Change over time in internal cerebral vein pulsation in premature infants at risk of intraventricular hemorrhage

BACKGROUND

Prolonged continuation of augmented internal cerebral vein (ICV) pulsation may be related to the development of premature intraventricular hemorrhage (IVH). However, the characteristics of ICV flow patterns in premature infants are unclear.

AIM

To investigate the changes over time in ICV pulsation in premature infants at risk of IVH.

STUDY DESIGN

A 5-year retrospective observational study of a single-center trial.

SUBJECTS

In total, 112 very-low-birth-weight infants with gestational age of ≤32 weeks.

OUTCOME MEASURES

ICV flow was measured every 12 h until 96 h after birth and thereafter on days 7, 14, and 28. The ICV pulsation index (ICVPI), which is a ratio of the minimum/maximum speed of ICV flow, was calculated. We recorded longitudinal ICVPI change and compared ICVPI among three groups classified according to gestational age.

RESULTS

ICVPI started declining after day 1 and reached the minimum median value in 49-60 h after birth (1.0 during 0-36 h, 0.9 during 37-72 h, and 1.0 after 73-84 h). ICVPI was significantly lower during 25-96 h than during 0-24 h and on days 7, 14, and 28. ICVPI in the 23-25-week group was significantly lower between 13-24 h and day 14 than that in the 29-32-week group, and the same was observed for the 26-28-week group between 13-24 h and 49-60 h.

CONCLUSIONS

ICV pulsation was affected by time after birth and gestational age, and this ICVPI fluctuation may reflect a postnatal circulatory adaptation.

LioNeo project: a randomised double-blind clinical trial for nutrition of very-low-birth-weight infants

We assessed the effectiveness of lyophilised banked human milk (HM) as a fortifier to feed very-low-birth-weight infants (VLBWI). This study aimed to evaluate the safety and tolerability of HM with HM lyophilisate as an additive compared with the standard additive (cows' milk protein). In this phase I double-blind randomised controlled clinical trial, set in the intensive and intermediate care units of a tertiary hospital, forty VLBWI were enrolled and allocated into two groups: HM plus HM lyophilisate (LioNeo) or HM plus commercial additive (HMCA). The inclusion criteria were preterm infants, birth weight 750-1500 g, small or adequate for gestational age, exclusively receiving donor HM, volume ≥ 100 ml/kg per d and haemodynamically stable. Participants were followed up for 21 consecutive days. The primary outcome measures were necrotising enterocolitis (NEC), late-onset sepsis (LOS), death, gastrointestinal (GI) bleeding or perforation, diarrhoea, regurgitation, vomiting and abdominal distension. The LioNeo and HMCA groups had similar weights at baseline. The regression models showed no differences between the groups in terms of the primary outcomes. Diarrhoea, GI perforation, NEC and LOS were absent in the LioNeo group (one LOS and one NEC in the HMCA group). Multiple regression analysis with the total volume of milk as a covariate did not show significant differences. The lyophilisation of donor HM was considered safe and tolerable for use in stable haemodynamically VLBWI.

Association Between Antibiotic Overexposure and Adverse Outcomes in Very-Low-Birth-Weight Infants Without Culture-Proven Sepsis or Necrotizing Enterocolitis: A Multicenter Prospective Study

OBJECTIVES

To explore the associations between higher antibiotic use rates (AURs) and adverse outcomes in very-low-birth-weight (VLBW) infants without culture-proven sepsis or necrotizing enterocolitis (NEC) in a multicenter of China.

METHODS

A prospective cohort study was performed on VLBW infants admitted to 24 neonatal intensive care units from January 1, 2018, to December 31, 2018. AUR was calculated as calendar days of antibiotic therapy divided by total hospital days. The composite primary outcome was defined as mortality or severe morbidity, including any of the following: severe neurologic injury, bronchopulmonary dysplasia (BPD), and stage 3 or higher retinopathy of prematurity.

RESULTS

A total of 1,034 VLBW infants who received antibiotics without culture-proven sepsis or NEC were included in this study. The overall AUR of eligible VLBW infants was 55%, and the AUR of each eligible VLBW infant ranged from 3 to 100%, with a median of 56% (IQR 33%, 86%). After generalized propensity score and logistic regression analysis of 4 groups of VLBW infants with different AUR range, infants in the higher quartile AUR, (Q3, 0.57~0.86) and (Q4, 0.87~1.00), had higher odds of composite primary outcome (adjusted OR: 1.81; 95% CI: 1.23-2.67; adjusted OR 2.37; 95% CI: 1.59-3.54, respectively) and BPD (adjusted OR: 3.09; 95% CI: 1.52-6.57; adjusted OR 3.17; 95% CI: 1.56-6.57, respectively) than those in the lowest AUR (Q1).

CONCLUSIONS

Antibiotic overexposure in VLBW infants without culture-proven sepsis or NEC was associated with increased risk of composite primary outcome and BPD. Rational empirical antibiotic use in VLBW infants is urgently needed in China.

Risk factors and clinical characteristics for bronchopulmonary dysplasia associated pulmonary hypertension in very-low-birth-weight infants

BACKGROUND

Pulmonary hypertension (PH) is a common complication of bronchopulmonary dysplasia (BPD) in very-low-birth-weight infants (VLBWIs). Although recent studies have increased awareness that PH contributes significantly to the high morbidity and mortality of BPD, the risk factors and clinical characteristics for PH in VLBWIs are little known.

OBJECTIVES

To investigate the risk factors and clinical characteristics for BPD-associated pulmonary hypertension (BPD-PH) in VLBWIs.

METHODS

A retrospective case-control observational study of VLBWIs with BPD admitted to a neonatal intensive care unit (NICU) over 4 years. According to echocardiograms confirming elevated pulmonary artery pressure after 28 days after birth, we divided BPD infants into PH group (n = 18) and non-PH group (n = 65). We compared pre- and postnatal characteristics between VLBWIs with or without PH. Multivariable logistic regression analysis was conducted with backward selection.

RESULTS

A total of 83 infants with BPD were divided into PH group (n = 18) or non-PH group (n = 65). The average birth weight of the infants with BPD was 1078.1 g. Compared with those infants of the non-PH group, the birth weight of BPD-PH infants was significantly lower (968.1 ± 187.7 vs. 1108.5 ± 185.8, P = 0.006). Infants in the PH group had a higher incidence of patent ductus arteriosus (PDA) and underwent longer durations of oxygen therapy and mechanical ventilation compared to those in the non-PH group. In all subjects, birth weight (OR 0.995; 95% CI 0.991-0.999; P = 0.025) and PDA (OR 13.355; 95% CI 2.950-60.469; P = 0.001) were found to be specific risk factors for BPD-PH in this cohort.

CONCLUSIONS

The study shows PDA and birth weight are specific risk factors for BPD-PH in VLBWIs.

Predicting in-hospital length of stay for very-low-birth-weight preterm infants using machine learning techniques

BACKGROUND/PURPOSE

The in-hospital length of stay (LOS) among very-low-birth-weight (VLBW, BW < 1500 g) infants is an index for care quality and affects medical resource allocation. We aimed to analyze the LOS among VLBW infants in Taiwan, and to develop and compare the performance of different LOS prediction models using machine learning (ML) techniques.

METHODS

This retrospective study illustrated LOS data from VLBW infants born between 2016 and 2018 registered in the Taiwan Neonatal Network. Among infants discharged alive, continuous variables (LOS or postmenstrual age, PMA) and categorical variables (late and non-late discharge group) were used as outcome variables to build prediction models. We used 21 early neonatal variables and six algorithms. The performance was compared using the coefficient of determination (R²) for continuous variables and area under the curve (AUC) for categorical variables.

RESULTS

A total of 3519 VLBW infants were included to illustrate the profile of LOS. We found 59% of mortalities occurred within the first 7 days after birth. The median of LOS among surviving and deceased infants was 62 days and 5 days. For the ML prediction models, 2940 infants were enrolled. Prediction of LOS or PMA had R² values less than 0.6. Among the prediction models for prolonged LOS, the logistic regression (ROC: 0.724) and random forest (ROC: 0.712) approach had better performance.

CONCLUSION

We provide a benchmark of LOS among VLBW infants in each gestational age group in Taiwan. ML technique can improve the accuracy of the prediction model of prolonged LOS of VLBW.

Intrauterine growth restriction affects z-scores of anthropometric parameters during the first 6 years in very low-birth-weight-children born at less than 30 weeks of gestation

OBJECTIVE

Little is known about physical constitution outcomes for very preterm infants. Here, we compare z-scores of anthropometric parameters up to 6 years of age in children born with very low birth weight (VLBW) at less than 30 weeks of gestation, with or without intrauterine growth restriction (IUGR).

DESIGN

Participants were divided into four subgroups: male (M), small for gestational age (SGA) (n = 30); M, appropriate for gestational age (AGA) (n = 59); female (F), SGA (n = 24); and F, AGA (n = 61). z-Scores of body weight (BW), body length (BL), and body mass index (BMI) were assessed at birth, 1 year corrected age, 3 years of age, and 6 years of age.

RESULTS

For boys, BW and BMI were significantly lower among SGA children than among AGA children at all assessments, but there was no difference in BL at 3 or 6 years. For girls, BW and BL were significantly lower among SGA children than among AGA children at all assessments, but no difference was detected in BMI after 1.5 years. No significant variation in the z-score of BW or BMI in either SGA group was observed after 1 year. BL z-score in all groups gradually increased until 6 years of age.

CONCLUSION

IUGR affects BW and BMI in boys and BW and BL in girls during the first 6 years in VLBW children born at less than 30 weeks of gestation. SGA children did not catch up in BW or BMI from 1 to 6 years of age.

The association between brain morphological development and the quality of general movements

AIM

To clarify the morphologic characteristics of the brain, which are the foundation of the emergence of general movements (GMs) in very-low-birth-weight infants.

STUDY DESIGN

Prospective cohort study. GMs were scored according to a semiquantitative scoring system: the GMs optimality score (GMOS) at preterm and term ages. Brain magnetic resonance imaging (MRI) at term-equivalent age was scored using a validated scoring system (MRI score). We examined the relationship between the two scores by multiple regression analysis with relevant clinical background.

SUBJECTS

We included 50 very-low-birth-weight infants cared for at Oita University Hospital from August 2012 to August 2018 who underwent MRI and GMs assessment. Their median gestational age and birth weight were 29w2d and 1145 g, respectively.

RESULTS

The MRI score and systemic steroid administration were related to preterm GMOS, and the MRI score was related to term GMOS. The component cerebellum score and cortical grey matter score of the MRI score were associated with preterm GMOS, and the cerebellum and the cerebral white matter scores were associated with term GMOS.

CONCLUSION

The quality of GMs was associated with brain morphological development. The co-evaluation of GMs and brain morphology leads to accurate developmental prediction.

Early Total Enteral Feeding versus Conventional Enteral Feeding in Stable Very-Low-Birth-Weight Infants: A Randomised Controlled Trial

OBJECTIVE

To evaluate the effect of early total enteral feeding (ETEF) when compared with conventional enteral feeding (CEF) in stable very-low-birth-weight (VLBW; 1,000-1,499 g) infants on the postnatal age (in days) at attaining full enteral feeds.

METHODS

In this unblinded randomised controlled trial, 180 infants were allocated to an ETEF (n = 91) or a CEF group (n = 89). Feeds were initiated as total enteral feeds in the ETEF group and as minimal enteral nutrition (20 mL/kg) in the CEF group. The rest of the day's requirement in the CEF group was provided as parenteral fluids. The primary outcome was postnatal age at attaining full enteral feeds. The secondary outcomes included episodes of feed intolerance, incidence of sepsis and necrotising enterocolitis (NEC), and duration of hospital stay.

RESULTS

The baseline variables including birth weight and gestational age were similar in the two groups. The infants of the ETEF group attained full enteral feeds earlier than those of the CEF group (6.5 ± 1.5 vs. 10.1 ± 4.1 days postnatal age; mean difference -3.6 [-4.5 to -2.7]; p < 0.001). Total episodes of feed intolerance and clinical sepsis were fewer, with a shorter duration of hospital stay, in the ETEF group (15.5 vs. 19.6 days) (p = 0.01). The incidence of NEC was similar in the two groups.

CONCLUSION

ETEF in stable VLBW infants results in earlier attainment of full feeds and decreases the duration of hospital stay without any increased risk of feed intolerance or NEC.

Mask Continuous Positive Airway Pressure Therapy with Simultaneous Extrauterine Placental Transfusion for Resuscitation of Preterm Infants - A Preliminary Study

Background

Delayed cord clamping or cord milking improves cardiovascular stability and outcome of preterm infants. However, both techniques may delay initiation of respiratory support. To allow lung aeration during cord blood transfusion, we implemented an extrauterine placental transfusion (EPT) approach. This study aimed to provide a detailed description of the EPT procedure and to evaluate its impact on the outcome of infants.

Methods

A retrospective analysis was performed comprising 60 preterm infants (22^0/7 to 31^6/7 weeks of gestation). Of these, 40 were transferred to the resuscitation unit with the placenta still connected to the infant. In this EPT group, continuous positive airway pressure support was initiated while, simultaneously, placental blood was transfused by holding the placenta 40-50 cm above the infant's heart. The cords of another 20 infants were clamped before respiratory support was started (standard group). Data on the infants' outcome were compared retrospectively. In a subgroup of 22 infants (n = 14 EPT, n = 8 standard), respiratory function monitor recordings were performed and both heart rates and SpO₂ levels in the first 10 min of life were compared between groups.

Results

Although infants in the EPT group were lighter (EPT: 875 ± 355 g, standard: 1,117 ± 389 g; p = 0.02) and younger (26^6/7 weeks ± 19 days vs. 28^2/7 weeks ± 18 days; p = 0.045), there was no difference in neonatal outcome, including the incidence of intraventricular hemorrhage, bronchopulmonary disease, and red blood cell transfusions (all p > 0.1). Moreover, no differences in SpO₂ levels and heart rates were observed in the infants whose resuscitations were recorded using a respiratory function monitor.

Conclusions

In this retrospective analysis, EPT had no negative effects on the outcome of the infants, which warrants further evaluation in prospective randomized studies.

Delivery mode and intraventricular hemorrhage risk in very-low-birth-weight infants: Observational data of the German Neonatal Network

BACKGROUND

Very-low-birth-weight infants (VLBWI) are frequently delivered by cesarean section (CS). However, it is unclear at what gestational age the benefits of spontaneous delivery outweigh the perinatal risks, i.e. intraventricular hemorrhage (IVH) or death.

OBJECTIVES

To assess the short-term outcome of VLBWI on IVH according to mode of delivery in a population-based cohort of the German Neonatal Network (GNN).

STUDY DESIGN

A total cohort of 2203 singleton VLBWI with a birth weight <1500g and gestational age between 22 0/7 and 36 6/7 weeks born and discharged between 1st of January 2009 and 31st of December 2015 was available for analysis. VLBWI were stratified into three categories according to mode of delivery: (1) planned cesarean section (n=1381), (2) vaginal delivery (n=632) and (3) emergency cesarean section (n=190). Outcome was assessed in univariate and logistic regression analyses.

RESULTS

Prevalence of IVH was significantly higher in the vaginal delivery (VD) (26.6%) and emergency CS group (31.1%) as compared to planned CS (17.2%), respectively. In a logistic regression analysis including known risk factors for IVH, vaginal delivery (OR 1.725 [1.325-2.202], p≤0.001) and emergency cesarean section (OR 1.916 [1.338-2.746], p≤0.001) were independently associated with IVH risk. In the subgroup of infants >30 weeks of gestation prevalence for IVH was not significantly different in VD and planned CS (5.3% vs. 4.4%).

CONCLUSIONS

Our observational data demonstrate that elective cesarean section is associated with a reduced risk of IVH in preterm infants <30 weeks gestational age when presenting with preterm labor.

Low Plasma Protein Levels at Birth Are Associated with Poor Cardiovascular Adaptation and Serious Adverse Outcome in Infants with Gestational Age <32 Weeks: The ProHémie Study

BACKGROUND

Retrospective studies suggest that early hypoproteinemia has prognostic value for adverse outcome in preemies, but the underlying pathophysiology is unknown. We hypothesized that the prognostic relevance of hypoproteinemia could be related to its association with impaired cardiovascular function and organ perfusion during transition.

OBJECTIVES

To describe the plasma protein status and the measures of cardiovascular function according to the outcome in infants <32 weeks' gestation.

METHODS

One hundred and twenty-eight infants were prospectively included from birth to discharge. During the first 24 h of life, we assessed the cardiovascular function and systemic and organ blood flow by Doppler ultrasound, and monitored cerebral and renal regional oxygen saturation (cRSO2, rRSO2) using near-infrared spectroscopy. These measures were analyzed in relationship to hypoproteinemia (total plasma protein level <40 g/L at 12 h of life) and severe adverse outcome (death or survival with severe neurological injury).

RESULTS

Hypoproteinemia was associated with a higher risk of a severe adverse outcome after adjustment of confounding variables (adjusted OR = 6.8; 95% CI 1.3-34). Compared to normoproteinemic infants and after adjustment for gestational age, hypoproteinemic ones had more significantly: hypotension (7 vs. 13%, p = 0.03), abnormal capillary refilling time (20 vs. 36%, p < 0.001), abnormal renal blood flow (resistive index 0.78 ± 0.11 vs. 0.85 ± 0.09, p = 0.04), lower rRSO2 (82.9 ± 9.2 vs. 73.6 ± 10.5%, p = 0.04), and lower systemic vascular resistance (0.155 ± 0.058 vs. 0.108 ± 0.037 mm Hg/L/kg; p = 0.04). The cRSO2 patterns were significantly decreased in infants with severe adverse outcome and independent from protein status.

CONCLUSION

Hypoproteinemia is associated with impaired cardiovascular function. Further studies are required to elucidate the interplay between changes in protein levels, postnatal hemodynamics and clinical outcome.