Postnatal weight gain and retinopathy of prematurity in preterm infants: a population-based retrospective cohort study

OBJECTIVE

Infants who meet the screening guidelines for retinopathy of prematurity (ROP) based on birth weight and gestational age undergo serial ophthalmological examinations for its detection and treatment. However, <10% of patients require treatment, and less than half develop ROP. Poor postnatal weight gain has been reported to be a strong indicator of ROP development; however, the information regarding this is unclear. Therefore, this study aimed to determine the relationship between postnatal weight gain and ROP development in preterm infants.

METHODS

The data of 675 preterm infants with gestational age ≤32 weeks, who were hospitalized in our neonatal intensive care unit, were obtained retrospectively from file records. The infants' demographic characteristics, clinical findings, and weekly weight gain (g/kg/day) during the first 8 weeks were recorded. The univariate was used to examine the risk factors for ROP followed by multivariate regression.

RESULTS

The incidence of ROP in the infants included in the study was 41% (n = 278) and 13.3% (n = 37) of them required treatment. In the infants of the group that developed ROP, the mean birth weight and gestational age were significantly lower than those in the group that did not develop ROP (973 ± 288 and 1301 ± 349 g, p = 0.001 and 28.48 ± 1.95 and 30.08 ± 1.60 weeks, p = 0.001, respectively). As the gestational week and birth weight decreased, ROP development and the risk of ROP-requiring treatment increased. In the infants of the group that developed ROP, the mean weight gain in the postnatal third week was detected as significantly lower compared to those in the group that did not develop ROP (13.9 ± 8.2 and 15.4 ± 6.8 g, p = 0.034). On multiple logistic regression analysis, birth weight (<750 g) (odds ratio [OR], 8.67; 95% confidence interval [CI], 3.99-18.82, p = 0.001), blood transfusion (OR, 2.39; 95% CI, 1.34-4.24, p = 0.003), necrotizing enterocolitis (OR, 4.79; 95% CI, 1.05-26.85, p = 0.045), bronchopulmonary dysplasia (OR, 2.03; 95% CI, 1.22-3.36, p = 0.006), antenatal steroid therapy (OR, 1.60; 95% CI, 1.05-2.43, p = 0.028), surfactant administration (OR, 2.06; 95% CI, 1.32-3.2, p = 0.001) were independent risk factors for ROP development.

CONCLUSION

Postnatal weight gain may not be an accurate predictor of ROP development after adjusting for confounding factors. However, the analysis of independent risk factors that influenced the development of ROP revealed a statistically significant effect in cases of low birth weight, blood transfusion, necrotizing enterocolitis, bronchopulmonary dysplasia, and antenatal steroid and surfactant therapies. These findings may help ophthalmologists and neonatologists to pay special attention to this patient group during ROP scanning.

Upregulation of hepatic nuclear receptors in extremely preterm ovine fetuses undergoing artificial placenta therapy

OBJECTIVE

Extremely preterm infants have low Nuclear Receptor (NR) expression in their developing hepatobiliary systems, as they rely on the placenta and maternal liver for compensation. NRs play a crucial role in detoxification and the elimination of both endogenous and xenobiotic substances by regulating key genes encoding specific proteins. In this study, we utilized an Artificial Placenta Therapy (APT) platform to examine the liver tissue expression of NRs of extremely preterm ovine fetuses. This fetal model, resembling a "knockout placenta," lacks placental and maternal support, while maintaining a healthy extrauterine survival.

METHODS

Six ovine fetuses at 95 ± 1 d gestational age (GA; term = ∼150 d)/∼600 g delivery weight were maintained on an APT platform for a period of 120 h (APT Group). Six age-matched, in utero control fetuses were delivered at 99-100 d GA (Control Group). Fetal liver tissue samples and blood samples were collected at delivery from both groups and assessed mRNA expression of NRs and target transporters involved in the hepatobiliary transport system using quantitative PCR. Data were tested for group differences with ANOVA (p < .05 deemed significant).

RESULTS

mRNA expression of NRs was identified in both the placenta and the extremely preterm ovine fetal liver. The expression of HNF4α, LRH1, LXR, ESR1, PXR, CAR, and PPARα/γ were significantly elevated in the liver of the APT Group compared to the Control Group. Moreover, target transporters NTCP, OATP1B3, BSEP, and MRP4 were upregulated, whereas MRP2 and MRP3 were unchanged. Although there was no evidence of liver necrosis or apoptotic changes histologically, there was an impact in the fetal liver of the ATP group at the tissue level with a significant increase in TNFα mRNA, a cytokine involved in liver inflammation, and blood elevation of transaminases.

CONCLUSION

A number of NRs in the fetal liver were significantly upregulated after loss of placental-maternal support. However, the expression of target transporter genes appeared to be insufficient to compensate role of the placenta and maternal liver and avoid fetal liver damage, potentially due to insufficient excretion of organic anions.

Body Size, Cerebral Blood Flow, Ambient Temperature, and Relative Brain Temperatures in Newborn Infants under Incubator Care

Subtle changes in body temperature affect the outcomes of ill newborns. However, the temperature profile of neonatal brains remains largely unknown. In open-cot care, increased cerebral perfusion is correlated with higher superficial brain temperatures. This study investigated the dependence of brain temperature (relative to rectal temperature) on ambient temperature, body size, cerebral perfusion, and metabolism in infants receiving incubator care. Rectal, scalp, and brain temperatures, superior vena cava flow, and brain oxygenation were assessed using echocardiography, thermo-compensatory temperature monitoring, and near-infrared spectroscopy in 60 newborns. These infants had a mean postconceptional age of 36.9 (2.2) weeks and weighed 2348 (609) g at the time of evaluation. The ambient temperature was maintained at 30.0 (1.0) °C. A higher rectal temperature was associated with greater postconceptional age (p = 0.002), body weight (p < 0.001), and head circumference (p < 0.001). Relative scalp, superficial brain, and deep brain temperatures were associated with smaller head circumference (p < 0.001, p = 0.030, and p = 0.015, respectively) and superior vena cava flow (p = 0.002, p = 0.003, and p = 0.003, respectively). In infants receiving incubator care, larger head sizes and increased brain perfusion were associated with lower relative scalp and brain temperatures. When considered alongside previous reports, cerebral perfusion may contribute to maintaining stable cerebral tissue temperature against ambient temperature changes.

Observational study showed that using video consultations was a viable way of delivering an early discharge programme for preterm infants

AIM

The aim of this study is to evaluate an early discharge programme with video consultations for preterm infants.

METHODS

A homecare programme for preterm infants was developed. Prospective data on readmissions, length of stay, growth, breastfeeding rates, and parent self-reports about satisfaction were collected from April 2021 to August 2023. Additionally, retrospective data were collected from the Norwegian Neonatal Network Central Database from 2020.

RESULTS

Preterm infants, 72 and parents, 128 were included. The infants were discharged from the hospital at a median of 35 + 6 (34 + 0-42 + 4) weeks postmenstrual age. The median length of stay in the program was 18 days (3-37). There were four readmissions. The Z-score of infant weight slightly increased during the follow up, with a mean of 0.16. By discharge, 75% of the infants were exclusively breastfed. Growth and breastfeeding rates were in line with retrospective data (85 infants). The response rate of the parents to the survey was 61 (52%). Overall, the parents (n = 54) were highly satisfied (96%). The video consultations contributed to ensuring parents to feel safe in caring for their infant at home.

CONCLUSION

Follow up by video consultations is a viable healthcare service for preterm infants, the infants' growth is sufficient, breastfeeding rates are maintained, and parents feel safe and satisfied.

Is Necrotizing Enterocolitis and Spontaneous Intestinal Perforation Part of Same Disease Spectrum - New Insights?

The diagnosis of NEC is based on the presence of pneumatosis, dilated bowel loops, portal venous gas, or pneumoperitoneum on the abdominal x-ray. Published studies suggest that the appearance of pneumatosis most likely depends on the gestational age, with a shift occurring between 27-28 weeks. For infants of gestational age under 27 weeks, pneumoperitoneum is the most likely presentation of bowel injury due to the thin bowel wall and the colonization of the gut with the non-gas-producing bacteria. Assessment of postoperative morbidity and white matter injury on the brain MRI at term equivalent age in a cohort of preterm infants failed to identify differences between SIP and NEC groups when confirmed by histology. These findings illustrate the difficulty in conclusively identifying cases as SIP or NEC, particularly when gestational age is considered and raise speculation that both conditions lie on the same spectrum of intestinal injury.

Association of hypermagnesemia at birth and admission hypothermia in pre-term infants: A secondary analysis of a prospective cohort study

BACKGROUND

Hypothermia on admission is associated with increased mortality in preterm infants. Drugs administered to pregnant women is implicated in its occurrence. Since magnesium sulfate has a myorelaxant effect, we aimed evaluating the association of hypermagnesemia at birth and admission hypothermia (axillary temperature <36.5°C) in preterm infants.

METHODS

We performed a secondary analysis of a prospective cohort study database including inborn infants <34 weeks, without congenital malformations. Hypermagnesemia was considered if the umbilical magnesium level >  2.5 mEq/L. Maternal and neonatal variables were used to adjust the model, submitted to the multivariate hierarchical modelling process.

RESULTS

We evaluated 249 newborns with median birth weight and gestational age of 1375 (IQR 1020-1375) g and 31 (IQR 28-32) weeks, respectively. Hypermagnesemia occurred in 28.5% and admission hypothermia occurred in 28.9% . In the univariate analysis, the following variables were identified as being associated with admission hypothermia: hypermagnesemia (OR 3.71; CI 2.06-6.68), resuscitation (OR 2.39; CI 1.37-4.19), small to gestational age (OR 1.91; CI1.03-3.53), general anesthesia (OR 3.34; CI 1.37-8.13), birth weight (OR 0.998; CI 0.998-0.999) and gestational age (OR 0.806; CI 0.725-0.895). In the hierarchical regression model, hypermagnesemia remained independent associated with admission hypothermia (OR 3.20; CI 1.66-6.15), as well as birth weight (OR 0.999; CI 0.998-0.999) and tracheal intubation (3.83; CI 1.88-7.80).

CONCLUSION

Hypermagnesemia was associated with an increased risk of admission hypothermia, as did tracheal intubation and lower birth weight.

Subventricular zone stem cell niche injury is associated with intestinal perforation in preterm infants and predicts future motor impairment

Brain injury is highly associated with preterm birth. Complications of prematurity, including spontaneous or necrotizing enterocolitis (NEC)-associated intestinal perforations, are linked to lifelong neurologic impairment, yet the mechanisms are poorly understood. Early diagnosis of preterm brain injuries remains a significant challenge. Here, we identified subventricular zone echogenicity (SVE) on cranial ultrasound in preterm infants following intestinal perforations. The development of SVE was significantly associated with motor impairment at 2 years. SVE was replicated in a neonatal mouse model of intestinal perforation. Examination of the murine echogenic subventricular zone (SVZ) revealed NLRP3-inflammasome assembly in multiciliated FoxJ1+ ependymal cells and a loss of the ependymal border in this postnatal stem cell niche. These data suggest a mechanism of preterm brain injury localized to the SVZ that has not been adequately considered. Ultrasound detection of SVE may serve as an early biomarker for neurodevelopmental impairment after inflammatory disease in preterm infants.

The aetiology of preterm birth and risks of cerebral palsy and cognitive impairment: A systematic review and meta-analysis

AIM

The associations between the aetiology of preterm birth and later neurodevelopmental outcomes are unclear. A systematic review and meta-analysis examined the existing evidence.

METHODS

The PubMed and Embase databases were searched for papers published in English from inception to 16 December 2020. We included original papers on the causes of preterm birth and the risks of cerebral palsy (CP) and suboptimal cognitive development. Two reviewers independently evaluated the studies and extracted the data.

RESULTS

The literature search yielded 5472 papers and 13 were selected. The aetiology of preterm birth was classified under spontaneous or medically indicated delivery. A meta-analysis was performed, comprising 104 902 preterm infants from 11 papers on CP. Preterm infants born after a medically indicated delivery had a lower CP risk than infants born after spontaneous delivery, with a pooled odds ratio of 0.59 (95% confidence interval 0.40-0.86). This result was robust in the subgroup and sensitivity analyses. Cognitive development was reported in three papers, which suggested that worse outcomes were associated with medically indicated deliveries.

CONCLUSION

The aetiology of preterm delivery may contribute to the risk of CP and cognitive delay. Further research is needed, using individual-level meta-analyses to adjust for possible confounders, notably gestational age.

Bridging the gap between healthcare sectors: Facilitating the transition from NICU to the municipality and home for families with premature infants

PURPOSE

The transition from hospital to home can be challenging for parents of prematurely born infants. The aim of this ethnographic study was to describe a multidisciplinary and cross-sectoral discharge conference for families with premature infants transitioning from a neonatal intensive care unit to municipal healthcare services.

DESIGN AND METHODS

An ethnographically/anthropologically inspired qualitative design was adopted. We conducted four participant observations of multidisciplinary and cross-sectoral discharge conferences and 12 semistructured interviews with four neonatologists, four nurses, and four health visitors who had attended one of the conferences. Salient themes were generated by two-part analysis consisting of a thematic analysis followed by Turner's ritual analysis.

RESULTS

This study illustrated how multidisciplinary and cross-sectoral discharge conferences improved the quality of care for premature infants and their families in their transition process which was perceived as complex. These conferences contributed to promoting a sense of coherence and continuity of care. The healthcare professionals experienced that this event may be characterized as a ritual, which created structures that promoted cross-sectoral cooperation and communication while increasing interdisciplinary knowledge sharing. Thus, the conferences triggered a sense that the participants were building bridges to unite healthcare sectors, ensuring a holistic and coordinated approach to meet the unique needs of the infants and their families.

IMPLICATIONS FOR PRACTICE

This study presented a unique holistic and family-centered approach to constructing multidisciplinary and cross-sectoral discharge conferences that seemed to underpin the quality of interdisciplinary and health-related knowledge sharing and establish a crucial starting point for early interventions, preventive measures, and health-promoting efforts. Hopefully, our findings will encourage others to rethink the discharge conference as a transitional ritual that may potentially bridge the gap between healthcare sectors. Specifically, our findings contribute to the mounting body of knowledge of family-centered care by showing how healthcare professionals may-in a meaningful and tangible manner-operate, develop, and implement this somewhat elusive theoretical foundation in their clinical practice.

Positive end-expiratory pressure and surfactant administration mode influence function in ex-vivo premature sheep lungs

AIM

Respiratory distress syndrome often necessitates endotracheal surfactant administration in extremely preterm infants. Our study aimed to explore a multi-modal simulation tool for investigating treatment strategies in ex vivo sheep lungs during spontaneous breathing.

METHODS

An electromechanical lung simulator (xPULM) mimicking spontaneous breathing was coupled with a non-aerated premature sheep lung, replicating a premature respiratory system. Changes in tidal volume for different positive end-expiratory pressure (PEEP) levels prior to and after either bolus or nebulised surfactant administration were compared.

RESULTS

In two preterm sheep lungs, we observed a progressive decline in tidal volume with increasing PEEP levels prior to surfactant delivery from 0.30 ± 0.01 mL at zero PEEP to 0.04 ± 0.01 mL at 15 cmH2O PEEP. Our measurements showed that both bolus (p < 0.05) and nebulised (p < 0.05) surfactant administration resulted in a significant increase in tidal volume, with no significant difference (p = 0.71) between the two methods.

CONCLUSION

The experimental setup demonstrated the feasibility of xPULM for investigating the effectiveness of different PEEP levels and modes of surfactant administration with respect to tidal volume in premature sheep lungs. The lack of adequate lung water resorption in our model warrants further investigations.

The ASQ did not predict low IQ scores when children born VPT were six years

AIM

There is a need for methods that can provide valid assessment tools in a follow-up programme without great financial costs. This study assessed the accuracy of the 60-month Ages and Stages Questionnaire as a screening tool to predict a low intelligence quotient score at 6 years in children born very preterm.

METHODS

Totally, 54 children participated in a six-year follow-up study, which included an intelligence quotient test at 6 years of age and a 60-month Ages and Stages Questionnaire at four and a half or 5 years of age at respond. We used the receiver operating characteristic curve and evaluated the optimal cut-off score to predict a low intelligence quotient score.

RESULTS

At four and a half years, the optimal cut-off value for predicting a low intelligence quotient score was 242, with a sensitivity of 67% and a specificity of 59%. At 5 years, only one child had a low intelligence quotient score, and the analysis was not performed.

CONCLUSION

Our results did not support the use of the 60-month Ages and Stages Questionnaire as a valuable screening tool to predict a low intelligence quotient score in children born very preterm at 6 years of age.

Time intervals between pumping did not affect breastmilk protein produced by mothers of preterm infants

AIM

Few studies investigate factors that might influence the content of expressed breastmilk. This study aims to investigate the influence of the intervals between breastmilk pumping and the time of the day on protein and fat concentration in breastmilk.

METHODS

Mothers of very preterm infants in a neonatal ward who expressed more than 400 mL per day were included. Expressed breastmilk was obtained from each mother over 30 h who were pumping at strictly planned and varying intervals: 2, 3, 4 and 6 h. All samples were analysed using infrared transmission spectroscopy.

RESULTS

Ten mothers participated at a median of 22 days postpartum. A total of 176 milk samples were analysed, and the average protein and fat concentrations in g/100 mL were 1.1 ± 0.23 and 4.2 ± 1.3, respectively. The time intervals between breast pumping sessions did not impact protein content, but fat content decreased by longer intervals (p < 0.01). The time of the day for milk pumping did not influence the protein or fat content.

CONCLUSION

A single milk sample collected after any 2-6 h interval, at any time during the day, represents the protein content in the breastmilk, but not the fat content which decreased with longer intervals.

Novel growth reference ImaGrow differed from existing charts for preterm children aged 0-2 years

AIM

This study aimed to address the critical need for more accurate growth reference charts for preterm infants, with a particular focus on low- and very low-birth-weight infants.

METHODS

The subjects were recruited at a single tertiary centre. The cohort comprised singleton and twin infants born before 37 weeks of gestation, with data collected from 2000 to 2016. Standardised measurements of body parameters were recorded in this mixed longitudinal survey. LMS method was utilised for data analysis. Statistical analysis was performed using SPSS Statistics Version 21. The validation with another new cohort was executed.

RESULTS

A total of 1781 infants (52.5% boys) met the inclusion criteria. The median gestational age at birth was 30 weeks, with a median birth weight of 1350 grams. The main findings included the construction of ImaGrow charts for low- and very low-birth-weight infants and significant differences in growth trajectories compared to Fenton+WHO charts.

CONCLUSION

Our comprehensive growth references, ImaGrow, are based on a long-term auxological assessment of preterm infants and differ from charts derived from size-at-birth standards or charts for term babies. These charts have significant implications for clinical practice in monitoring and assessing the growth of preterm infants.

Close Collaboration with Parents-Implementation and effectiveness

AIM

There has been a need to develop programs to facilitate family-centered care. This paper describes the content of a program called Close Collaboration with Parents, its implementation, and research on its effectiveness.

METHODS

The program is a systematic training with a focus on staff communication and observation skills and skills to support parenting. The primary implementation strategy is mentoring. Staff engage in bedside practices and reflections with mentors covering all four phases of the program. The effects of this unit-wide program have been evaluated using a pre-post study design, a qualitative study design, and a register-based study design.

RESULTS

The program has been successfully implemented in 26 units so far. Our research has shown that the training benefits infants, parents, staff, and healthcare organisations. Specifically, family-centered care practices improved after the program, the parents' presence and parent-infant skin-to-skin contact increased, infant growth improved and the length of hospital stays shortened. The mothers' depressive symptoms decreased in the long term.

CONCLUSION

We have described an educational program for the multidisciplinary staff of a neonatal intensive care unit, Close Collaboration with Parents. The program has changed hospital care cultures for the benefit of infants, parents, staff, and even the healthcare organisation.

Corrigendum: Structural and functional changes of bioactive proteins in donor human milk treated by vat-pasteurization, retort sterilization, ultra-high-temperature sterilization, freeze-thawing and homogenization

[This corrects the article DOI: 10.3389/fnut.2022.926814.].

Characterising the motion and cardiorespiratory interaction of preterm infants can improve the classification of their sleep state

AIM

This study aimed to classify quiet sleep, active sleep and wake states in preterm infants by analysing cardiorespiratory signals obtained from routine patient monitors.

METHODS

We studied eight preterm infants, with an average postmenstrual age of 32.3 ± 2.4 weeks, in a neonatal intensive care unit in the Netherlands. Electrocardiography and chest impedance respiratory signals were recorded. After filtering and R-peak detection, cardiorespiratory features and motion and cardiorespiratory interaction features were extracted, based on previous research. An extremely randomised trees algorithm was used for classification and performance was evaluated using leave-one-patient-out cross-validation and Cohen's kappa coefficient.

RESULTS

A sleep expert annotated 4731 30-second epochs (39.4 h) and active sleep, quiet sleep and wake accounted for 73.3%, 12.6% and 14.1% respectively. Using all features, and the extremely randomised trees algorithm, the binary discrimination between active and quiet sleep was better than between other states. Incorporating motion and cardiorespiratory interaction features improved the classification of all sleep states (kappa 0.38 ± 0.09) than analyses without these features (kappa 0.31 ± 0.11).

CONCLUSION

Cardiorespiratory interactions contributed to detecting quiet sleep and motion features contributed to detecting wake states. This combination improved the automated classifications of sleep states.

Deciphering Mechanisms of Respiratory Fetal-to-Neonatal Transition in Very Preterm Infants

Rationale: The respiratory mechanisms of a successful transition of preterm infants after birth are largely unknown. Objectives: To describe intrapulmonary gas flows during different breathing patterns directly after birth. Methods: Analysis of electrical impedance tomography data from a previous randomized trial in preterm infants at 26-32 weeks gestational age. Electrical impedance tomography data for individual breaths were extracted, and lung volumes as well as ventilation distribution were calculated for end of inspiration, end of expiratory braking and/or holding maneuver, and end of expiration. Measurements and Main Results: Overall, 10,348 breaths from 33 infants were analyzed. We identified three distinct breath types within the first 10 minutes after birth: tidal breathing (44% of all breaths; sinusoidal breathing without expiratory disruption), braking (50%; expiratory brake with a short duration), and holding (6%; expiratory brake with a long duration). Only after holding breaths did end-expiratory lung volume increase: Median (interquartile range [IQR]) = 2.0 AU/kg (0.6 to 4.3), 0.0 (-1.0 to 1.1), and 0.0 (-1.1 to 0.4), respectively; P < 0.001]. This was mediated by intrathoracic air redistribution to the left and non-gravity-dependent parts of the lung through pendelluft gas flows during braking and/or holding maneuvers. Conclusions: Respiratory transition in preterm infants is characterized by unique breathing patterns. Holding breaths contribute to early lung aeration after birth in preterm infants. This is facilitated by air redistribution during braking/holding maneuvers through pendelluft flow, which may prevent lung liquid reflux in this highly adaptive situation. This study deciphers mechanisms for a successful fetal-to-neonatal transition and increases our pathophysiological understanding of this unique moment in life. Clinical trial registered with www.clinicaltrials.gov (NCT04315636).

Hyperglycemia in pregnancy did not worsen the short-term outcomes of very preterm infants: a propensity score matching study

Background

Hyperglycemia in pregnancy (HGP) has generally been considered a risk factor associated with adverse outcomes in offspring, but its impact on the short-term outcomes of very preterm infants remains unclear.

Methods

A secondary analysis was performed based on clinical data collected prospectively from 28 hospitals in seven regions of China from September 2019 to December 2020. According to maternal HGP, all infants were divided into the HGP group or the non-HGP group. A propensity score matching analysis was used to adjust for confounding factors, including gestational age, twin or multiple births, sex, antenatal steroid administration, delivery mode and hypertensive disorders of pregnancy. The main complications and the short-term growth status during hospitalization were evaluated in the HGP and non-HGP groups.

Results

A total of 2,514 infants were eligible for analysis. After matching, there were 437 infants in the HGP group and 874 infants in the non-HGP group. There was no significant difference between the two groups in main complications including respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity, patent ductus arteriosus, culture positive sepsis, intraventricular hemorrhage, periventricular leukomalacia, anemia, feeding intolerance, metabolic bone disease of prematurity, or parenteral nutrition-associated cholestasis. The incidences of extrauterine growth retardation and increased growth retardation for weight and head circumference in the non-HGP group were all higher than those in the HGP group after matching (P < 0.05).

Conclusions

HGP did not worsen the short-term outcomes of the surviving very preterm infants, as it did not lead to a higher risk of the main neonatal complications, and the infants' growth improved during hospitalization.

Mydriasis for retinopathy of prematurity screening in Europe: A cross-sectional online survey

PURPOSE

To compile real-time data on the preferred mydriasis practice patterns for retinopathy of prematurity (ROP) screening in Europe.

METHODS

A cross-sectional online survey was conducted from December 2022 to January 2023, using a self-report online questionnaire which was distributed via email to the members of the European Pediatric Ophthalmological Society and the Greek National ROP Task Force. A six-week period of recruitment was determined, and a reminder email was sent after two weeks. Descriptive statistics were used to explore the data, which was summarized with frequencies and percentages.

RESULTS

Sixty-six responses were recorded (response rate: 29.5%), representing practices in 55 Neonatal Intensive Care Units from 21 European countries. In 94.5%, the applied mydriatic regimen consists of phenylephrine with at least one muscarinic antagonist, either tropicamide or cyclopentolate. The concentration of phenylephrine ranges from 0.5% to 5%, of tropicamide from 0.25% to 1%, and of cyclopentolate from 0.2% to 1%. The most commonly used regimen (43.6%) contains phenylephrine 2.5% and tropicamide 0.5%, administered either combined or separately. About 54.5% of the reported mydriatic solutions are non-commercial, in-house preparations. Systemic adverse events, including oxygen desaturation, bradycardia and cardiopulmonary arrest were reported in 14.5%.

CONCLUSION

There is considerable heterogeneity in the applied mydriatic regimens for ROP screening in Europe, reflecting the absence of universal guidelines. The wide use of in-house preparations underlines the gap in the pharmaceutical industry. Concern should be raised against the wide use of undiluted commercial drugs, that reach adult dose, in the fragile population of preterm infants.

A structured programme to promote breastfeeding improved the rates in very preterm infants at discharge

AIM

We developed the Promotion of Breastfeeding (PROBREAST) programme and evaluated what effect it had on the breastfeeding rate in infants born at less than 32 weeks of gestation or weighing ≤1500 grams.

METHODS

We compared the breastfeeding rate in two cohorts of patients who were born before (n = 72; January 2017 to June 2018) and after (n = 80; July 2018 to December 2019) the application of the programme. Moreover, we compared the correlation between type of feeding at discharge and post-discharge breastfeeding rate, between exclusive breastfeeding, postnatal growth and neurodevelopment.

RESULTS

Infants in the PROBREAST group had an exclusive breastfeeding rate at discharge higher (42 vs. 16%, p < 0.001) than that in the historical control group. Exclusive breastfeeding was negatively correlated with weight z-score at discharge, but not at 12 and 24 months corrected age, and was positively correlated with cognitive score at 24 months corrected age.

CONCLUSION

The application of a structured programme for the promotion of breastfeeding improved the breastfeeding rate in very preterm infants. We demonstrated that exclusive breastfeeding at discharge improved their neurodevelopment without impairing growth.

The impact of cyclooxygenase inhibitor use on urinary prostaglandin metabolites in preterm infants

BACKGROUND

There is limited evidence on the association between the clinical course of patent ductus arteriosus (PDA) and prostaglandin (PG) metabolites. This study aimed to determine the influence of PDA treatment on urinary PG metabolite excretion in very-low-birth-weight (VLBW) infants.

METHODS

Urine samples were collected from 25 VLBW infants at 1, 3, and 7 days of age. Infants were separated into two groups: a PDA-treated group that received a cyclooxygenase-2 (COX) inhibitor (n = 12) and a control group that did not receive a COX inhibitor during the first 7 days after birth (n = 13). Urinary PG metabolite tetranor prostaglandin E2 metabolite (t-PGEM) and tetranor prostaglandin D2 metabolite (t-PGDM) levels were analyzed using liquid chromatography-tandem mass spectrometry.

RESULTS

Urinary t-PGEM excretion levels were not significantly different between the groups at 1, 3, and 7 days of age. Urinary t-PGDM excretion levels at 1 day of age were higher in PDA-treated infants than in control infants (median [interquartile range]: 5.5 [2.6, 12.2] versus 2.1 [1.0, 3.9] ng/mg creatinine; p = 0.017); however, among PDA-treated infants, the levels were significantly lower at 3 and 7 days than at 1 day of age (5.5 [2.6, 12.2] versus 3.4 [1.7, 4.5] and 4.0 [1.7, 5.3] ng/mg creatinine, respectively; p < 0.05). The urinary t-PGDM excretion level in the control group did not significantly differ among the time points.

CONCLUSION

PDA and COX inhibitor administration affected PG metabolism in VLBW infants. Our results indicated that urinary t-PGDM excretion was significantly associated with PDA-treatment in preterm infants.

Analgosedation for less-invasive surfactant administration: Variations in practice

BACKGROUND

Less-invasive surfactant administration (LISA) is widely used for surfactant delivery to spontaneously breathing preterm infants on nasal CPAP. However, the use of analgesia and/or sedation for the LISA procedure remains controversial.

METHODS

We conducted a cross-sectional survey of all tertiary neonatal intensive care units (NICUs) in Austria, Germany, and Switzerland to assess current practices of analgosedation for LISA in preterm infants.

RESULTS

Eighty-eight of 172 (51.2%) NICUs responded to the survey, of which 83 (94.3%) perform LISA. Analgosedation for LISA is used in 60 (72.3%) NICUs. Twenty-eight of those (46.7%) have unit protocols to guide analgosedation while 32 (53.3%) administer medication at the discretion of the attending physician. Ketamine (45.0% of NICUs), propofol (41.7%), fentanyl (21.7%), morphine (20.0%), and midazolam (20.0%) were most frequently used for analgosedation for LISA. Nine (10.7%) NICUs reported the use of pain or distress scores during LISA.

CONCLUSION

LISA is well established among tertiary NICUs in the German-speaking countries. However, there are considerable variations regarding the use of analgosedation. More evidence is required to guide clinicians seeking to safely and effectively deliver surfactant via a thin catheter to spontaneously breathing preterm infants.

Secular Trends in Patent Ductus Arteriosus Management in Infants Born Preterm in the National Institute of Child Health and Human Development Neonatal Research Network

We evaluated changes in patent ductus arteriosus (PDA) diagnosis and treatment from 2012 through 2021 in a network of US academic hospitals. PDA treatment decreased among infants born at 26-28 weeks but not among infants born at 22-25 weeks. Rates of indomethacin use and PDA ligation decreased while acetaminophen use and transcatheter PDA closure increased.

Do Lower Levels of Fetal Hemoglobin in Preterm Infants Relate to Oxidative Stress?

Fetal hemoglobin (HbF) has a higher affinity to oxygen than adult hemoglobin, allowing for a slower oxygen transfer to peripheral tissue, creating a microenvironment conducive to adequate fetal development in utero. However, most preterm infants receive packed red blood cell transfusions from adult donors leading to a drastic nonphysiological descent of circulating HbF. We hypothesized that this drop could enhance oxygen delivery to peripheral tissues generating a hyperoxic pro-oxidant environment. To investigate this, we assessed differences in oxidative stress biomarkers determined in urine samples in a cohort of 56 preterm infants born <32 weeks' gestation. Median oxidative stress biomarkers were compared between patients with circulating HbF above or below median HbF levels using Wilcoxon rank sum test. Oxidative stress biomarkers were significantly higher in the group of patients with lower levels of HbF. This study provides the initial evidence indicating elevated levels of oxidative stress biomarkers in preterm neonates with lower HbF levels. Based on the results, we hypothesize that HbF may contribute to preventing free radical-associated conditions during the newborn period. Antioxid. Redox Signal. 40, 453-459.

Sex-Based Differences in the Sonographic Characterization of Diaphragm Thickness in Preterm Infants With Bronchopulmonary Dysplasia at Term Corrected Age: A Secondary Analysis of a Prospective Study

OBJECTIVE

To determine the sex-specific diaphragm thickness in infants with bronchopulmonary dysplasia (BPD) as well as in healthy term and near-term infants.

METHODS

We performed a secondary analysis of an observational study to compare the sonographic diaphragm thickness at end expiration (DTexp ) in female and male infants. The study included infants with BPD and healthy near-term and term infants. To account for differences in anthropometric measurements, we calculated the DTexp as a ratio of body surface area (BSA). Statistical analysis was performed using R statistical software.

RESULTS

Of the 111 infants included, 54 (48.6%) were female. There were no significant differences in mean (SD) birth gestation [26.2 (2.1) vs 26.3 (2.1) weeks] and mean study age [38.0 (2.0) vs 37.4 (1.1) weeks] of male vs female infants with BPD. The mean (SD) DTexp [1.5 (0.4) mm vs 1.2 (0.3) mm, P = .02] and DTexp /BSA [8.3 (2.3) mm/m2 vs 6.7 (1.6) mm/m2 , P < .01] were significantly thicker in female than male infants with BPD. In contrast, there were no significant differences in DTexp between sexes [1.5 (0.4) mm vs 1.5 (0.3) mm, P = .89] within the healthy control group. Moreover, there were no differences in inspiratory diaphragm thickness, diaphragm thickness fraction, or excursion between males and females in the BPD or healthy groups.

CONCLUSIONS

Male infants with BPD exhibit thinner diaphragm thickness compared with female infants. Its implication on higher rates of BPD in preterm males is unclear, but this finding highlights the need for further investigation.

Associations between gut microbiota and adverse neurodevelopmental outcomes in preterm infants: a two-sample Mendelian randomization study

Gut microbiota are associated with adverse neurodevelopmental outcomes in preterm infants; however, the precise causal relationship remains unclear. In this study, we conducted a two-sample Mendelian randomization (MR) analysis to comprehensively study the relationship between gut microbiota and adverse neurodevelopmental outcomes in preterm infants and identify specific causal bacteria that may be associated with the occurrence and development of adverse neurodevelopmental outcomes in preterm infants. The genome-wide association analysis (GWAS) of the MiBioGen biogroup was used as the exposure data. The GWAS of six common adverse neurodevelopmental outcomes in premature infants from the FinnGen consortium R9 was used as the outcome data. Genetic variations, namely, single nucleotide polymorphisms (SNPs) below the locus-wide significance level (1 × 10-5) and genome-wide statistical significance threshold (5 × 10-8) were selected as instrumental variables (IVs). MR studies use inverse variance weighting (IVW) as the main method. To supplement this, we also applied three additional MR methods: MR-Egger, weighted median, and weighted mode. In addition, the Cochrane's Q test, MR-Egger intercept test, Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO), and leave-one-out methods were used for sensitivity analysis. Our study shows a causal relationship between specific gut microbiota and neurodevelopmental outcomes in preterm infants. These findings provide new insights into the mechanism by which gut microbiota may mediate adverse neurodevelopmental outcomes in preterm infants.

Associations of maternal inflammatory states with human milk composition in mothers of preterm infants

Introduction

Overweight/obesity (ow/ob) is increasing in prevalence in pregnant women, and it is associated with other pro-inflammatory states, such as pre-eclampsia, gestational diabetes, and preterm labor. Data are lacking if mothers experiencing inflammatory states who deliver preterm have mother's own milk (MOM) with differing inflammatory markers or pro-inflammatory fatty acid (FA) profiles.

Methods

The aim was to explore associations of maternal pre- and perinatal inflammatory states with levels of inflammatory markers and/or FAs in longitudinal samples of MOM from mothers of preterm infants born <1,250 g. Inflammatory states included pre-pregnancy ow/ob, diabetes, chorioamnionitis (chorio), preterm labor (PTL), premature rupture of membranes (PROM), pre-eclampsia, and cesarian delivery. In MOM, inflammatory markers studied included c-reactive protein (CRP), free choline, IFN-Ɣ, IL-10, IL-1β, IL-1ra, IL-6, IL-8, and TNF-α, and FAs included omega-6:omega-3 ratio, arachidonic acid, docosahexaenoic acid, linoleic acid, monounsaturated FAs, and saturated FAs. The above inflammatory states were assessed individually, and the healthiest mothers (normal BMI, no chorio, and ± no pre-eclampsia) were grouped. Regression analysis tested associations at baseline (day 5) and over time using generalized estimating equations.

Results

A total of 92 infants were included who were delivered to mothers (42% ow/ob) at a median gestational age of 27.7 weeks and birth weight of 850 g. MOM CRP was 116% higher (relative change 2.16) in mothers with ow/ob at baseline than others (p = 0.01), and lower (relative change 0.46, 0.33, respectively) in mothers in the two "healthy groups" at baseline (both p < 0.05) than others. MOM IL-8 levels were lower with chorio and PTL at baseline. No significant associations were found for other individual or grouped inflammatory states nor for other MOM inflammatory markers nor FA profiles at baseline.

Discussion

In conclusion, MOM CRP levels are positively associated with inflammatory states, such as ow/ob. Reassuringly, there was no association between FA profiles or most other inflammatory markers and maternal inflammatory states. Further studies are needed to determine potential associations or ramifications of MOM CRP in vulnerable preterm infants.

USE OF HAND-HELD OPTICAL COHERENCE TOMOGRAPHY DURING RETINOPATHY OF PREMATURITY SCREENING DEMONSTRATES AN INCREASED OUTER RETINA FROM EARLY POSTMENSTRUAL AGE IN PRETERM INFANTS WITH RETINOPATHY OF PREMATURITY

PURPOSE

To identify structural markers of active retinopathy of prematurity (ROP) in foveal and parafoveal retinal layers using hand-held optical coherence tomography.

METHODS

Hand-held optical coherence tomography images (n = 278) were acquired from a prospective mixed cross-sectional longitudinal observational study of 87 participants (23-36 weeks gestational age; n = 30 with ROP, n = 57 without ROP) between 31 and 44 weeks postmenstrual age excluding treated ROP and features of cystoid macular edema. Six retinal layer thicknesses from the fovea to the parafovea were analyzed at five locations up to 1,000 µ m, temporally and nasally.

RESULTS

The mean outer retinal thickness during active ROP increased at the fovea and parafovea from postmenstrual age 33 weeks to 39 weeks ( P < 0.001), whereas the parafoveal inner nuclear layer and retinal nerve fiber layer reduced ( P < 0.001). Outer retinal thickness at the fovea from 33 weeks to 39 weeks postmenstrual age was consistently thicker in infants with ROP across all levels of prematurity (gestational age).

CONCLUSION

Increased foveal and parafoveal outer retina measured using hand-held optical coherence tomography shows potential as a marker for ROP screening.

Association of aEEG and brain injury severity on MRI at term-equivalent age in preterm infants

AIM

Measures to detect and monitor brain injury in preterm infants are amplitude-integrated electroencephalography (aEEG) and magnetic resonance imaging (MRI). To investigate the association between aEEG and MRI in a large cohort of preterm infants. Five hundred and twenty-three preterm infants were included in the study.

METHODS

AEEG was interpreted for the total maturation score (TMS) according to Burdjalov. Cerebral MRI was evaluated using a validated scoring system by Kidokoro.

RESULTS

One hundred and forty-six infants (27.9%) showed some form of brain injury, with 111 infants (21.2%) showing mild injury and 35 (6.7%) showing severe injury. TMS were significantly higher in infants without injury compared to severe injury. When comparing infants with isolated intraventricular haemorrhage  to infants without brain injury, TMS were significantly lower.

CONCLUSION

Prediction of adverse outcome is an important aspect of neonatal care. The combination of diagnostic measures evaluating brain injury might enhance our abilities in neonatal care to provide accurate information about later outcome. Early aEEG is predictive for the severity of brain injury detected by MRI at term-equivalent age. Whether aEEG is also predictive for neurodevelopmental outcome needs to be further investigated in relation to the various patterns of preterm brain injury.

Characterization of exosomal microRNAs in preterm infants fed with breast milk and infant formula

Breastfeeding not only reduces infection-related morbidity, but also increases growth of preterm infants. Advantages of breast milk (BM) for preterm infants are significant. They continue to be studied. However, because not all preterm infants can receive breastfeeding, bovine-based infant formula (IF) is used as an alternative, which may increase the risk of several preterm complications. Exosomes isolated from biofluids are emerging as biomarkers in research of various diseases. Here, we characterized miRNA contents of exosomes in urine and serum samples of preterm infants who were BM and IF fed and performed transcriptomic analysis of small RNA libraries. We identified significantly up-regulated 6 miRNAs and 10 miRNAs, respectively. Gene Ontology (GO) analysis revealed that target genes of these miRNAs might participate in neuronal development, immunity modulation, detoxification of reactive oxygen species, and transmembrane exchange. Our data suggest that exosome-based systemic screening for preterm infants with breastfeeding might be a screening tool for identifying target molecules involved in therapy for preterm infants in neonatal intensive care unit (NICU) and for future application as nutraceutical formulations or pharmaceuticals.

Correlation between the Closure Time of Patent Ductus Arteriosus in Preterm Infants and Long-Term Neurodevelopmental Outcome

In patent ductus arteriosus (PDA) in preterm infants, the relationship between treatment timing and long-term developmental prognosis remains unclear. The purpose of this study was to clarify the relationship between the age in days when ductus arteriosus closure occurred and long-term development. Preterm infants with a birth weight of less than 1500 g who were admitted to our NICU over a period of 9 years (2011-2019) and were diagnosed with PDA were included. A new version of the K-type developmental test for corrected ages of 1.5 and 3 years was used as an index of development. The relationship between the duration of PDA and the developmental index was evaluated using Pearson's correlation coefficient, and multiple regression analysis was performed. Development quotient (DQ) at the ages of 1.5 and 3 years showed a correlation with the PDA closure date and the standard deviation (SD) value of the term birth weight. Multiple regression analysis showed a positive correlation of the DQ at 1.5 and 3 years with the SD value of the term birth weight and a negative correlation with the PDA closure date. In addition, a stronger correlation was found in the "posture/motor" sub-item at 3 years. On the other hand, the analysis including preterm infants without PDA showed that preterm infants with PDA closure on the 6th day or later after birth had a significantly lower 3-year-old DQ than preterm infants with a PDA exposure within 5 days. In conclusion, it is suggested that the decrease in cerebral blood flow due to PDA in preterm infants has an adverse effect on long-term neurodevelopment. Appropriate interventions, including surgical treatment for PDA in preterm infants without delay, ideally within 5 days of birth, may be effective in improving the developmental prognosis.

Visual stimulation in the neonatal intensive care unit: A systematic literature review

We aimed to systematically categorize evidence on the types of early visual stimulation applied to preterm infants (PTIs) admitted to neonatal intensive care units (NICUs), aiming to improve visual function parameters. This study was conducted according to PRISMA and registered in PROSPERO with CRD42022333753. Last search was conducted on March 15, 2023, in four different databases. Articles written in English, Portuguese, Spanish, or Italian, and available in full text were included. Two independent authors performed study selection, data extraction, and bias risk assessment. If there was any disagreement, a third author was contacted. A total of eight studies were included. From these, 62.5% presented a low risk of bias. 100% used a multisensory intervention, which included visual stimulation. In 50%, visual intervention consisted of black and white stimulation cards placed inside the incubator for three minutes. The outcomes showed positive benefits in visual function parameters and other reported clinical benefits in breastfeeding and neuromuscular development. This review demonstrated there is still scarce literature on the effects of early visual stimulation on purely visual functional outcomes, although the existing findings are promising. Parental involvement has been generating unquestionable benefits for the binomial mother-infant and gaining greater acceptance by health professionals.

Case Report: Neonatal genital prolapse in a pair of premature Twins

Neonatal genital prolapse is a rare situation. This report presents a unique case involving a pair of premature female twins who both developed vaginal wall prolapse without any neurological deficits. Multiple factors such as selective intrauterine growth restriction, feeding intolerance, extrauterine growth retardation, and elevated intra-abdominal pressure after birth may have contributed to the development of this phenomenon. Notably, the severity of prolapse was more pronounced in the twin with lower birth weight and smaller for gestational age. After a five-month follow-up period, the twins' prolapsed vaginal wall fully retracted due to a combination of conservative treatment and enhanced nutritional support.

Handling of human milk to prevent acquired cytomegalovirus infection in Japanese neonatal intensive care units: The first nationwide survey

BACKGROUND

Human milk (HM) has been proven to provide immunological and nutritional advantages to neonates; however, acquired cytomegalovirus (CMV) infection can be associated with raw HM. In Japan, there are no standardized guidelines concerning HM handling. This cross-sectional survey was performed to reveal specific trends in HM handling in neonatal intensive care units (NICUs) in Japan.

METHODS

A questionnaire was sent to 255 NICUs participating in the Japanese Neonatologist Association in May 2020. It involved HM handling practices, such as maternal screening, pasteurization, storage, and the workforce.

RESULTS

Of 255 NICUs, 174 (67.8%) responded to the survey. Maternal CMV screening was carried out in 37 units (22.2%), and CMV inactivation in HM was performed in 44 units (26.5%). For CMV inactivation, a freeze-thawing method was employed in about 90% of units. In 70% of units providing CMV inactivation, CMV inactivation was conducted regardless of bodyweight and corrected gestational age of infants until the infants' discharge. Acquired CMV infection in preterm neonates was observed in 43 units (25.7%) in the survey period.

CONCLUSION

A wide range of HM handling practices are used in Japanese NICUs. A national guideline for handling HM in NICUs should be created to promote the infection control of CMV.

Treatment of preterm brain injury via gut-microbiota-metabolite-brain axis

BACKGROUND

Brain injury in preterm infants potentially disrupts critical structural and functional connective networks in the brain. It is a major cause of neurological sequelae and developmental deficits in preterm infants. Interesting findings suggest that the gut microbiota (GM) and their metabolites contribute to the programming of the central nervous system (CNS) during developmental stages and may exert structural and functional effects throughout the lifespan.

AIM

To summarize the existing knowledge of the potential mechanisms related to immune, endocrine, neural, and blood-brain barrier (BBB) mediated by GM and its metabolites in neural development and function.

METHODS

We review the recent literature and included 150 articles to summarize the mechanisms through which GM and their metabolites work on the nervous system. Potential health benefits and challenges of relevant treatments are also discussed.

RESULTS

This review discusses the direct and indirect ways through which the GM may act on the nervous system. Treatment of preterm brain injury with GM or related derivatives, including probiotics, prebiotics, synbiotics, dietary interventions, and fecal transplants are also included.

CONCLUSION

This review summarizes mechanisms underlying microbiota-gut-brain axis and novel therapeutic opportunities for neurological sequelae in preterm infants. Optimizing the initial colonization and microbiota development in preterm infants may represent a novel therapy to promote brain development and reduce long-term sequelae.

Infant massage as a stress management technique for parents of hospitalized extremely preterm infants

Mothers of infants born extremely preterm requiring prolonged medical intervention in the Neonatal Intensive Care Unit (NICU) are at high risk of developing stress. Parent-administered infant massage is a well-established, safe intervention for preterm infants with many developmental benefits, but the published literature has mostly examined its impact on infants and parents through self-reported or observational measures of stress. The aim of this study was to measure salivary cortisol, a biomarker for stress, in extremely preterm infants and their mothers immediately pre and post parent-administered infant massage in order to detect potential changes in physiologic stress. Twenty-two mother-infant dyads completed massage education with a physical or occupational therapist. All dyads provided salivary cortisol samples via buccal swab immediately pre- and post-massage at the second session. Of mothers determined to be "cortisol responders" (15/22), salivary cortisol levels were lower after massage (pre-minus post-level: -26.47 ng/dL, [CI = -4.40, -48.53], p = .016, paired t-test). Our primary findings include a clinically significant decrease (as measured by percent change) in maternal cortisol levels immediately post parent-administered massage, indicating decreased physiological stress. Integration of infant massage into NICU clinical practice may support maternal mental health, but further powered studies are necessary to confirm findings.

Nordic survey showed wide variation in discharge practices for very preterm infants

AIM

We aimed to describe clinical practices and criteria for discharge of very preterm infants in Nordic neonatal units.

METHODS

Medical directors of all 89 level-2 and level-3 units in Denmark, Finland, Iceland, Norway and Sweden were invited by e-mail to complete a web-based multiple-choice survey with the option to make additional free-text comments.

RESULTS

We received responses from 83/89 units (93%). In all responding units, discharge readiness was based mainly on clinical assessment with varying criteria. In addition, 36% used formal tests of cardiorespiratory stability and 59% used criteria related to infant weight or growth. For discharge with feeding tube, parental ability to speak the national language or English was mandatory in 45% of units, with large variation among countries. Post-discharge home visits and video-consultations were provided by 59% and 51%, respectively. In 54% of units, parental preparation for discharge were not initiated until the last two weeks of hospital stay.

CONCLUSION

Discharge readiness was based mainly on clinical assessment, with criteria varying among units despite similar population characteristics and care structures. This variation indicates a lack of evidence base and may unnecessarily delay discharge; further studies of this matter are needed. Earlier parental preparation and use of interpreters might facilitate earlier discharge.

Effects of white noise on preterm infants in the neonatal intensive care unit: A meta-analysis of randomised controlled trials

AIM

To critically assess the effects of white noise on the pain level, weight gain and vital signs (heart rate, respiratory rate and oxygen saturation) of preterm infants in neonatal intensive care units (NICUs).

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

Ten databases (PubMed, Cochrane Library, Embase, Web of Science, CINAHL, PsycINFO, SinoMed, China National Knowledge Infrastructure, VIP and Wanfang Data) were systematically reviewed from inception to July 2022. Two reviewers evaluated the risk of bias separately using the Cochrane Collaboration criteria and extracted data using a predesigned information form.

RESULTS

The meta-analysis included eight eligible RCTs. According to statistical analysis, white noise significantly affected the pain level, weight gain, heart rate, respiratory rate and oxygen saturation in preterm infants. Regardless of the outcome measurement timing, gestational age and birth weight of preterm infants, subgroup analysis demonstrated that white noise reduced the pain level, heart rate and respiratory rate and promoted weight gain in preterm infants in NICUs.

CONCLUSION

White noise is a practical and potentially useful therapy for premature neonates in NICUs. No Patient or Public Contribution.

Modeling Developmental Changes in Caffeine Clearance Considering Differences between Pre- and Postnatal Period

Taguchi et al. reported that postmenstrual age (PMA) is a promising factor in describing and understanding the developmental change of caffeine (CAF) clearance. The aim of the present study was to quantify how developmental changes occur and to determine the effect of the length of the gestational period on CAF clearance. We performed a nonlinear mixed effect model (NONMEM) analysis and evaluated the fit of six models. A total of 115 samples were obtained from 52 patients with a mean age of 34.3 ± 18.2 d. The median values of gestational age (GA) and postnatal age (PNA) were 196 and 31 d, respectively. Serum CAF levels corrected for dose per body surface area (BSA) (C/D ratioBSA) were dependent on PMA rather than PNA, which supports the findings of a previous study. NONMEM analysis provided the following final model of oral clearance: CL/F = 0.00603∙WT∙∙0.877GA ≤ 196 L/h. This model takes into account developmental changes during prenatal and postnatal periods separately. The model successfully described the variation in clearance of CAF. Our findings suggest that the dosage of CAF in preterm infants should be determined based not only on body weight (WT) but also on both PNA and GA.

Maternal Wellbeing Five Years after a Very Preterm Delivery: Prevalence and Influencing Factors in a European Cohort

(1) Background: Mothers of very preterm (VPT) infants may experience psychological symptoms compromising long-term emotional wellbeing. This study describes the emotional wellbeing of mothers of five-year-old children born VPT. We assess the association between sociodemographic, perinatal and neonatal characteristics, and the child's health and development at five years old and maternal emotional wellbeing. (2) Methods: Data are from the prospective European "Effective Perinatal Intensive Care in Europe" (EPICE) and subsequent "Screening for Health In very Preterm infantS in Europe" (SHIPS) projects including births <32 weeks' gestational age in 11 countries in 2011/12. Data were abstracted from obstetric and neonatal records. At five years old, 2605 mothers answered a parental questionnaire including the Mental Health Inventory-5 (MHI-5). Associations between sociodemographic and health characteristics and the mother's MHI-5 score were investigated using multilevel multivariate linear regression analysis with the country modelled as a random effect and inverse probability weighting to correct for attrition bias. (3) Results: The mean MHI-5 score was 71.3 (SD 16.7) out of 100 (highest emotional wellbeing) with a variation among countries from 63.5 (SD 16.8; Poland) to 82.3 (SD 15.8; the Netherlands). MHI-5 scores were significantly lower for mothers whose child had a severe health problem, developmental, or speech delay, for multiparous and single mothers, and when at least one of the parents was unemployed. (4) Conclusions: The emotional wellbeing of mothers of VPT infants differs between European countries. Identifying sociodemographic characteristics and child's health and developmental conditions that affect maternal emotional wellbeing may help to identify groups of mothers who need special assistance to cope with consequences of the delivery of a VPT child.

Personalized Evidence-Based Management of Patent Ductus Arteriosus in Preterm Infants

There is no universal consensus on management of patent ductus arteriosus (PDA) in preterm infants and it varies significantly worldwide, even among the clinicians within units. The decision to treat requires a thorough understanding of the clinical status of the patient, clinical evaluation of PDA, echocardiographic diagnosis, and hemodynamic impact of ductal shunt on the pulmonary and systemic circulation. In this article, updated evidence on the efficacy and adverse effects of pharmacological treatment options and expectant management are presented, while highlighting the long-term benefits of PDA treatment remains equivocal and controversial. The authors propose a schematic targeted PDA treatment approach based on gestational and chronological age for practical clinical use, and they emphasize important future directions including advancement in PDA device closure techniques, diagnostic echo-parameters, hemodynamic evaluation to assess the impact on other organs, and understanding the long-term outcomes.

Effects of Complete Oral Motor Intervention and Nonnutritive Sucking Alone on the Feeding Performance of Premature Infants: A Systematic Review and Meta-Analysis

We explore the effect of complete oral motor intervention (OMI) and nonnutritive sucking (NNS) alone on oral feeding in preterm infants through a meta-analysis. We searched the Embased, Medline, Cochrane Library, and Web of Science databases for randomized controlled trials up to 8 August 2023, based on established selection criteria. Quality evaluations of the studies were carried out by applying both the Cochrane risk of bias assessment tool and the Jadad scale. The outcome measures of three clinical indicators included transition time to oral feeding, weight gain, and hospitalization duration. We conducted a meta-analysis using a random-effects model to determine the pooled effect sizes, expressed as standardized mean differences (SMDs) and their corresponding confidence intervals (CIs). Additionally, we undertook a subgroup analysis and meta-regression to investigate any potential moderating factors. Eight randomized controlled trials with 419 participants were selected. Meta-analysis revealed that receiving a complete OMI had significantly reduced transition time compared with those receiving NNS alone in preterm newborns (SMD, -1.186; 95% CI, -2.160 to -0.212, p = 0.017). However, complete OMI had no significant effect on shortened hospitalization duration (SMD, -0.394; 95% CI, -0.979 to 0.192, p = 0.188) and increased weight gain (SMD, 0.346; 95% CI, -0.147 to 0.838, p = 0.169) compared with NNS alone. In brief, a complete OMI should not be replaced by NNS alone. However, we were unable to draw decisive conclusions because of the limitations of our meta-analysis. Future well-designed randomized controlled trials are necessary to confirm our conclusion.

State of the Art of Probiotic Use in Neonatal Intensive Care Units in French-Speaking European Countries

The effectiveness of probiotics in reducing the incidence of necrotizing enterocolitis has been supported by a very large number of studies. However, the utilization of probiotics in preterm infants remains a topic of debate. This study aims to assess the rate of probiotic use in European neonatal intensive care units (NICUs), compare administration protocols, and identify barriers and concerns associated with probiotic use. An online questionnaire was distributed via email to European NICUs between October 2020 and June 2021. Different questions related to the frequency of probiotic use were proposed. Data on probiotic administration protocols and reasons for non-utilization were collected. The majority of responses were from France and Switzerland, with response rates of 85% and 89%, respectively. A total of 21% of French NICUs and 100% of Swiss NICUs reported routine probiotic use. There was significant heterogeneity in probiotic administration protocols, including variations in probiotic strains, administration, and treatment duration. The main obstacles to routine probiotic use were the absence of recommendations, lack of consensus on strain selection, insufficient scientific evidence, and concerns regarding potential adverse effects. The rate of routine probiotic administration remains low in European NICUs, with heterogeneity among protocols. Further trials are necessary to elucidate optimal treatment modalities and ensure safety of administration.

XIII International Conference on Kangaroo Mother Care - Different opinions, experiences and related KMC issues: Good practices, stabilisation concept, nutrition and basic respiratory support

AIM

This study aimed to summarise the views and experiences of the participants in the workshop of the XIII International Conference on Kangaroo Mother Care (KMC).

METHODS

The results of the discussions held during the workshop of the XIII International Conference on KMC were summarised. There were 152 participants from 47 countries. Four main KMC topics were discussed: good practices, immediate implementation, nutrition and basic ventilation.

RESULTS

Several agreements were reached, namely that professional societies and governments should develop official recommendations to promote KMC as standard care for preterm and low birth weight infants and that parents should be involved as active caregivers in neonatal care units. Moreover, the criteria for referring community-born infants to KMC require standardisation. Important inequalities in resource availability among high-, middle- and low-income countries were recognised for all topics. Specific needs were identified for parenteral nutrition and fortifiers, nasal continuous positive airway pressure (nCPAP) and oxygen blenders, which are rarely available in low- and middle-income countries. Immediate implementation of KMC was discussed as a new concept. Its benefits were recognised, but its application has some variability.

CONCLUSION

Adequate preterm care requires a basic neonatal package, including KMC, nCPAP, immediate management protocols and adequate nutrition and feeding strategies. The differences in resources among high-, middle- and low-income countries highlight the wide disparities in neonatal care according to the place of birth.

Erythrocyte transfusions are associated with retinopathy of prematurity in extremely low gestational age newborns

AIM

Retinopathy of prematurity (ROP) is a major morbidity in preterm infants causing visual impairment including blindness. Prevention and timely treatment are critical. We investigated the potential role of red blood cell (RBC) transfusions as risk factor for ROP development.

METHODS

Retrospective cohort study of data from 68 tertiary level neonatal intensive care units in Germany. Preterm infants born at 22 + 0 to 28 + 6 weeks of gestation between January 2009 and December 2021 were enrolled.

RESULTS

We included n = 12 565 infants. Prevalence of any ROP was 49.2% with most infants being diagnosed with stage 1 (21.5%) and 2 disease (17.2%). ROP stage 3 was present in 10.2%, stage 4 in 0.3%, and ROP requiring treatment in 6.6%. Infants with ROP had significantly more frequently a history of RBC transfusions. Adjusting for confounders, RBC transfusions were associated with increased odds of ROP (OR 1.4, p < 0.001), ROP progression (OR 2.1, p < 0.01) and ROP requiring treatment (OR 3.6, p < 0.001). Restrictive transfusion approaches correlated with decreased (OR 0.7, p < 0.001), liberal regimes with increased odds (OR 1.2, p = 0.001).

CONCLUSION

The present study confirmed an association of RBC transfusions and ROP. Our findings emphasise the need for anaemia prevention and critical re-evaluation of transfusion practices in preterm infants.

Analysis of trends in retinopathy of prematurity over 5 years in a tertiary neonatal intensive care unit

AIM

The aim of the study was to look at the incidence and trend of retinopathy of prematurity (ROP) between 2017 and 2021 in a tertiary neonatal intensive care unit (NICU) in Australia and to compare potential modifiable risk factors of ROP between preterm infants who required treatment for ROP and who did not need treatment.

METHODS

This retrospective study used the data of newborn infants who were <31 weeks gestational age (GA) or birth weight (BW) of <1250 g born between 2017 and 2021 at a tertiary NICU in Australia (n = 261). Univariate analysis using t test for continuous data, Fischer exact test for categorical data and multiple logistic regression analysis were undertaken to identify any significant differences between two groups.

RESULTS

A total number of 261 infants were studied. 55.9% of infants developed any type of ROP (146 infants out of 261 infants), type 1 ROP was 5.4% (14 out of 261) and aggressive ROP (AROP) was 3% (8 out of 261). Out of 146 infants who were diagnosed with ROP, 22 (15%) of them required treatment. Mean GA for those who underwent ROP treatment was 25.6 (±1.47) weeks and for those who did not require treatment was 27.6 (±1.95) weeks. The mean BWs for those who needed treatment was 764 (±189.32) g and for those who did not need treatment was 1039 (±306.06) g. The mean duration of invasive ventilation for infants with ROP requiring treatment and those who did not require treatment were 23.95 (±22.41) days and 9.89 (±17.2) days. The total duration of oxygen requirement was 235.54 (±160.5) days and 121.11 (±117.34) days for those who needed treatment and those who did not need treatment respectively. Among infants who required treatment for ROP, 68.18% required blood transfusion whereas among those who did not need treatment, 24.19% required blood transfusion.

CONCLUSION

Lower GA, lower BW, longer duration of invasive ventilation, longer total duration of oxygen requirement and blood transfusion in first 2 weeks of life were significant in preterm infants who required treatment for ROP compared with those who did not.

Selective modulation of monocyte and neutrophil responses with activated protein C in preterm infants

BACKGROUND

Inflammation is associated with many disorders of preterm infants including periventricular leukomalacia, chronic lung disease, and necrotizing enterocolitis. Activated protein c (APC) has shown positive immunomodulatory effects.

OBJECTIVES

We aimed to study neutrophil and monocyte function in response to lipopolysaccharide (LPS) and APC stimulation ex vivo in preterm infants <32 weeks gestation over the first week of life compared to neonatal and adult controls.

METHODS

Peripheral blood was taken on day 1, 3, and 7 and stimulated with LPS in the absence or presence of APC. Expression of toll-like receptor 4 (TLR4) and CD11b and reactive oxygen intermediate (ROI) release from neutrophils and monocytes was examined by flow cytometry.

RESULTS

LPS induced neutrophil ROI in adults and preterm infants and was significantly reduced by APC. Baseline and LPS-induced monocyte ROI production in preterm neonates was increased compared to adult and term controls. Neutrophil TLR4 baseline expression was higher in term controls compared to preterm infants.

CONCLUSION

Increased systemic ROI release in preterm infants may mediate tissue damage, ROI was reduced by APC. However, due to the high risk of hemorrhage further examination of APC mutant forms with anti-inflammatory but decreased anticoagulant properties is merited.

Postural Control Measurements to Predict Future Motor Impairment in Preterm Infants: A Systematic Review

Preterm infants are more likely to demonstrate developmental delays than fullterm infants. Postural measurement tools may be effective in measuring the center of pressure (COP) and asymmetry, as well as predicting future motor impairment. The objective of this systematic review was to evaluate existing evidence regarding use of pressure mats or force plates for measuring COP and asymmetry in preterm infants, to determine how measures differ between preterm and fullterm infants and if these tools appropriately predict future motor impairment. The consulted databases included PubMed, Embase, Scopus, and CINAHL. The quality of the literature and the risk of bias were assessed utilizing the ROB2: revised Cochrane risk-of bias tool. Nine manuscripts met the criteria for review. The postural control tools included were FSA UltraThin seat mat, Conformat Pressure-Sensitive mat, Play and Neuro-Developmental Assessment, and standard force plates. Studies demonstrated that all tools were capable of COP assessment in preterm infants and support the association between the observation of reduced postural complexity prior to the observation of midline head control as an indicator of future motor delay. Postural measurement tools provide quick and objective measures of postural control and asymmetry. Based on the degree of impairment, these tools may provide an alternative to standardized assessments that may be taxing to the preterm infant, inaccessible to therapists, or not sensitive enough to capture motor delays.

Association between bronchopulmonary dysplasia and death or neurodevelopmental impairment at 3 years in preterm infants without severe brain injury

Objective

We investigated the association between bronchopulmonary dysplasia (BPD) and 3 years death or neurodevelopmental impairment (NDI) in very preterm infants without severe brain injury.

Method

Our prospective cohort study recruited preterm infants who were born prior to 32 weeks of gestational age and survived in the neonatal intensive care unit until 36 weeks of corrected age. Upon reaching 3 years of age, each infant was assessed for death or NDI such as cerebral palsy, cognitive deficit, hearing loss, and blindness. Correlations between BPD and death or NDI were determined using multiple logistic regression analyses adjusted for confounding factors.

Result

A total of 1,417 infants without severe brain injury who survived until 36 weeks of corrected age were initially enrolled in the study. Over the study period, 201 infants were lost to follow-up and 5 infants were excluded. Our final dataset, therefore, included 1,211 infants, of which 17 died after 36 weeks of corrected age and 1,194 were followed up to 3 years of age. Among these infants, 337 (27.8%) developed BPD. Interestingly, by 3 years of age, BPD was demonstrated to be independently associated with death or NDI, with an adjusted odds ratio of 1.935 (95% confidence interval: 1.292-2.899, p = 0.001), in preterm infants without severe neonatal brain injury.

Conclusion

Our findings indicate that BPD is strongly associated with death or NDI in preterm infants without severe neonatal brain injury at 3 years of age. Further research is needed to understand the mechanisms linking the development of BPD with death or NDI and whether appropriate treatment of BPD may ameliorate or prevent the development of neurological complications.

Combining Cardiorespiratory Signals and Video-Based Actigraphy for Classifying Preterm Infant Sleep States

The classification of sleep state in preterm infants, particularly in distinguishing between active sleep (AS) and quiet sleep (QS), has been investigated using cardiorespiratory information such as electrocardiography (ECG) and respiratory signals. However, accurately differentiating between AS and wake remains challenging; therefore, there is a pressing need to include additional information to further enhance the classification performance. To address the challenge, this study explores the effectiveness of incorporating video-based actigraphy analysis alongside cardiorespiratory signals for classifying the sleep states of preterm infants. The study enrolled eight preterm infants, and a total of 91 features were extracted from ECG, respiratory signals, and video-based actigraphy. By employing an extremely randomized trees (ET) algorithm and leave-one-subject-out cross-validation, a kappa score of 0.33 was achieved for the classification of AS, QS, and wake using cardiorespiratory features only. The kappa score significantly improved to 0.39 when incorporating eight video-based actigraphy features. Furthermore, the classification performance of AS and wake also improved, showing a kappa score increase of 0.21. These suggest that combining video-based actigraphy with cardiorespiratory signals can potentially enhance the performance of sleep-state classification in preterm infants. In addition, we highlighted the distinct strengths and limitations of video-based actigraphy and cardiorespiratory data in classifying specific sleep states.