SIP is equal to enterostomy in terms of mortality and revision rate; however, length of stay and weight gain can be presumably positively influenced. • Primary anastomosis is a valid treatment option even for patients weighing less than 1000 g.

Neurodevelopmental Outcome in Extremely Low Birth Weight Infants at 2-3 Years of Age

Background and objectives: The aims of this study were to examine the relationship between neurological outcomes at 3- and 6-months corrected age with the neurodevelopmental outcome at 3 years of age; to identify the perinatal/neonatal risk factors for poor neurodevelopmental outcomes at 3 years of age. Materials and methods: In our single-centre longitudinal cohort study, of the 73 consecutive infants admitted to our Neonatal Intensive Care Unit (NICU), 49 infants (80%) received both Hammersmith Infant Neurological Examination (HINE) at 3- and 6-months corrected age and Bayley–III neurodevelopmental assessment at 2–3 years chronological age. At 3 months follow up, 8.2% had suboptimal scores (below 10th percentile) on the HINE. At 6 months follow up, 4.1% had suboptimal scores (below 10th percentile) on the HINE. The means(±SD) for Bayley-III cognitive, language, and motor subscales were (96.3 ± 9.8), (99.9 ± 11.9), (93.2 ± 9.9). Results: At 3 months corrected age, higher total HINE scores and subscores for function of cranial nerves, posture, tone, were associated with better cognitive scores while poorer scores for function of cranial nerves, posture, movements, tone, and total HINE score were associated with lower motor scores. Infants with a HINE subscore of function of cranial nerves in the suboptimal range have three times higher odds of having a motor delay. Infants with a HINE subscore of function of cranial nerves in the suboptimal range have more than two times higher odds of having a language delay. At 6 months corrected age, poorer scores for function of cranial nerves, movements, tone, reflexes, and total HINE score were associated with worse Bayley-III motor scores whilst infants who have a total HINE score and a subscore of reflexes in the suboptimal range have four and seven times, respectively, higher odds of having a motor delay. Conclusions: Early identification of infants at risk for adverse long-term outcomes is essential in introducing early intervention therapies for optimizing neurodevelopmental outcomes.

Spontaneous Closure of the Ductus Arteriosus in Preterm Infants: A Systematic Review

The optimal management strategy for patent ductus arteriosus in preterm infants remains a topic of debate. Available evidence for a treatment strategy might be biased by the delayed spontaneous closure of the ductus arteriosus in preterm infants, which appears to depend on patient characteristics. We performed a systematic review of all literature on PDA studies to collect patient characteristics and reported numbers of patients with a ductus arteriosus and spontaneous closure. Spontaneous closure rates showed a high variability but were lowest in studies that only included preterm infants with gestational ages below 28 weeks or birth weights below 1,000 g (34% on day 4; 41% on day 7) compared to studies that also included infants with higher gestational ages or higher birth weights (up to 55% on day 3 and 78% on day 7). The probability of spontaneous closure of the ductus arteriosus keeps increasing until at least 1 week after birth which favors delayed treatment of only those infants that do not show spontaneous closure. Better prediction of the spontaneous closure of the ductus arteriosus in the individual newborn is a key factor to find the optimal management strategy for PDA in preterm infants.

Brain, interrupted: alpha/delta EEG ratio in survivors of pre- and post-natal adversity

RESULTS

Young adults born at extremely low birth weight (prenatal adversity; N = 64, M_age = 23.14 years, SD_age = 1.26 years) had a lower alpha/delta ratio score compared to normal birth weight controls (N = 76, M_age = 23.60 years, SD_age = 1.09 years), while youth exposed to child maltreatment (postnatal adversity; N = 39, M_age = 16.18 years, SD_age = 1.15) had a higher alpha/delta ratio compared to controls (N = 23, M_age = 16.00 years, SD_age = 1.50 years).

CONCLUSIONS

Our results suggest that being exposed to pre- and post-natal adversity may have different long-term consequences on brain development. We speculate that these differences might be associated with some of the different functional outcomes known to characterize each type of adverse experience.

Extremely low birth weight influences the relationship between stress and telomere length in adulthood

This study examined the link between two biological markers of stress vulnerability at 22-26 years of age and telomere length at 30-35 among extremely low birth weight (ELBW; <1000 g) survivors and normal birth weight (NBW; >2500 g) control participants. Sixteen ELBW and 22 NBW participants provided baseline afternoon salivary cortisol samples and resting frontal electroencephalogram (EEG) alpha asymmetry data at 22-26 years. Buccal cells were assayed for telomere length at 30-35 years. Analyses controlled for sex, postnatal steroid exposure, childhood socioeconomic status, time of cortisol sample collection, and body mass index at 22-26 years. Salivary cortisol and frontal asymmetry at age 22-26 independently predicted telomere length at age 30-35, such that relatively higher cortisol and greater relative right frontal asymmetry at rest predicted telomere shortening among NBW controls, but not among ELBW survivors. However, similar associations were not noted in ELBW survivors, suggesting that ELBW survivors may have different mechanisms of stress coping as a result of their early-life exposures. These findings offer preliminary evidence in support of the role of stress in the genesis of cellular senescence at least among those born at NBW, but that these links may differ in those born preterm.

Subtypes of behavioral functioning in 8-12 year old very preterm children

BACKGROUND

Very preterm children often have difficulties in behavioral functioning, but there is large heterogeneity in the severity of these difficulties and in the combination of the difficulties observed. Few studies so far addressed this heterogeneity by examining whether more homogeneous subtypes of behavioral functioning can be identified.

AIMS

To identify behavioral subtypes in a group of very preterm children, examine whether such subtypes are related to neonatal medical complications and/or parental education level (to better understand origins) and to examine whether such subtypes are associated with IQ and neurocognitive deficits in attention and executive function (to study underlying mechanisms of dysfunction).

STUDY DESIGN

Cross-sectional cohort study.

SUBJECTS

135 very preterm (gestational age < 30 weeks and/or birthweight < 1000 g) children aged 8-12 years.

MEASURES

Parent and teacher questionnaires covering a broad range of behavioral domains, parental education level, neonatal medical complications, short-form Wechsler Intelligence Scale for Children-III and performance-based attention and executive function measures.

RESULTS

Cluster analysis indicated two behavioral subtypes: a subtype characterized by low behavioral problems (76% of children) and a subtype characterized by high behavioral problems across behavioral domains (24% of children). Lower parental education level, lower IQ and poorer verbal working memory, visuospatial working memory and inhibition were associated with the high problems subtype, but neonatal medical complications were not.

CONCLUSIONS

The majority of very preterm children was assigned to the low behavioral problems subtype. However, if problems do occur, they are wide-spread across behavioral domains and accompanied by problems in neurocognitive domains.

Near-Infrared Spectroscopy in Extremely Preterm Infants

With advances in neonatal care, survival of premature infants at the limits of viability has improved significantly. Despite these improvement in mortality, infants born at 22-24 weeks gestation are at a very high risk for short- and long-term morbidities associated with prematurity. Many of these diseases have been attributed to abnormalities of tissue oxygenation and perfusion. Near-infrared spectroscopy utilizes the unique absorption properties of oxyhemoglobin and deoxyhemoglobin to provide an assessment of regional tissue oxygen saturation, which can be used to calculate the fractional tissue oxygen extraction. This allows for a non-invasive way to monitor tissue oxygen consumption and enables targeted hemodynamic management. This mini-review provides a brief and complete overview of the background and physiology of near-infrared spectroscopy, practical use in extremely preterm infants, and potential applications in the neonatal intensive care unit. In this mini-review, we aim to summarize the three primary application sites for near-infrared spectroscopy, disease-specific indications, and available literature regarding use in extremely preterm infants.

Volume Targeted Ventilation and High Frequency Ventilation as the Primary Modes of Respiratory Support for ELBW Babies: What Does the Evidence Say?

Respiratory management of the extremely low birth weight (ELBW) newborn has evolved over time. Although non-invasive ventilation is being increasingly used for respiratory support in these ELBW infants, invasive ventilation still remains the primary mode in this population. Current ventilators are microprocessor driven and have revolutionized the respiratory support for these neonates synchronizing the baby's breath to ventilator breaths. High frequency ventilators with the delivery of tidal volumes less than the dead space have been introduced to minimize barotrauma and chronic lung disease. Despite these advances, the incidence of chronic lung disease has not decreased. There is still controversy regarding which mode is ideal as the primary mode of ventilation in ELBW infants. The most common modes seem to be pressure targeted conventional ventilation, volume targeted conventional ventilation and high frequency ventilation which includes high frequency oscillatory ventilation, high frequency jet ventilation and high frequency flow interrupter. In recent years, several randomized controlled trials and meta-analyses have compared volume vs. pressure targeted ventilation and high frequency ventilation. While volume targeted ventilation and high frequency ventilation does show promise, substantial practice variability among different centers persists. In this review, we weighed the evidence for each mode and evaluated which modes show promise as the primary support of ventilation in ELBW babies.

Time to positivity (TTP) of neonatal blood cultures: a trend analysis over a decade from Ireland

Background and aims: Blood culture (BC) remains gold standard for the evaluation and diagnosis of neonatal sepsis. Time when BC becomes positive and the type of microorganism isolated are crucial in deciding the antimicrobial management. Likely pathogenicity of organisms growing in BC could potentially be predicted based on the "time to positivity" (TTP). We aimed to estimate the predictive value of isolating a likely pathogenic organism depending on TTP; evaluate the aetiological trend and neonatal mortality rate due to culture-proven neonatal sepsis for over a decade and verify whether the application of a "36 hour rule" to discontinue empiric antibiotics in well newborn infants with negative BC would be safe.Methods: Retrospective review of BC results over a 14-year period from a regional neonatal unit in Ireland. Laboratory data were independently extracted in relation to BC results from the laboratory information management system (LIMS-iLAB). Neonatal mortality data were collected from multiple sources. Statistical analysis included logistic regression, chi-square, and Mann-Whitney U-test.Results: Over a 14-year period 11,432 neonatal BC specimens were incubated of which 605 (5.3%) turned positive. Overall, the commonest organism grown was coagulase-negative Staphylococcus (CoNS), 416 (68.8%). Main pathogenic organisms were Staphylococcus aureus 23 (3.8%), Enterococcus spp. 22 (3.6%), E.coli 21 (3.5%), group B Streptococcus (GBS) 18 (3.0%), and Klebsiella species 9 (1.5%). Gram-negative organisms had the shortest TTP, with Klebsiella spp. having a median TTP of 10 h and E. coli 11 h. For Gram-positives, GBS had a median TTP of 12 h, Enterococcus species 14 h, with S. aureus growing at a median time of 15 h. All of the Klebsiella spp. and other Coliforms were detected within 24 h, with, 95.2% of E.coli, 94.4% of GBS, 95.5% of Enterococci, and 95.7% of S. aureus, flagging positive in 24 h. Using logistic regression the omnibus test of the coefficients in the resulting model was significant (p < .001). Our observed coefficient (β) for TTP was 0.144; shorter the TTP higher was the likelihood of isolating a pathogenic organism, with an odds ratio (OR) of 1.155. We also report a relatively low blood culture proven sepsis-specific neonatal mortality rate of 0.403/1000 live births and in all such instances observed TTP was less than 24 h.Conclusion: Duration of this study exceeds that of most of the neonatal blood culture TTP analysis published to-date. A shorter TTP is an important adjunct to suggest the growth of a pathogenic organism while managing suspected neonatal sepsis. TTP if < 24 h per se would not necessarily confirm the growth of a highly pathogenic organism; however, if a positive growth is likely to happen for a significant neonatal pathogen, in more than 98% the TTP would be within 24 h. This offers the clinician more of negative predictive value than a positive one; when there is no growth in BC. Our observation on TTP reiterate the National Institute of Health and Care Excellence (NICE) guideline of discontinuation of empiric antibiotics after 36 h in and clinically well and BC negative newborn infants.

Successful conservative treatment of intestinal perforation in VLBW and ELBW neonates: a single centre case series and review of the literature

Background

The current standard treatment of neonates with intestinal perforation is surgery. However, the mortality rate after surgical treatment for intestinal perforation is very high for very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates. In this review, conservative treatment of pneumoperitoneum among VLBW and ELBW neonates is investigated.

Methods

Between January 2015 and December 2017, data from all of the VLBW and ELBW neonates with pneumoperitoneum who survived without surgical treatment were collected from Shenzhen Maternity and Child Healthcare Hospital in Guangdong, China. Twenty-two neonates with birth weight less than 1500 g were diagnosed with pneumoperitoneum. Following careful evaluation and discussion, eleven were treated conservatively and this was successful in eight. Details of the eight neonates including birth weight, gestational age, gender, risk factors, time of the perforation, treatment and prognosis were retrospectively recorded. A literature review was performed of previously reported cases that had used conservative treatment.

Results

The median gestational age and birth weight of the eight neonates were 27^+ 1 weeks (range 24w^+ 3 to 31w^+ 6) and 855 g (range 650 g to 1440 g), respectively. Pneumoperitoneum was confirmed by X-ray in all at a median of 8 days of life. They received full parenteral support for a median of 22 days. All eight neonates received a combination of piperacillin-tazobactam and meropenem as first-choice antibiotics, two of them also received fluconazole as anti-fungal medication. Median duration of hospitalisation was 80 days.

Conclusions

Conservative treatment with careful surveillance may be a practical choice for the VLBW and ELBW neonates with intestinal perforation. Further studies are needed for confirmation.

Practice variation in the management of patent ductus arteriosus in extremely low birth weight infants in the United States: Survey results among cardiologists and neonatologists

BACKGROUND

Patent ductus arteriosus (PDA) is highly prevalent in extremely low birth weight (ELBW), preterm infants. There are diverse management approaches for the PDA in ELBW infants. The objectives of this research were to identify current PDA management practices among cardiologists and neonatologists in the United States, describe any significant differences in management, and describe areas where practices align.

METHODS

A survey of 10 questions based on the management of PDA in ELBW infants was conducted among 100 prominent neonatologists from 74 centers and 103 prominent cardiologists from 75 centers. Among the cardiologists, approximately 50% were interventionists who perform transcatheter PDA closures (TCPC). Fisher's exact test was performed to compare practice variations among neonatologists and cardiologists. A potentially biased audience including a combination of health care providers belonging to cardiology, neonatology, and surgery were also surveyed during the International PDA Symposium. The results of this survey were not included for statistical comparison, due to this audience being potentially influenced by the Symposium.

RESULTS

Statistically significant differences were identified between neonatologists and cardiologists regarding the impact of PDA closure on morbidity and mortality, with 80% cardiologists responding that it does vs 54% of neonatologists (P < 0.001), the need for PDA closure (P < .001), and the preferred method of PDA closure if indicated (P < .001). There was agreement between neonatologists and cardiologists on symptomatic therapy; however more neonatologists favored watchful waiting over intervention in contrast to more cardiologists favoring intervention over observation (77% vs 95%, P < .001). Survey responses also identified a need for further training and research on TCPC.

CONCLUSION

Neonatologists and cardiologists have notable differences in managing PDA, and continued discussion across cardiology and neonatology has the potential to facilitate more of a consensus on best management practices. Further investigation is needed to identify outcomes in transcatheter PDA closure, particularly in ELBW infants.

Live broadcast of transcatheter PDA closure in a 700 grams ELBW infant during the International PDA Symposium

OBJECTIVE

The objective of this article is to describe a live case transmission of transcatheter closure of a patent ductus arteriosus (PDA) in an extremely low birth weight (ELBW) infant during the first International PDA Symposium conducted in Memphis, Tennessee.

SETTING

A multidisciplinary team approach including audiovisual specialists, information technology specialists, physicians, nurses, and other health care specialists was required to perform the transcatheter PDA closure (TCPC) in an ELBW infant at LeBonheur Children's Hospital and the procedure was broadcast live to the attendees at the International PDA Symposium allowing for a two-way audiovisual discussion during the procedure.

PATIENT

The patient was a 14 days old 24-week premature ELBW infant, who weighed 700 g at the time of the procedure. The patient was requiring mechanical ventilation secondary to pulmonary hemorrhage. The PDA measured 4 mm in diameter and 12 mm in length.

INTERVENTIONS

TCPC was performed safely without any procedural complications using a specialized minimally invasive technique.

OUTCOME MEASURES

The patient was weaned off the ventilator in < 7 days after the procedure. The child was discharged 9 weeks after the procedure (35 weeks' corrected gestation) weighing 2.2 kg, on full oral feeds and no supplemental oxygen.

RESULTS

The successful TCPC allowed for this child to have an uneventful hospital course. The case also highlights the technical nuances involved in setting up the live transmission.

CONCLUSIONS

This case demonstrated to the audience in the International PDA Symposium the feasibility and safety of performing TCPC in an ELBW infant. Live cases are useful in exhibiting the nuances involved in any new technique and allows for best learning experience.

Transport of extremely low birth weight neonates for persistent ductus arteriosus closure in the catheterization lab

OBJECTIVE

The objective of this article is to describe the elements involved with transporting extremely low birth weight (ELBW) infants from referring centers to our center's neonatal intensive care unit (NICU) and then from the NICU to the catheterization lab for transcatheter closure of patent ductus arteriosus (PDA).

SETTING

Several referring centers are over 300 miles away. ELBW infants are transferred in to our NICU safely for the procedure and transferred back following the procedure. A multidisciplinary team approach is necessary in order to achieve a safe transport of these fragile patients.

PATIENTS

To date, we have over 12 centers referring patients that weigh <1000 g for transcatheter PDA closure (TCPC). Three of these centers are over 300 miles away. Five other centers are between 100 and 300 miles from the hospital in which we perform TCPC.

INTERVENTIONS

Fixed-wing aircrafts are necessary for long-distance transfers. Various modes of mechanical ventilators including transport oscillators are built into temperature- and humidity-controlled incubators in which these infants are transported. Ambulances are used to take the patient between the airport and the hospital. Shorter distance transports are accomplished via helicopters or ambulances. Transfer from the NICU to the catheterization lab to perform TCPC is a relatively easier endeavor.

OUTCOME MEASURES

Patients' body temperature, fluid balance, and hemodynamics have to be maintained throughout the transport and the procedure for best outcomes.

RESULTS

There has been 100% procedural success of performing TCPC in ELBW infants with no hemodynamic compromise during transport.

CONCLUSIONS

TCPC has shown promise in improving overall patient outcomes that the potential hazards associated with complex transport measures are worth it. Successful transfer to and from referring centers and to and from the catheterization lab can be accomplished safely with increasing institutional experience.

The association of early postnatal weight loss with outcome in extremely low birth weight infants

BACKGROUND

To compare outcomes of extremely low birth weight (ELBW) infants having different weight losses in the first 3 days of life.

METHODS

One hundred and twenty six ELBW infants were evaluated retrospectively for weight loss percentages on the third day of life compared to their birth weight. We examined the weight loss on the third day of life compared to the birth weight for the ELBW infants and tested its association with mortality and morbidities. The mortality was subgrouped as overall mortality and mortality in the first 7 days of life. The morbidities were patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). BPD was defined as need for supplemental oxygen at 36 weeks' postconceptional age. We grouped the infants into four quartiles according to weight loss percentage on the third day of life: Group 1 (Quartile 1), infants with weight loss of 0-3% of birth weight; Group 2 (Quartile 2); infants with weight loss of 3.1-7.5%, Group 3 (Quartile 3), infants with weight loss of 7.51-12%; and Group 4 (Quartile 4), infants with weight loss of more than 12%. The mortality and morbidities were analyzed according to these groups and other risk factors.

RESULTS

Overall mortality and mortality in the first 7 days of life were significantly higher in Groups 1 (36% and 27%) and 4 (43% and 24%), compared to Groups 2 (10% and 10%) and 3 (18% and 9%), respectively.

CONCLUSION

Weight loss less than 3% and more than 12% was significantly associated with an increase in mortality. There was a positive correlation between weight loss on the third day of life and IVH.

CONCLUSION

Inappropriate weight loss in ELBW infants is associated with increased mortality and IVH. Appropriate weight loss can improve outcomes in this population.

Relationship between amikacin blood concentration and ototoxicity in low birth weight infants

Amikacin (AMK) is used as empiric therapy for severe infections such as sepsis in low birth weight (LBW) infants. AMK administered once daily (OD) in adults is reported to be therapeutically effective and prevent side effects, however, evidence on AMK administration in LBW infants is limited, with no clear indications of effectiveness. We performed therapeutic drug monitoring analysis of 20 infants treated with AMK OD for severe infections such as bacteremia. Treatment effectiveness was admitted by the patients' medical records, and side effects of renal dysfunction and ototoxicity were investigated. The mean gestational age was 30.4 ± 5 weeks and mean body weight (Bw) was 1280.2 ± 809.8 g. The mean AMK dose was 14.1 ± 2.6 mg/kg and mean administration period was 10.1 ± 4.1 days. Blood concentration was measured 6.3 ± 2.3 days after AMK administration; mean peak and trough concentrations were 29.1 ± 7.5 μg/mL and 7.6 ± 6.9 μg/mL, respectively. Additionally, therapeutic effect was observed in all patients, and no significant change in serum creatinine (CRE) concentration (a marker of renal dysfunction) was observed, suggesting no renal dysfunction. Ototoxicity was observed in 4 patients, 3 of whom had trough concentrations ≥10 μg/mL. When we categorized patients into two groups using a trough cut-off value of 10 μg/mL, no difference in AMK dose was observed. However, there were significant differences in peak concentration, Bw, volume of distribution and CRE. Our findings suggest AMK trough concentration ≥10 μg/mL significantly affects ototoxicity in neonates.

Earlier achievement of full enteral feeding in extremely low birth weight neonates is not associated with growth improvement in the first 2 years of life

Limiting the number of days until achievement of full enteral feeding in extremely low birth weight neonates (ELBW; < 1000 g) might affect growth in the first years of life. This study compared the Z scores in growth over time of two cohorts of ELBW neonates that were comparable on maternal and neonatal characteristics and characteristics of hospitalization, but differed in enteral feeding strategy during neonatal admission. In the 2010-2014 cohort, full enteral feeding was achieved on average 16 days earlier than in the 2000-2005 cohort. In both cohorts, weight, height, and head circumference were recorded at birth and at the corrected ages of 9 and 24 months. A linear mixed model with repeated measures controlling for neonates small for gestational age showed no significant effect of different strategies in achievement of full enteral feeding on any anthropometric Z scores over time. Although full enteral feeding was achieved earlier in the 2010-2014 cohort, this was not associated with growth patterns during the first two years of life.

CONCLUSION

The effect of a change in strategy to achieve full enteral feeding at an earlier stage in ELBW neonates was assessed. Early enteral feeding strategies do not necessarily improve growth during the first two years of life. What is Known: • Feeding strategies during neonatal stay may affect growth in the first years of life. • Strategies to achieve full enteral feeding earlier were implemented, but data on the impact on subsequent growth after discharge are limited. What is New: • Full enteral feeding was achieved earlier, but this was not associated with improved growth during the first 2 years of life after discharge. • Early enteral feeding strategies do not necessarily improve growth during the first 2 years of life.

Transcutaneous bilirubin estimation in extremely low birth weight infants receiving phototherapy: a prospective observational study

Background

Measurement of transcutaneous bilirubin (TcB) is a quick, reliable and painless method to guide management of hyperbilirubinemia. Studies in term and late preterm infants have found that TcB measurements from covered areas (TcB-C) during phototherapy (PHT) co-relate well with serum bilirubin levels. Limited data exists in extremely low birth weight (ELBW) infants.

Methods

In this prospective observational study, an opaque patch was placed on the back of an ELBW infant prior to initiation of PHT. TcB-C and TcB-E (TcB from exposed area) levels were measured at birth and at 24-h intervals for 5 days. Total serum bilirubin (TSB) levels were also measured within 30 min of obtaining TcB levels. A Wilcoxon signed rank test was used for data analysis. A mixed effect model was used to adjust for repeated measurements over time. The p value < 0.05 was considered significant.

Results

A total of 19 infants were enrolled in the study, with a mean gestational age of 26 ± 2 weeks and mean weight 827 ± 127 g. The difference between TcB-C and TSB was 2.68 ± 2.41 mg/dl (mean ± SD, p <  0.001). In contrast, the difference between TcB-E and TSB was − 0.51 ± 1.74 mg/dl (p = 0.02). TcB-C consistently overestimates TSB, while TcB-E consistently underestimates TSB.

Conclusions

During PHT exposure, TcB-C does not correlate with TSB values in ELBW infants. TcB-C levels cannot be used as a surrogate for TSB measurement in ELBW infants.

Failed umbilical artery catheterization and adverse outcomes in extremely low birth weight infants

Purpose: To determine whether successful catheterization of the umbilical artery is associated with a reduced risk of death or neurodevelopment impairment among critically ill extremely low birth weight (ELBW) infants. Study design: A retrospective chart review was conducted between 2007 and 2014 at Stanford University for all ELBW infants that required intubation immediately after birth. The primary outcome was death or neurodevelopmental impairment at 18-22 months. We measured the association of successful umbilical artery catheterization with the primary outcome using multivariable logistic regression with adjustment for gestational age. Bayesian analysis was also performed due to small sample size. Results: Eighty-four ELBW infants met inclusion criteria. Successful umbilical artery catheterization occurred in 88% of infants and failed catheterization in 12%. Death or neurodevelopmental impairment occurred in 41% of infants with successful catheterization, compared to 60% of infants with failed catheterization of the umbilical artery, adjusted odds ratio 0.3, 95% confidence interval 0.1-1.3, p = .11. The Bayesian analysis indicated a 92% posterior probability of reduced death or neurodevelopmental impairment with successful catheterization and a 68% posterior probability of reduced death or neurodevelopmental by absolute risk difference of 20% or more, adjusted relative risk 0.74, 95% confidence interval 0.45-1.14. Conclusions: Among critically ill ELBW infants, successful catheterization of the umbilical artery compared to failed catheterization was not statistically significantly associated with the primary outcome. However, the Bayesian analysis indicated a high likelihood of benefit associated with successful umbilical artery catheterization.

Behaviour of 4- to 5-year-old nondisabled ELBW children: Outcomes following group-based physiotherapy intervention

BACKGROUND

Extreme prematurity or extremely low birth weight (ELBW) can adversely affect behaviour. Nondisabled ELBW children are at risk of behavioural problems, which may become a particular concern after commencement of formal education. This study explored the frequency of behavioural and emotional problems amongst nondisabled ELBW children at 4 to 5 years of age and whether intervention had a positive influence on behaviour. The relationship between behaviour, gender, and other areas of performance at 5 years was explored.

METHODS

Fifty 4-year-old children (born <28 weeks gestation or birth weight <1,000 g) with minimal/mild motor impairment were randomly allocated to intervention (n = 24) or standard care (n = 26). Intervention was 6 group-based physiotherapy weekly sessions and home programme. Standard care was best practice advice. The Child Behavior Checklist (CBCL) for preschool children was completed at baseline and at 1-year post-baseline. Other measures at follow-up included Movement Assessment Battery for Children Second Edition, Beery Visual-Motor Integration Test 5th Edition, and Peabody Picture Vocabulary Test 4th Edition.

RESULTS

The whole cohort improved on CBCL total problems score between baseline (mean 50.0, SD 11.1) and 1-year follow-up (mean 45.2, SD 10.3), p = .004. There were no significant differences between groups over time on CBCL internalizing, externalizing, or total problems scores. The intervention group showed a mean difference in total problems score of -3.8 (CI [1.5, 9.1]) between times, with standard care group values being -4.4 (CI [1.6, 7.1]). Males had higher total problems scores than females (p = .026), although still performed within the "normal" range. CBCL scores did not correlate with other scores.

CONCLUSIONS

The behaviour of nondisabled ELBW children was within the "normal" range at 4 to 5 years, and both intervention and standard care may have contributed to improved behavioural outcomes. Behaviour was not related to performance in other developmental domains.

Early-Onset Invasive Candidiasis in Extremely Low Birth Weight Infants: Perinatal Acquisition Predicts Poor Outcome

Background

Neonatal invasive candidiasis (IC) presenting in the first week of life is less common and less well described than later-onset IC. Risk factors, clinical features, and disease outcomes have not been studied in early-onset disease (EOD, ≤7 days) or compared to late-onset disease (LOD, >7 days).

Methods

All extremely low birth weight (ELBW, <1000 g) cases with IC and controls from a multicenter study of neonatal candidiasis enrolled from 2001 to 2003 were included in this study. Factors associated with occurrence and outcome of EOD in ELBW infants were determined.

Results

Forty-five ELBW infants and their 84 matched controls were included. Fourteen (31%) ELBW infants had EOD. Birth weight <750 g, gestation <25 weeks, chorioamnionitis, and vaginal delivery were all strongly associated with EOD. Infection with Candida albicans, disseminated disease, pneumonia, and cardiovascular disease were significantly more common in EOD than in LOD. The EOD case fatality rate (71%) was higher than in LOD (32%) or controls (15%) (P = .0001). The rate of neurodevelopmental impairment and mortality combined was similar in EOD (86%) and LOD (72%), but higher than in controls (32%; P = .007).

Conclusions

ELBW infants with EOD have a very poor prognosis compared to those with LOD. The role of perinatal transmission in EOD is supported by its association with chorioamnionitis, vaginal delivery, and pneumonia. Dissemination and cardiovascular involvement are common, and affected infants often die. Empiric treatment should be considered for ELBW infants delivered vaginally who have pneumonia and whose mothers have chorioamnionitis or an intrauterine foreign body.

Genome-wide association study of sepsis in extremely premature infants

OBJECTIVE

To identify genetic variants associated with sepsis (early-onset and late-onset) using a genome-wide association (GWA) analysis in a cohort of extremely premature infants.

STUDY DESIGN

Previously generated GWA data from the Neonatal Research Network's anonymised genomic database biorepository of extremely premature infants were used for this study. Sepsis was defined as culture-positive early-onset or late-onset sepsis or culture-proven meningitis. Genomic and whole-genome-amplified DNA was genotyped for 1.2 million single-nucleotide polymorphisms (SNPs); 91% of SNPs were successfully genotyped. We imputed 7.2 million additional SNPs. p Values and false discovery rates (FDRs) were calculated from multivariate logistic regression analysis adjusting for gender, gestational age and ancestry. Target statistical value was p<10-5. Secondary analyses assessed associations of SNPs with pathogen type. Pathway analyses were also run on primary and secondary end points.

RESULTS

Data from 757 extremely premature infants were included: 351 infants with sepsis and 406 infants without sepsis. No SNPs reached genome-wide significance levels (5×10-8); two SNPs in proximity to FOXC2 and FOXL1 genes achieved target levels of significance. In secondary analyses, SNPs for ELMO1, IRAK2 (Gram-positive sepsis), RALA, IMMP2L (Gram-negative sepsis) and PIEZO2 (fungal sepsis) met target significance levels. Pathways associated with sepsis and Gram-negative sepsis included gap junctions, fibroblast growth factor receptors, regulators of cell division and interleukin-1-associated receptor kinase 2 (p values<0.001 and FDR<20%).

CONCLUSIONS

No SNPs met genome-wide significance in this cohort of extremely low birthweight infants; however, areas of potential association and pathways meriting further study were identified.

Mother- and father-infant interactions at 3 months of corrected age: The effect of severity of preterm birth

Early interactions of 92 preterm infants with their mothers (n=54) and fathers (n=38) were explored at 3 months using CARE-Index. Results showed differences in interactions based on parent's gender, with higher control in mothers and unresponsiveness in fathers, while no effect of severity of birth weight emerged.

High prevalence of cytomegalovirus infection in surgical intestinal specimens from infants with necrotizing enterocolitis and spontaneous intestinal perforation: A retrospective observational study

BACKGROUND

Necrotizing enterocolitis (NEC) is a severe, often fatal gastrointestinal emergency that predominantly affects preterm infants, and there is evidence that neonatal cytomegalovirus (CMV) infection may in some cases contribute to its pathogenesis.

OBJECTIVES

This study aimed to evaluate the prevalence of CMV in infants with NEC.

STUDY DESIGN

Seventy intestinal specimens from 61 infants with NEC, spontaneous intestinal perforation (SIP), or related surgical complications were collected at Karolinska University Hospital and Uppsala University Hospital, Sweden. Ten specimens from autopsied infants without bowel disease served as controls. Samples were analyzed for CMV immediate-early antigen (IEA), CMV late antigen (LA), 5-lipoxigenase (5LO) and CMV-DNA by immunohistochemistry (IHC) and in situ hybridization (ISH), respectively. In 10 index samples, CMV DNA was analyzed with Taqman PCR after laser capture microdissection (LCM) of cells positive for CMV IEA by IHC.

RESULTS

CMV IEA was detected by IHC in 57 (81%) and CMV LA in 45 (64%) of 70 intestinal specimens from index cases; 2 (20%) of 10 control specimens were positive for both antigens. 5LO was detected in intestinal tissue section obtained from all examined index and controls. CMV DNA was detected in 4 of 10 samples (40%) after LCM. By ISH, all 13 IHC-IEA-positive samples were positive for CMV DNA; however, 3 of 5 IHC-IEA-negative samples (60%) were also positive.

CONCLUSIONS

CMV-specific antigens and CMV DNA were highly prevalent in intestinal specimens from infants with NEC, SIP, and related surgical complications. Our findings provide further evidence that neonatal CMV infection contributes to the pathogenesis of these diseases and may affect patient outcome.

Risk Factors for Extubation Failure in Extremely Low Birth Weight Infants

BACKGROUND

Although antenatal steroids and early use nasal continuous positive airway pressure (NCPAP) have significantly improved outcomes of neonatal respiratory distress syndrome, intubation with ventilator support is still commonly required in extremely low birth weight (ELBW) infants. The optimal timing of extubation in ELBW infants remains unclear.

METHODS

We retrospectively analyzed all ELBW preterm infants who were admitted to our neonatal intensive care unit (NICU) from January 2009 to December 2013. Demographic, ventilation, and arterial blood gas analysis results prior to and 2 hours after extubation were collected. Extubation failure was defined as reintubation due to deterioration of respiratory condition within 7 days after extubation. Risk factors for extubation failure were analyzed.

RESULTS

In total, 173 ELBW infants were born and admitted to our NICU during these 5 years. Among these 173 infants, 77 (44.5%) used NCPAP only during their hospitalization (20 diagnosed with chronic lung disease (CLD), 25.9%). Among the 95 patients that required intubation, 27 patients expired so extubation was not attempted. Sixteen of 68 (23.5%) survival cases required reintubation within 7 days after extubation. We found that gestational age, birth body weight, and sex ratio did not differ between the successful extubation group and the failed extubation group. Univariate analysis showed that the failed extubation group had a lower arterial pH right before and 2 hours after extubation, with a lower bicarbonate level after extubation. Further multivariate logistic regression analysis revealed an association between poor acid-base homeostasis 2 hours after extubation (pH < 7.3 and HCO₃ < 18 mM/L) and extubation failure (odds ratio 4.56 and 6.187 and 95% confidence interval: 1.263∼16.462 and 1.68∼22.791, respectively).

CONCLUSION

This study shows that nearly half of ELBW infants do not require intubation. Among ELBW infants who require invasive ventilator support, those who have lower postextubation arterial pH and bicarbonate levels are at high risk of extubation failure.

Mother-Toddler Play Interaction in Extremely, Very Low Birth Weight, and Full-Term Children: A Longitudinal Study

Introduction: Although preterm birth represents a risk factor for early mother-infant interactions, few studies have focused on toddlerhood, an important time for the development of symbolic play, autonomous skills, and child's socialization competences. Moreover, no study has looked at the effect of birth weight on mother-child interactions during this period. Expanding on the available literature on prematurity, the main objective of this study was to explore the quality of mother-toddler interactions during play, using a longitudinal research design, as well as taking into account the effect of birth weight. Method: 16 Extremely Low Birth Weight (ELBW), 24 Very Low Birth Weight (VLBW), 25 full-term children, and their mothers were recruited for the present study. Mother-child dyads were evaluated at 18, 24, and 30 months of child age. Ten minutes of mother-child play interaction were recorded and later coded according to the Emotional Availability Scales (EAS). Furthermore, the child's level of development was assessed through the Griffiths Scale, and its contribution controlled for. Results: ELBW dyads showed an overall lower level of emotional availability, compared to VLBW and full-term dyads, but no main effect of birth weight was found on specific EA dimensions. Moreover, a significant effect of child age emerged. Overall scores, and Child Responsiveness and Involvement scores improved over time, independently of birth weight. Lastly, a significant effect of the interaction between birth weight and child age was found. Between 18 and 30 months, the overall quality of the interaction significantly increased in ELBW and VLBW dyads. Additionally, between 18 and 30 months, VLBW children significantly improved their responsiveness, while their mothers' sensitivity, structuring, and non-intrusive behaviors improved. In contrast, no change emerged in full-term dyads, although scores were consistently higher than those of the other groups. Discussion: Birth weight affects the quality of mother-toddler interactions. Monitoring the relational patterns of preterm dyads during toddlerhood is important, especially in the case of ELBW children.

Evaluation of the relationship between opioid exposure in extremely low birth weight infants in the neonatal intensive care unit and neurodevelopmental outcome at 2 years

BACKGROUND

Extremely low birth weight (ELBW) infants are exposed to many painful procedures while in the neonatal intensive care unit (NICU), such as catheter insertion and endotracheal intubation. Exposure of ELBW infants to repetitive pain and stress in the NICU can lead to cardiovascular instability and may alter neuronal and synaptic organization. Opioid analgesics are administered to reduce pain, stress and to potentially reduce poor neurologic outcomes. They may also be utilized as sedation for mechanically ventilated ELBW infants. There is limited data in regards to neurodevelopmental outcomes of preterm infants exposed to opioids, and available studies have conflicting results.

OBJECTIVE

To examine the relationship between cumulative opioid dose in ELBW infants in the NICU and neurodevelopmental outcomes at 20 months corrected age (CA).

STUDY DESIGN

100 ELBW infants who had complete neurodevelopmental assessments at 20 months CA were categorized by cumulative opioid exposure during the NICU stay (high vs. low/no opioid). Outcome measures included cognitive, motor and language scores from the Bayley Scales of Infant and Toddler Development-III (BSITD-III). Multiple regression analyses adjusted for the impact of social and neonatal risk factors on outcome.

RESULTS

There were 60 patients with high and 40 with low/no opioid exposure. Infants in the high dose group had a higher number of median ventilator days (53.5 vs. 45.6 days, p=0.046) and a higher incidence of necrotizing enterocolitis (5% vs. 21.7%, p=0.022). There were no significant differences in BSITD-III scores between the two opiate groups. In multivariate analysis cumulative opioid dose was associated with lower cognitive scores on the BSITD-III even after adjusting for social and neonatal risk factors (β=-0.247, p=0.012).

CONCLUSION

Cumulative opioid dose is associated with worse cognitive scores at 20 months CA even after adjusting for social and neonatal risk factors.

Longitudinal assessment of renal size and function in extremely low birth weight children at 7 and 11 years of age

BACKGROUND

There are a lack of studies describing a longitudinal association between preterm delivery and renal complications later in life. We assessed renal size and function in preterm infants born with extremely low birth weight (ELBW) during 4 years of follow-up, comparing these parameters to age-matched children born full term (term controls).

METHODS

The results of selected renal laboratory tests [levels of cystatin C, creatinine, blood urea nitrogen (BUN)] and of renal ultrasound evaluations were compared between the ELBW group and the term control group at age 7 and 11 years.

RESULTS

The study population consisted of 64 children born with ELBW (ELBW children) who had been recruited at birth and 36 children born at term (term children) who took part in both follow-up assessments. Renal ultrasound examination revealed a significantly smaller renal volume in the 7- and 11-year-old ELBW children compared to the term controls [right kidney volume: 50.8 vs. 61.2 ml/m(2), respectively, at 7 years (p <0.01) and 51.4 vs. 58.2 ml/m(2), respectively, at 11 years (p <0.01); left kidney volume: 51.4 vs. 60.3 ml/m(2), respectively, at 7 years (p <0.01) and 55.2 vs. 60.7 ml/m(2), respectively, at 11 years (p = 0.02)]. Renal function in ELBW children was also affected. Serum cystatin C levels were significantly higher in ELBW children than in the controls at 7 years of age, and this difference remained statistically significant at 11 years of age [0.63 vs. 0.59 mg/l, respectively, at 7 years (p = 0.02) and 0.72 vs. 0.61 mg/l, respectively, at 11 years (p = 0.01)]. Six ELBW children also had elevated cystatin C levels (0.97-1.11 mg/l) at 11 years of age. Cystatin C levels were within normal range in the ELBW children at age 7 years and in term children in both follow-up studies. BUN levels were higher in ELBW children at the age of 11 years (4.49 vs. 4.15 mmol/l; p = 0.028).

CONCLUSION

Continued follow-up of these patients will reveal whether the observed worsening in renal function will persist into adulthood.

Massive pneumatosis without necrosis: A case report of Clostridium perfringens sepsis in an extremely low birth weight infant

Pneumatosis intestinalis and free intraperitoneal air on abdominal radiographs are considered pathognomonic signs of necrotizing enterocolitis (NEC). We report a unique case of late-onset fulminant sepsis due to Clostridium perfringens presenting with shock, extensive pneumatosis intestinalis and free intraperitoneal air in an extremely low birth weight infant without histopathological evidence of bowel necrosis or NEC.

Design and feasibility of "PREMATurity as predictor of children's Cardiovascular-renal Health" (PREMATCH): A pilot study

The microvasculature and macrovasculature undergo extensive, organ-specific perinatal maturation. Multiple studies show associations between low birth weight and subsequent cardiovascular dysfunction in adulthood, suggesting that extreme preterm birth interferes with this maturation process. Therefore, we designed PREMATCH (PREMATurity as predictor of Cardiovascular–renal Health) to phenotype the microcirculation and macrocirculation during childhood in former preterm infants. A well-characterized cohort of former extreme preterm birth survivors and gender- and age-matched controls (aged 8–13 years) will be investigated for microvascular and macrovascular structure and function. In addition to cognitive performance and anthropometrics, we will investigate (i) the microvascular structure and function by endothelial function (photoplethysmography), sublingual capillary glycocalyx function (sidestream dark field imaging) and retinal structure (diameters of arterioles and venules); and (ii) the macrovascular phenotype by cardiac and renal ultrasound, repeated blood pressure measurements and arterial pulse-wave recordings. The PREMATCH study is unique in its design, and ongoing recruitment demonstrates excellent feasibility. The expectation is that the results of this study will identify risk factors during childhood for subsequent cardiovascular–renal disease in the adult life of former preterm infants, while further analysis on mediators in neonatal life of this cardiovascular–renal outcome may provide new information on perinatal risk factors.

ADHD among young adults born at extremely low birth weight: the role of fluid intelligence in childhood

Poor executive function (EF) has been linked to attention-deficit/hyperactivity disorder (ADHD). Children born at extremely low birth weight (ELBW; <1000 g) have been found to show both poor EF, as well as elevated levels of symptoms of ADHD. In the present study, we examined whether fluid intelligence moderates the link between birth weight and later ADHD symptoms by prospectively following a cohort of 179 survivors who were born at ELBW. When participants were 8 years-old, they were matched with 145 normal birth weight (NBW; ≥2500 g) control participants. At age 8, fluid intelligence was measured, and during young adulthood (ages 22–26), participants' self-reported levels of ADHD symptoms were examined. We found that ELBW survivors, who also showed poor fluid intelligence, had the highest rates of ADHD symptoms, and particularly, symptoms of inattention. These findings point to the importance of examining developmental trajectories that contribute to risk for psychopathology in those exposed to intrauterine adversity.

CRP levels in extremely low birth weight (ELBW) septic infants

OBJECTIVE

Testing the validity of C-reactive protein (CRP) in extremely low birth weight (ELBW) infants.

METHODS

During a five-year period, 483 infants with probable (36%) and definite sepsis (64%) were enrolled in the study.

RESULTS

ELBW infants with definitive sepsis had CRP levels comparable with full-terms (p=0.992). However, the highest (hs) values were observed in infants >2500 g, 24 h after the septic work up whereas in those with birth weight (BW) <1000 g after 48 h. Highest CRP levels of infants with early sepsis were similar to those of the late onset ones (p=0.825). The causative microorganism had a strong influence on CRP values, as Gram negative germs produced significantly higher CRP levels in comparison to infants with Gram positive sepsis.

CONCLUSIONS

Highest CRP values in <1000 g infants increase in levels comparable to full terms, but with a 24-h delay.

Drug effects on endogenous brain activity in preterm babies

BACKGROUND

Animal experiments have suggested that the quality of the early intermittent brain activity is important for shaping neuronal connectivity during developmental phase that corresponds to early prematurity. This is a pilot study aiming to assess whether spontaneous activity transients (SAT) in the early preterm babies are affected by drugs that are routinely used in neonatal intensive care.

METHODS

We collected retrospectively seventeen EEG recordings (15 babies, conceptional age 26-33weeks, no brain lesions) that were divided into groups according to drug administration at the time of EEG: phenobarbital, fentanyl, theophylline, and controls. SATs were extracted from the EEG for further analysis with several advanced time-series analysis paradigms.

RESULTS

The visual appearance of SATs was unaffected by drugs. Phenobarbital reduced the total power of the SAT events. Both fentanyl and phenobarbital reduced the length of SATs, and enhanced the oscillations at higher frequencies. Theophylline reduced the oscillatory activity at middle frequencies during SAT, but enhanced oscillations at higher frequencies during time-period prior to SAT.

CONCLUSIONS

Our findings suggest, that (i) all drugs examined affect brain activity in ways that are not seen in the visual EEG interpretation, and that (ii) both acute and long term (i.e. developmental) effects of these drugs on brain may warrant more attention as a part of optimizing preterm neurological care.

Death or neurodevelopmental impairment at 18 to 22 months corrected age in a randomized trial of early dexamethasone to prevent death or chronic lung disease in extremely low birth weight infants

OBJECTIVE

To evaluate the incidence of death or neurodevelopmental impairment (NDI) at 18-22 months corrected age in subjects enrolled in a trial of early dexamethasone treatment to prevent death or chronic lung disease in extremely low birth weight infants.

STUDY DESIGN

Evaluation of infants at 18-22 months corrected age included anthropomorphic measurements, a standard neurological examination, and the Bayley Scales of Infant Development-II, including the Mental Developmental Index and the Psychomotor Developmental Index. NDI was defined as moderate or severe cerebral palsy, Mental Developmental Index or Psychomotor Developmental Index <70, blindness, or hearing impairment.

RESULTS

Death or NDI at 18-22 months corrected age was similar in the dexamethasone and placebo groups (65% vs 66%, P = .99 among those with known outcome). The proportion of survivors with NDI was also similar, as were mean values for weight, length, and head circumference and the proportion of infants with poor growth (50% vs 41%, P = .42 for weight less than 10th percentile); 49% of infants in the placebo group received treatment with corticosteroid compared with 32% in the dexamethasone group (P = .02).

CONCLUSION

The risk of death or NDI and rate of poor growth were high but similar in the dexamethasone and placebo groups. The lack of a discernible effect of early dexamethasone on neurodevelopmental outcome may be due to frequent clinical corticosteroid use in the placebo group.