Mothers' acceptability of using novel technology with video and audio recording during newborn resuscitation: A cross-sectional survey

OBJECTIVE

This study aims to assess the acceptability of a novel technology, MAchine Learning Application (MALA), among the mothers of newborns who required resuscitation.

SETTING

This study took place at Bharatpur Hospital, which is the second-largest public referral hospital with 13 000 deliveries per year in Nepal.

DESIGN

This is a cross-sectional survey.

DATA COLLECTION AND ANALYSIS

Data collection took place from January 21 to February 13, 2022. Self-administered questionnaires on acceptability (ranged 1-5 scale) were collected from participating mothers. The acceptability of the MALA system, which included video and audio recordings of the newborn resuscitation, was examined among mothers according to their age, parity, education level and technology use status using a stratified analysis.

RESULTS

The median age of 21 mothers who completed the survey was 25 years (range 18-37). Among them, 11 mothers (52.4%) completed their bachelor's or master's level of education, 13 (61.9%) delivered first child, 14 (66.7%) owned a computer and 16 (76.2%) carried a smartphone. Overall acceptability was high that all participating mothers positively perceived the novel technology with video and audio recordings of the infant's care during resuscitation. There was no statistical difference in mothers' acceptability of MALA system, when stratified by mothers' age, parity, or technology usage (p>0.05). When the acceptability of the technology was stratified by mothers' education level (up to higher secondary level vs. bachelor's level or higher), mothers with Bachelor's degree or higher more strongly felt that they were comfortable with the infant's care being video recorded (p = 0.026) and someone using a tablet when observing the infant's care (p = 0.046). Compared with those without a computer (n = 7), mothers who had a computer at home (n = 14) more strongly agreed that they were comfortable with someone observing the resuscitation activity of their newborns (71.4% vs. 14.3%) (p = 0.024).

CONCLUSION

The novel technology using video and audio recordings for newborn resuscitation was accepted by mothers in this study. Its application has the potential to improve resuscitation quality in low-and-middle income settings, given proper informed consent and data protection measures are in place.

Differential gene expression in two consecutive pregnancies between same sex siblings and implications on maternal constraint

The objective of this study was to investigate how placental gene expression differs in two consecutive pregnancies in same sex siblings, and its possible association with the "maternal constraint" hypothesis. Material was gathered from the BASIC study (Biological, Affect, Stress, Imaging, and Cognition in Pregnancy and the Puerperium), a population based prospective study that was started in 2009 in Uppsala. Over 900 specimens of placenta biopsies were collected and out of these 10 women gave birth twice, to the same sex child, and were included in this study. The total RNA was isolated and prepared from frozen villous tissue from the placenta and further analyzed by use of Ion AmpliSeq Human Transcriptome Gene Expression kit. A total of 234 genes differed significantly between the first and second pregnancy placentas, when adjusting for delivery mode, maternal BMI and gestational age. Of special interest was the down-regulated group of genes in the second pregnancy. Exemplified by Pentraxin 3, SRY-Box Transcription Factor 9, and Serum Amyloid A1, which all were associated with biological processes involved in the immune system and inflammation. Further, protein-protein interaction analysis visualized them as hub genes interacting with several of the other differentially expressed genes. How these altered gene expressions affect maternal constraint during pregnancy needs further validation in lager study cohorts and also future validation in functional assays.

Combined maternal central adiposity measures in relation to infant birth size

Improvement of prenatal identification of large-for-gestational-age (LGA) infants could lower the risk for adverse outcomes. Therefore, we sought to evaluate the association of a combination of maternal waist circumference (WC) and abdominal fat depths with infant birth size. A cohort study including 1240 women was performed between 2015 and 2018 at Uppsala University Hospital, Sweden. Maternal WC was measured at the first antenatal visit, and visceral (VF) and subcutaneous (SCF) fat depths by ultrasound at the second-trimester anomaly scan. Waist circumference, VF, and SCF were categorized as low or high (cut-offs WC ≥ 88 cm, VF ≥ 54 mm, SCF ≥ 21 mm). Outcomes were birth weight standard deviation score (BWSDS) and LGA (BWSDS > 90th and > 97th percentile). Secondary outcome was small-for-gestational-age (SGA, BWSDS < 10th and < 3rd percentile). Univariate analysis of variance and logistic regression analyses were performed adjusted for maternal weight, height, parity, smoking, country of birth, pregestational diabetes, and chronic hypertension. For both high and low WC, high VF was positively associated with BWSDS and LGA. There was no association with SGA. The results did not demonstrate any value of the combination of WC and fat depth measures in predicting infant birth size but suggested VF as a marker for large infants.

Maternal early mid-pregnancy adiponectin in relation to infant birth weight and the likelihood of being born large-for-gestational-age

This study aimed to evaluate the association of maternal adiponectin with infant birth size in 1349 pregnant women at Uppsala University Hospital, Sweden. The mean age of the women was 31.0 years, and 40.9% were nulliparous. Maternal early mid-pregnancy adiponectin was measured in microgram/mL. Linear regression models were performed to evaluate the association between adiponectin and infant birth weight. Logistic regression models were used to evaluate adiponectin in relation to the odds of giving birth to an infant large-for-gestational-age (LGA, infant birth weight standard deviation score > 90th percentile). Adjustments were made for early pregnancy BMI and diabetes mellitus. Prior adjustments, adiponectin was inversely associated with infant birth weight (β - 17.1, 95% confidence interval (CI) - 26.8 to - 7.4 g, P < 0.001), and one microgram/mL increase in adiponectin was associated with a 9% decrease in the odds of giving birth to an LGA infant (odds ratio 0.91, CI 0.85-0.97, P = 0.006). The associations did not withstand in the adjusted models. We found a significant interaction between adiponectin and infant sex on birth size. This interaction was driven by an inverse association between maternal adiponectin and birth size in female infants, whereas no such association was found in males.

The Optimal State Scoring Tool: guidance for interdisciplinary care of infants with severe bronchopulmonary dysplasia and its relation to linear growth

OBJECTIVE

Infants with severe bronchopulmonary dysplasia (sBPD) have complex medical courses. We developed the clinician-rated Optimal State Scoring Tool (OSST) that measures factors relevant to clinical improvement of sBPD and investigated preliminary validity using linear growth outcome and OSST scores in sBPD patients.

METHODS

Tool development process and pilot findings are provided for 13 patients evaluated longitudinally. OSST scores, length measurements, and steroid dependency values were obtained. Changes in OSST scores and lengths were examined using linear mixed-effect models.

RESULTS

OSST scores were significantly correlated with linear growth (95% CI 0.36, 0.57). The steroid-dependent group showed significantly slower rate of linear growth (95% CI 0.74, 1.05) and slower rate of increase in OSST scores (95% CI 0.99, 2.13) compared to the non-steroid-dependent group, with the OSST showing the largest effect size.

CONCLUSION

Pilot data reflect promising evidence for OSST construct validity in monitoring clinical outcomes in sBPD patients.

Neonatal outcomes of elective labor induction in low-risk term pregnancies

The rate of labor induction has increased in recent years. The results of previously conducted studies examining associations between elective induction of labor (IOL) and neonatal outcomes have been contradictory. The aim of this study was to examine the intrinsic neonatal risks following IOL. We conducted a population-based cohort study, including all women with recorded low-risk singleton pregnancies at a gestational age between 37 + 0 and 41 + 6 weeks in Sweden from 1999 to 2017. Data were collected from the Swedish Medical Birth register. Two study groups were compared-the elective induction group with the spontaneous labor onset group. The results showed that the rate of elective IOL increased from 7.2% in 1999 to 16.4% in 2017. Elective IOL was associated with a higher OR for chorioamnionitis, bacterial sepsis, intracranial hemorrhage, assisted ventilation, hyperbilirubinemia, APGAR < 7 at 5 min, and neonatal seizures compared to deliveries with spontaneous labor onset. Regarding mortality outcomes, no significant differences were shown between the groups for either early term or full-term deliveries. We conclude that IOL is associated with neonatal complications, although causality could not be established in this observational study. It is important to be aware of the increased risk and perform IOL with caution.

Equally Good Neurological, Growth, and Health Outcomes up to 6 Years of Age in Moderately Preterm Infants Who Received Exclusive vs. Fortified Breast Milk-A Longitudinal Cohort Study

Moderately preterm infants (32-36 weeks of gestational age) have an increased risk of worse health and developmental outcomes compared to infants born at term. Optimal nutrition may alter this risk. The aim of this study was to investigate the neurological, growth, and health outcomes up to six years of age in children born moderately preterm who receive either exclusive or fortified breast milk and/or formula in the neonatal unit. In this longitudinal cohort study, data were collected for 142 children. Data were collected up to six years of age via several questionnaires containing questions about demographics, growth, child health status, health care visits, and the Five to Fifteen Questionnaire. Data on the intake of breast milk, human milk fortification, formula, and growth during hospitalization were collected from the children's medical records. No statistically significant differences in neurological outcomes, growth, or health at six years of age were found between the two groups (exclusive breast milk, n = 43 vs. fortified breast milk and/or formula, n = 99). There is a need for research in larger populations to further assess potential effects on health and developmental outcomes when comparing the use of exclusive versus fortified breast milk for moderately preterm infants during neonatal hospitalization.

Early Mid-pregnancy Blood-Based Proteins as Possible Biomarkers of Increased Infant Birth Size in Sex-Stratified Analyses

The objective of this study was to evaluate the associations of 92 maternal blood-based proteins with increased infant birth size. The study was performed at the Uppsala University Hospital, Sweden, and included 857 mother and child dyads. The mean age of the women was 30.3 years, and 53.2% were nulliparous. Blood samples were collected at mean 18 + 2 weeks' gestation, and the Olink cardiovascular II panel was used to measure 92 proteins, either known to be or suspected to be markers of cardiovascular and inflammatory disease in humans. Multiple linear regression models adjusted for maternal age, parity, pre-conception BMI, height, and smoking were performed to evaluate the association of each individual protein with infant birth size. We also performed sex-stratified analyses. Eight proteins (Matrix metalloproteinase-12 (MMP-12), Prostasin (PRSS8), Adrenomedullin (ADM), Pappalysin-1 (PAPP-A), Angiotensin-converting enzyme 2 (ACE2), Sortilin (SORT1), Lectin-like oxidized LDL receptor 1 (LOX-1), and Thrombomodulin (TM)) were associated with infant birth size after false discovery rate adjustment. In the analyses including only female infants, ten proteins (MMP-12, Growth/differentiation factor 2 (GDF-2), PRSS8, SORT1, ADM, Interleukin-1 receptor antagonist protein (IL-1ra), Leptin (LEP), ACE2, TM, and Tumor necrosis factor receptor superfamily member 11A (TNFRSF11A)) were associated with infant birth size. Two proteins (PAPP-A and PRSS8) were associated with infant birth size among male infants. Our study suggests several proteins as potential biomarkers for increased birth weight, and our findings could act as a base for future research to identify new potential markers that could be added to improve screening for large infants.

Usability, acceptability and feasibility of a novel technology with visual guidance with video and audio recording during newborn resuscitation: a pilot study

OBJECTIVE

Inadequate adherence to resuscitation for non-crying infants will have poor outcome and thus rationalise a need for real-time guidance and quality improvement technology. This study assessed the usability, feasibility and acceptability of a novel technology of real-time visual guidance, with sound and video recording during resuscitation.

SETTING

A public hospital in Nepal.

DESIGN

A cross-sectional design.

INTERVENTION

The technology has an infant warmer with light, equipped with a tablet monitor, NeoBeat and upright bag and mask. The tablet records resuscitation activities, ventilation sound, heart rate and display time since birth. Healthcare providers (HCPs) were trained on the technology before piloting.

DATA COLLECTION AND ANALYSIS

HCPs who had at least 8 weeks of experience using the technology completed a questionnaire on usability, feasibility and acceptability (ranged 1-5 scale). Overall usability score was calculated (ranged 1-100 scale).

RESULTS

Among the 30 HCPs, 25 consented to the study. The usability score was good with the mean score (SD) of 68.4% (10.4). In terms of feasibility, the participants perceived that they did not receive adequate support from the hospital administration for use of the technology, mean score (SD) of 2.44 (1.56). In terms of acceptability, the information provided in the monitor, that is, time elapsed from birth was easy to understand with mean score (SD) of 4.60 (0.76).

CONCLUSION

The study demonstrates reasonable usability, feasibility and acceptability of a technological solution that records audio visual events during resuscitation and provides visual guidance to improve care.

Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants

Aim

The aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants.

Methods

We used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case–control study. For every infant with severe IVH (grade 3 or peri‐ventricular haemorrhagic infarction), one IVH‐free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case–control pairs).

Results

Total sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH.

Conclusion

Our results suggest a relationship between sodium‐rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion‐related factor.

Amino acid infusions in umbilical artery catheters enhance protein administration in infants born at extremely low gestational age

AIM

It is challenging to provide extremely low gestational age neonates (ELGANs) with adequate protein supply. This study aimed to investigate whether amino acid (AA) infusion in the umbilical artery catheter (UAC) in ELGANs is safe and enhances protein supply and growth.

METHOD

A before and after study including infants born <27 weeks, treated in Uppsala, Sweden, during 2004-2007, compared those receiving normal saline/10% dextrose in water with those receiving AA infusion in the UAC. Data were retrieved from the Extremely Preterm Infants in Sweden Study, hospital records and the Swedish Neonatal Quality Register. Group comparisons, univariate and multivariate analyses were conducted.

RESULTS

AA group (n = 41, females 39%) received on average approximately 0.3 g/kg/day more protein during the first postnatal week, compared to control group (n = 30, females 40%) (unstandardised coefficient (B) 0.26, p .001) but no difference was noted during 8-28 postnatal days. The type of infusion was not associated with growth variables. The incidence of neonatal morbidities and UAC-related thrombosis did not differ between the groups.

CONCLUSION

AA infusions in the UACs in ELGANs is safe and enhances protein supply during the first postnatal week. However, this practice is not associated with growth during the first 28 postnatal days.

Associations between capillary glucose during pregnancy and childhood growth to the age of five: a cohort study

The objective of this study was to evaluate the relationship between random capillary glucose levels in healthy pregnant women and infant size at birth and childhood growth to the age of five years. This population-based cohort study comprised 10,937 healthy mother-child dyads. Data on highest maternal random capillary glucose level during pregnancy and sequential anthropometric data on their children during the first five years of life were gathered from the Uppsala County Mother and Child Cohort. Statistical analyses were performed with linear regression and linear mixed effect regression models. We found that higher glucose level during pregnancy was associated with higher weight z-score (β 0.10, 95% confidence interval (CI) 0.08-0.11), length z-score (β 0.05, 95% CI 0.03-0.07) and BMI z-score (β 0.09, 95% CI 0.07-0.12) at birth, adjusted for maternal BMI and country of birth, smoking during pregnancy and parity. The association did not remain at 1½, 3, 4 and 5 years of age. There was a positive relationship between higher glucose level during pregnancy and a decrease in weight z-score, height z-score and BMI z-score from birth to 5 years of age. In conclusion, higher random capillary glucose levels in pregnant healthy women were associated with greater infant size at birth, as well as decreased growth velocity in early childhood.

Early Hyperglycemia in Very Preterm Infants Is Associated with Reduced White Matter Volume and Worse Cognitive and Motor Outcomes at 2.5 Years

INTRODUCTION

Hyperglycemia in very preterm infants is associated with increased morbidity and mortality. We aimed to investigate potential associations between early hyperglycemia, neonatal cerebral magnetic resonance imaging (MRI), and neurodevelopment at 2.5 years.

METHODS

The study population included 69 infants with gestational age (GA) 22.3-31.9 weeks (n = 29 with GA <28 weeks), born 2011-2014. Plasma glucose concentrations during the first week were checked according to clinical routines. Hyperglycemia was defined as glucose concentrations above 8.3 mmol/L (150 mg/dL) and above 10 mmol/L (180 mg/dL), respectively, categorized as the highest glucose days 0-2, number of days above 8.3 and 10 mmol/L, and prolonged (yes/no) 2 days or more above 8.3 and 10 mmol/L. The MRI analysis included morphological assessment, regional brain volumes, and assessment of apparent diffusion coefficient (ADC). Neurodevelopmental impairment (NDI) developed in 13 of 67 infants with available outcomes, of which 57 were assessed with the Bayley-III. Univariate and multiple linear and logistic regressions were performed with adjustments for GA, birth weight z-scores, and illness severity expressed as days on mechanical ventilation.

RESULTS

Hyperglycemia above 8.3 mmol/L and 10 mmol/L was present in 47.8% and 31.9% of the infants. Hyperglycemia correlated independently with lower white matter volume, but not with other regional brain volumes, and was also associated with lower ADC values in white matter. Hyperglycemia also correlated with lower Bayley-III cognitive and motor scores in infants with GA <28 weeks, but there was no significant effect on NDI.

CONCLUSION

Early hyperglycemia is associated with white matter injury and poorer neurodevelopment in very preterm infants.

Nordic study on human milk fortification in extremely preterm infants: a randomised controlled trial-the N-forte trial

INTRODUCTION

The mortality rate of extremely low gestational age (ELGA) (born <gestational week 28+0) infants remains high, and severe infections and necrotising enterocolitis (NEC) are common causes of death. Preterm infants receiving human milk have lower incidence of sepsis and NEC than those fed a bovine milk-based preterm formula. Despite this, fully human milk fed ELGA infants most often have a significant intake of cow's milk protein from bovine-based protein fortifier. The aim of this study is to evaluate whether the supplementation of human milk-based, as compared with bovine-based, nutrient fortifier reduces the prevalence of NEC, sepsis and mortality in ELGA infants exclusively fed with human milk.

METHODS AND ANALYSIS

A randomised-controlled multicentre trial comparing the effect of a human breast milk-based fortifier with a standard bovine protein-based fortifier in 222-322 ELGA infants fed human breast milk (mother's own milk and/or donor milk). The infants will be randomised to either fortifier before reaching 100 mL/kg/day in oral feeds. The intervention, stratified by centre, will continue until the target postmenstrual week 34+0. The primary outcome is a composite of NEC, sepsis or death. Infants are characterised with comprehensive clinical and nutritional data collected prospectively from birth until hospital discharge. Stool, urine, blood and breast milk samples are collected for analyses in order to study underlying mechanisms. A follow-up focusing on neurological development and growth will be performed at 2 and 5.5 years of age. Health economic analyses will be made.

ETHICS AND DISSEMINATION

The study is conducted according to ICH/GCP guidelines and is approved by the regional ethical review board in Linköping Sweden (Dnr 2018/193-31, Dnr 2018/384-32). Results will be presented at scientific meetings and published in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

The study was registered with ClinicalTrials.gov NCT03797157, 9 January 2019.

Neonatal hyperglycaemia is associated with worse neurodevelopmental outcomes in extremely preterm infants

OBJECTIVE

To assess the associations between neonatal hyperglycaemia and insulin treatment, versus long-term neurodevelopmental outcomes in children born extremely preterm.

DESIGN AND SETTING

Observational national cohort study (Extremely Preterm Infants in Sweden Study) using prospectively and retrospectively collected data. Neurodevelopmental assessment was performed at 6.5 years of age.

PATIENTS

533 infants born <27 gestational weeks during 2004-2007; 436 survivors were assessed at 6.5 years.

OUTCOME MEASURES

Neurodevelopmental disability (NDD), survival without moderate to severe NDD, Wechsler Intelligence Scale for Children IV Full scale intelligence quotient (WISC-IV FSIQ) and Movement Assessment Battery for Children 2 (MABC-2) total score.

RESULTS

Duration of neonatal hyperglycaemia >8 mmol/L was associated with WISC-IV scores-for each day with hyperglycaemia there was a decrease of 0.33 points (95% CI 0.03 to 0.62) in FSIQ. Neonatal hyperglycaemia >8 mmol/L occurring on 3 consecutive days was associated with lower MABC-2 scores (adjusted mean difference: -4.90; 95% CI -8.90 to -0.89). For each day with hyperglycaemia >8 mmol/L, there was a decrease of 0.55 points (95% CI 0.17 to 0.93) in MABC-2 total score. Insulin treatment was not associated with any of the outcome measures.

CONCLUSION

Neonatal hyperglycaemia >8 mmol/L was associated with lower intelligence scores and worse motor outcomes at 6.5 years of age. Insulin treatment was not associated with either worsened or improved neurodevelopmental outcomes. Randomised controlled trials are needed to clarify the role of insulin in treating hyperglycaemia in extremely preterm infants.

Association of maternal central adiposity measured by ultrasound in early mid pregnancy with infant birth size

We sought to investigate whether early mid pregnancy visceral and subcutaneous fat depths measured by ultrasound were associated with infant birth size, independent of early pregnancy BMI. A cohort study was performed at Uppsala University Hospital, Sweden, between 2015–2018. Visceral and subcutaneous fat depths were measured at the early second-trimester anomaly scan in 2498 women, giving birth to singleton, term infants. Primary outcomes were birthweight and LGA (birthweight standard deviation score > 90th percentile in the cohort). Linear and logistic regression models were used, adjusted for BMI, age, smoking, parity, maternal country of birth, gestational age and infant sex. A 5-mm increase in visceral fat depth was associated with an increase in birthweight of 8.3 g [95% confidence interval (CI) 2.5 − 14.1 g], after adjustments, and a 6% increase in the adjusted odds of having an infant born LGA (OR 1.06, CI 1.02–1.11). There was no association between subcutaneous fat depth and birthweight or LGA after covariate adjustments. Hence, visceral fat depth measured by ultrasound in early mid pregnancy was associated with excessive fetal growth, independent of early pregnancy BMI, and may be useful in models for predicting LGA infants.

Second Trimester Maternal Leptin Levels Are Associated with Body Mass Index and Gestational Weight Gain but not Birth Weight of the Infant

INTRODUCTION

Obesity is increasing among the pregnant population. Leptin has an important role in the regulation of energy balance and hunger. The aim of this study was to investigate the association between maternal leptin levels with maternal obesity, gestational weight gain (GWG), single nucleotide polymorphisms (SNPs) within the leptin gene, and the age-adjusted birth weight of the child.

MATERIAL AND METHODS

Maternal leptin levels (n = 740) and SNPs (n = 504) were analyzed in blood samples taken within the Uppsala Biobank of Pregnant women at pregnancy weeks 16-19.

RESULTS

Maternal leptin levels differed significantly between body mass index (BMI) groups. Normal weight women had the lowest median leptin levels and levels increased with each BMI group. Leptin SNP genotype was not associated with leptin levels or BMI. There was also no association between maternal leptin levels and age-adjusted birth weight of the child except for a negative association between leptin levels and birth weight in the morbid obese group.

DISCUSSION/CONCLUSION

Maternal BMI was identified as the best positive explanatory factor for maternal leptin levels. Leptin was a strong positive explanatory factor for GWG. Birth weight of children of uncomplicated pregnancies was, however, dependent on maternal height, BMI, GWG, and parity but not leptin levels, except for in morbid obese women where a negative association between maternal leptin levels and birth weight was found. We speculate that this indicates altered placental function, not manifested in pregnancy complication. We conclude that maternal leptin levels do not affect the birth weight of the child more than BMI, GWG, and parity.

Parents experiences of feeding their extremely preterm children during the first 2-3 years - A qualitative study

AIM

To describe parents of extremely preterm children experiences regarding feeding of their children during the first 3 years of the child's life.

METHODS

This is a qualitative study involving interviews conducted with 12 parents of nine children who had been cared for at one neonatal intensive care unit in Sweden. The interviews were conducted between May and September 2018; the data were analysed using qualitative content analysis.

RESULTS

All parents experienced some difficulties with their child's eating development and described feeding their child as sometimes both difficult and frustrating. Variation in when these difficulties arose made it hard for the parents to obtain the individual support they wanted and needed. Parents experienced a need for more support - from both staff members and parents with similar experiences - during and after their child's stay at the NICU.

CONCLUSION

All parents participating in the study experienced difficulties during some phase of their child's feeding development. They expressed the need for more specialised support both during and after their child's time at the hospital.

Large-for-gestational-age phenotypes and obesity risk in adulthood: a study of 195,936 women

While there is evidence that being born large-for-gestational-age (LGA) is associated with an increased risk of obesity later in life, the data are conflicting. Thus, we aimed to examine the associations between proportionality at birth and later obesity risk in adulthood. This was a retrospective study using data recorded in the Swedish Birth Register. Anthropometry in adulthood was assessed in 195,936 pregnant women at 10-12 weeks of gestation. All women were born at term (37-41 weeks of gestation). LGA was defined as birth weight and/or length ≥2.0 SDS. Women were separated into four groups: appropriate-for-gestational-age according to both weight and length (AGA - reference group; n = 183,662), LGA by weight only (n = 4,026), LGA by length only (n = 5,465), and LGA by both weight and length (n = 2,783). Women born LGA based on length, weight, or both had BMI 0.12, 1.16, and 1.08 kg/m² greater than women born AGA, respectively. The adjusted relative risk (aRR) of obesity was 1.50 times higher for those born LGA by weight and 1.51 times for LGA by both weight and height. Length at birth was not associated with obesity risk. Similarly, women born LGA by ponderal index had BMI 1.0 kg/m² greater and an aRR of obesity 1.39 times higher than those born AGA. Swedish women born LGA by weight or ponderal index had an increased risk of obesity in adulthood, irrespective of their birth length. Thus, increased risk of adult obesity seems to be identifiable from birth weight and ignoring proportionality.

Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks

AIM

Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.

METHODS

A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.

RESULTS

Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.

CONCLUSION

An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.

High birthweight was not associated with altered body composition or impaired glucose tolerance in adulthood

AIM

To investigate whether a high birthweight was associated with an increased proportion of body fat or with impaired glucose tolerance in adulthood.

METHODS

Our cohort comprised 27 subjects with birthweights of 4500 g or more, and 27 controls with birthweights within ±1 standard deviation scores, born at Uppsala University Hospital 1975-1979. The subjects were 34-40 years old at the time of study. Anthropometric data was collected, and data on body composition was obtained by air plethysmography and bioimpedance and was estimated with a three-compartment model. Indirect calorimetry, blood sampling for fasting insulin and glucose as well as a 75 g oral glucose tolerance test were also performed. Insulin sensitivity was assessed using homoeostasis model assessment 2 and Matsuda index.

RESULTS

There were no differences in body mass index, body composition or insulin sensitivity between subjects with a high birthweight and controls.

CONCLUSION

In this cohort of adult subjects, although limited in size, those born with a moderately high birthweight did not differ from those with birthweights within ±1 standard deviation scores, regarding body composition or glucose tolerance.

Changing diagnostic criteria for gestational diabetes in Sweden - a stepped wedge national cluster randomised controlled trial - the CDC4G study protocol

Background

The optimal criteria to diagnose gestational diabetes mellitus (GDM) remain contested. The Swedish National Board of Health introduced the 2013 WHO criteria in 2015 as a recommendation for initiation of treatment for hyperglycaemia during pregnancy. With variation in GDM screening and diagnostic practice across the country, it was agreed that the shift to new guidelines should be in a scientific and structured way. The aim of the Changing Diagnostic Criteria for Gestational Diabetes (CDC4G) in Sweden (www.cdc4g.se/en) is to evaluate the clinical and health economic impacts of changing diagnostic criteria for GDM in Sweden and to create a prospective cohort to compare the many long-term outcomes in mother and baby under the old and new diagnostic approaches.

Methods

This is a stepped wedge cluster randomised controlled trial, comparing pregnancy outcomes before and after the switch in GDM criteria across 11 centres in a randomised manner. The trial includes all pregnant women screened for GDM across the participating centres during January–December 2018, approximately two thirds of all pregnancies in Sweden in a year. Women with pre-existing diabetes will be excluded. Data will be collected through the national Swedish Pregnancy register and for follow up studies other health registers will be included.

Discussion

The stepped wedge RCT was chosen to be the best study design for evaluating the shift from old to new diagnostic criteria of GDM in Sweden. The national quality registers provide data on the whole pregnant population and gives a possibility for follow up studies of both mother and child. The health economic analysis from the study will give a solid evidence base for future changes in order to improve immediate pregnancy, as well as long term, outcomes for mother and child.

Trial registration

CDC4G is listed on the ISRCTN registry with study ID ISRCTN41918550 (15/12/2017)

Growth patterns during early childhood in children born small for gestational age and moderate preterm

Today we lack knowledge if size at birth and gestational age interact regarding postnatal growth pattern in children born at 32 gestational weeks or later. This population-based cohort study comprised 41,669 children born in gestational weeks 32–40 in Uppsala County, Sweden, between 2000 and 2015. We applied a generalized least squares model including anthropometric measurements at 1.5, 3, 4 and 5 years. We calculated estimated mean height, weight and BMI for children born in week 32 + 0, 35 + 0 or 40 + 0 with birthweight 50^th percentile (standardized appropriate for gestational age, sAGA) or 3^rd percentile (standardized small for gestational age, sSGA). Compared with children born sAGA at gestational week 40 + 0, those born sAGA week 32 + 0 or 35 + 0 had comparable estimated mean height, weight and BMI after 3 years of age. Making the same comparison, those born sSGA week 32 + 0 or 35 + 0 were shorter and lighter with lower estimated mean BMI throughout the whole follow-up period. Our findings suggest that being born SGA and moderate preterm is associated with short stature and low BMI during the first five years of life. The association seemed stronger the shorter gestational age at birth.

Preterm Birth is Associated With Increased Blood Pressure in Young Adult Women

Background While there is some evidence of elevated blood pressure later in life in preterm survivors, data on adult women are still lacking. Thus, we assessed the associations between preterm birth and blood pressure in young adult women. Methods and Results We studied 5232 young adult women who volunteered for military service in Sweden between 1990 and 2007. Anthropometric and clinic blood pressure data were collected during the medical examination at the time of conscription. There was a progressive decline in systolic and diastolic blood pressures, as well as in mean arterial pressure, with increasing gestational age. Women born preterm had an adjusted increase in systolic blood pressure of 3.8 mm Hg (95% CI , 2.5-5.1; P<0.0001) and mean arterial pressure of 1.9 mm Hg (95% CI , 0.9-2.8; P=0.0001) compared with young women born at term. Rates of systolic hypertension were also considerably higher in young women born preterm (14.0% versus 8.1%, P<0.0001), as were rates of isolated systolic hypertension. The adjusted relative risk of systolic hypertension in women born preterm was 1.72 (95% CI , 1.26-2.34; P<0.001) that of women born at term or post-term, but there was no significant difference in the risk of diastolic hypertension (adjusted relative risk, 1.60; 95% CI , 0.49-5.20). Conclusions Young adult women born preterm display elevated systolic blood pressure and an increased risk of hypertension compared with peers born at term or post-term.

Postnatal growth in children born small for gestational age with and without smoking mother

BACKGROUND

Maternal smoking impairs fetal growth; however, if postnatal growth differs between children born small for gestational age (SGA) with smoking and non-smoking mother is unknown.

METHODS

Cohort-study of term born children born appropriate for gestational age with non-smoking mother (AGA-NS, n = 30,561), SGA (birthweight <10^th percentile) with smoking mother (SGA-S, n = 171) or SGA with non-smoking mother (SGA-NS, n = 1761). Means of height and weight measurements, collected at birth, 1.5, 3, 4, and 5 years, were compared using a generalized linear mixed effect model. Relative risks of short stature (<10^th percentile) were expressed as adjusted risk ratios (aRR).

RESULTS

At birth, children born SGA-S were shorter than SGA-NS, but they did not differ in weight. At 1.5 years, SGA-S had reached the same height as SGA-NS. At 5 years, SGA-S were 1.1 cm taller and 1.2 kg heavier than SGA-NS. Compared with AGA-NS, SGA-S did not have increased risk of short stature at 1.5 or 5 years, while SGA-NS had increased risk of short stature at both ages; aRRs 3.0 (95% CI 2.6;3.4) and 2.3 (95% CI 2.0;2.7), respectively.

CONCLUSIONS

Children born SGA-S have a more rapid catch-up growth than SGA-NS. This may have consequences for metabolic and cardiovascular health in children with smoking mothers.

Maternal smoking early in pregnancy is associated with increased risk of short stature and obesity in adult daughters

We assessed anthropometry in 22,421 adult daughters in association with their mothers’ tobacco smoking early in pregnancy (at their first antenatal visit) in Sweden, particularly their risk of short stature and obesity. Adult daughters were grouped by maternal smoking levels during pregnancy: Non-smokers (58.5%), Light smokers (24.1%; smoked 1–9 cigarettes/day), and Heavier smokers (17.4%; smoked ≥10 cigarettes/day). Anthropometry was recorded on the adult daughters at approximately 26.0 years of age. Obesity was defined as BMI ≥30 kg/m², and short stature as height more than two standard deviations below the population mean. Daughters whose mothers were Light and Heavier smokers in early pregnancy were 0.8 cm and 1.0 cm shorter, 2.3 kg and 2.6 kg heavier, and had BMI 0.84 kg/m² and 1.15 kg/m² greater, respectively, than daughters of Non-smokers. The adjusted relative risk of short stature was 55% higher in women born to smokers, irrespectively of smoking levels. Maternal smoking had a dose-dependent association with obesity risk, with offspring of Heavier smokers 61% and of Light smokers 37% more likely to be obese than the daughters of Non-smokers. In conclusion, maternal smoking in pregnancy was associated with an increased risk of short stature and obesity in their adult daughters.

Reduced rate of treated retinopathy of prematurity after implementing lower oxygen saturation targets

OBJECTIVE

To evaluate an implementation of lower oxygen saturation targets with retinopathy of prematurity (ROP) as primary outcome, in infants at the lowest extreme of prematurity.

STUDY DESIGN

Retrospective cohort including infants born at 22-25 weeks of gestation in 2005-2015 (n = 325), comparing high (87-93%) and low (85-90%) targets; infants transferred early were excluded from the main analysis to avoid bias.

RESULTS

Overall survival was 76% in high saturation era, and 69% in low saturation era (p = .17). Treatment-requiring ROP was less common in low saturation group (14% vs 28%, p < .05) with the most prominent difference in the most immature infants. Including deceased infants in the analysis, necrotizing enterocolitis was more frequent in low saturation era (21% vs 10%, p < .05).

CONCLUSIONS

Implementing lower saturation targets resulted in a halved incidence of treatment-requiring ROP; the most immature infants seem to benefit the most. An association between lower oxygenation and necrotizing enterocolitis cannot be excluded.

High birth weight was associated with increased radial artery intima thickness but not with other investigated cardiovascular risk factors in adulthood

AIM

This study investigated whether a high birth weight was associated with increased risk factors for cardiovascular disease when Swedish adults reached 34-40.

METHODS

We studied 27 subjects born at Uppsala University Hospital in 1975-1979, weighing at least 4500 g, and compared them with 27 controls selected by the Swedish National Board of Welfare with birth weights within ±1 standard deviations scores and similar ages and gender. The study included body mass index (BMI), blood pressure, lipid profile, haemoglobin A1c (HbA1c), C-reactive protein (CRP) and high-frequency ultrasound measurements of intima-media thickness, intima thickness (IT) and intima:media ratio of the carotid and radial arteries.

RESULTS

Subjects with a high birth weight did not differ from controls with regard to BMI, blood pressure, lipid profile, high-sensitivity CRP, HbA1c or carotid artery wall dimensions. However, their radial artery intima thickness was 37% greater than the control group and their intima:media ratio was 44% higher.

CONCLUSION

Our findings indicate that a high birth weight was associated with increased radial artery intima thickness, but not with other investigated cardiovascular risk factors, at 34-40 years of age. The clinical implications of these findings should be investigated further, especially in subjects born with a very high birth weight.

Hyperglycemia in Extremely Preterm Infants-Insulin Treatment, Mortality and Nutrient Intakes

OBJECTIVE

To explore the prevalence of hyperglycemia and the associations between nutritional intakes, hyperglycemia, insulin treatment, and mortality in extremely preterm infants.

STUDY DESIGN

Prospectively collected data from the Extremely Preterm Infants in Sweden Study (EXPRESS) was used in this study and included 580 infants born <27 gestational weeks during 2004-2007. Available glucose measurements (n = 9850) as well as insulin treatment and nutritional data were obtained retrospectively from hospital records for the first 28 postnatal days as well as 28- and 70-day mortality data.

RESULTS

Daily prevalence of hyperglycemia >180 mg/dL (10 mmol/L) of up to 30% was observed during the first 2 postnatal weeks, followed by a slow decrease in its occurrence thereafter. Generalized additive model analysis showed that increasing parenteral carbohydrate supply with 1 g/kg/day was associated with a 1.6% increase in glucose concentration (P < .001). Hyperglycemia was associated with more than double the 28-day mortality risk (P < .01). In a logistic regression model, insulin treatment was associated with lower 28- and 70-day mortality when given to infants with hyperglycemia irrespective of the duration of the hyperglycemic episode (P < .05).

CONCLUSIONS

Hyperglycemia is common in extremely preterm infants throughout the first postnatal month. Glucose infusions seem to have only a minimal impact on glucose concentrations. In the EXPRESS cohort, insulin treatment was associated with lower mortality in infants with hyperglycemia. Current practices of hyperglycemia treatment in extremely preterm infants should be reevaluated and assessed in randomized controlled clinical trials.

Sodium supply influences plasma sodium concentration and the risks of hyper- and hyponatremia in extremely preterm infants

BACKGROUND

Hyper- and hyponatremia occur frequently in extremely preterm infants. Our purpose was to investigate plasma sodium (P-Na) concentrations, the incidence of hyper- and hyponatremia, and the impact of possible predisposing factors in extremely preterm infants.

METHODS

In this observational study, we analyzed data from the EXtremely PREterm (< 27 wk.) infants in Sweden Study (EXPRESS, n = 707). Detailed nutritional, laboratory, and weight data were collected retrospectively from patient records.

RESULTS

Mean ± SD P-Na increased from 135.5 ± 3.0 at birth to 144.3 ± 6.1 mmol/l at a postnatal age of 3 d and decreased thereafter. Fifty percent of infants had hypernatremia (P-Na > 145 mmol/l) during the first week of life while 79% displayed hyponatremia (P-Na < 135 mmol/l) during week 2. Initially, the main sodium sources were blood products and saline injections/infusions, gradually shifting to parenteral and enteral nutrition towards the end of the first week. The major determinant of P-Na and the risks of hyper- and hyponatremia was sodium supply. Fluid volume provision was associated with postnatal weight change but not with P-Na.

CONCLUSION

The supply of sodium, rather than fluid volume, is the major factor determining P-Na concentrations and the risks of hyper- and hyponatremia.

Association Between Preterm Birth and Lower Adult Height in Women

We examined whether being born preterm was associated with changes in adult anthropometry in women. We assessed data on 201,382 women (born in 1973-1988) from the Swedish Birth Register. The mean age was 26.0 years. Of the women in our cohort, 663 were born very preterm (<32 weeks of gestation), 8,247 were born moderately preterm (at least 32 weeks but <37 weeks), and 192,472 were born at term (37-41 weeks). Subgroup analyses were carried out among siblings and also after adjustment for maternal anthropometric data. Statistical tests were 2-sided. Decreasing gestational age was associated with lower height (-1.1 mm per week of gestation; P < 0.0001), so that women who were born very preterm were on average 12 mm shorter than women who were born moderately preterm (P < 0.0001) and 17 mm shorter than women born at term (P < 0.0001). Compared with women who were born at term, those who were born very preterm had 2.9 times higher odds of short stature (<155.4 cm), and those born moderately preterm had 1.43 times higher odds. Subgroup analyses showed no differences between women born moderately preterm and those born at term but accentuated differences from women born very preterm. Among siblings (n = 2,388), very preterm women were 23 mm shorter than those born at term (P = 0.003), with a 20-mm difference observed in subgroup analyses (n = 27,395) that were adjusted for maternal stature (P < 0.001). A shorter final height was associated with decreasing gestational age, and this association was particularly marked in women born very preterm.

Body Mass Index, Overweight, and Obesity in Swedish Women Born Post-term

BACKGROUND

There is increasing evidence that post-term birth (≥42 weeks of gestation) is associated with adverse long-term outcomes. We assessed whether women born post-term displayed increased risk of overweight and obesity in adulthood.

METHODS

Data were collected at first antenatal visit (~10-12 weeks of gestation) on singleton Swedish women aged ≥18 years in 1991-2009 (mean age 26.1 years), who were born post-term (n = 27 153) or at term (37-41 weeks of gestation; n = 184 245). Study outcomes were evaluated for continuous associations with gestational age. Stratified analyses were carried out comparing women born post-term or at term. Analyses were also run with a 2-week buffer between groups to account for possible errors in gestational age estimation, comparing women born very post-term (≥43 weeks of gestation; n = 5761) to those born within a narrower term window (38-40 weeks of gestation; n = 130 110).

RESULTS

Increasing gestational age was associated with greater adult weight and body mass index (BMI). Stratified analyses showed that women born post-term were 0.5 kg heavier and had BMI 0.2 kg/m(2) greater than those born at term. Differences were more marked between women born very post-term (≥43 weeks) vs. a narrower term group (38-40 weeks): 1.0 kg and 0.3 kg/m(2) . The adjusted relative risks of overweight/obesity and obesity in women born very post-term were 1.13 and 1.12 times higher, respectively, than in those born at term.

CONCLUSIONS

Post-term birth is associated with greater BMI and increased risk of overweight and obesity in adulthood, particularly among women born ≥43 weeks of gestation.

Computer-aided nutrition - Effects on nutrition and growth in preterm infants <32 weeks of gestation

BACKGROUND & AIMS

Preterm infants are often discharged from the NICU with suboptimal growth. The aim of our intervention study was to determine if a computer-aided nutrition calculation program could help to optimise the nutrition and secondary improve the growth of preterm infants.

METHODS

Intake of macro- and micronutrients and anthropometric data was collected in 78 preterm infants with GA ≤32+0 from birth to postnatal week 7. The nutrition of 43 preterm infants was ordinated with help of the program Nutrium™​ (IG). Before the introduction of the program 35 consecutive preterm infants served as control group (CG). Their data were collected in retrospect.

RESULTS

Amino acid, carbohydrate, fluid intake and total energy intake were statistically different at all time points. Fatty acid intake was statistically different expect for week 2 and 4. Similar differences were found for magnesium, calcium and phosphorus, zinc, copper and selenium. In contrast vitamin intake was higher in the control group. At birth there were no differences between the groups with respect to anthropometric data. Weight, length and head circumference (HC) SDS decreased in both groups from birth to day 28 of life (CG -1.2 SDS; -1.2 SDS; -0.8 SDS vs IG -0.9 SDS; -0.8 SDS; -0.4 SDS). The infants in the CG showed until discharge a partial catch-up but remained below birth SDS for weight and length (-0.5 SDS; -0.9 SDS). In the IG, infants reached birth values for weight and length (-0.1 SDS; 0 SDS). For HC both groups showed similar values at the time point for birth and discharge (CG +0.3 SDS vs IG +0.5 SDS).

CONCLUSION

By using a computer-aided nutrition calculation program better postnatal growth was achieved. Nutritional intake was increased in respect to nearly all micro- and macronutrients. There were no adverse effects. In contrast there was a tendency of decreased incidence of BPD, infection rate and PDA.

Obesity rates in two generations of Swedish women entering pregnancy, and associated obesity risk among adult daughters

We examined changes in obesity rates in two generations of Swedish women entering pregnancy, and assessed the effects of maternal body mass index (BMI) on the risk of overweight or obesity among adult daughters. This study covered an intergenerational retrospective cohort of 26,561 Swedish mothers and their 26,561 first-born daughters. There was a 4-fold increase in obesity rates, which rose from 3.1% among women entering pregnancy in 1982–1988 to 12.3% among their daughters in 2000–2008 (p < 0.0001) when entering pregnancy. The greater the maternal BMI, the greater the odds of overweight and/or obesity among daughters. Underweight mothers had half the odds of having an overweight or obese daughter in comparison to mothers of normal BMI (p < 0.0001). In contrast, the odds ratio of obese mothers having obese daughters was 3.94 (p < 0.0001). This study showed a strong association between maternal obesity and the risk of obesity among their first-born daughters. In addition, we observed a considerable increase in obesity rates across generations in mother-daughter pairs of Swedish women entering pregnancy. Thus, it is important to have preventative strategies in place to halt the worsening intergenerational cycle of obesity.

Infants born large-for-gestational-age display slower growth in early infancy, but no epigenetic changes at birth

We evaluated the growth patterns of infants born large-for-gestational-age (LGA) from birth to age 1 year compared to those born appropriate-for-gestational-age (AGA). In addition, we investigated possible epigenetic changes associated with being born LGA. Seventy-one newborns were classified by birth weight as AGA (10(th)-90(th) percentile; n = 42) or LGA (>90(th) percentile; n = 29). Post-natal follow-up until age 1 year was performed with clinical assessments at 3, 6, and 12 months. Genome-wide DNA methylation was analysed on umbilical tissue in 19 AGA and 27 LGA infants. At birth, LGA infants had greater weight (p < 0.0001), length (p < 0.0001), ponderal index (p = 0.020), as well as greater head (p < 0.0001), chest (p = 0.044), and abdominal (p = 0.007) circumferences than AGA newborns. LGA infants were still larger at the age of 3 months, but by age 6 months there were no more differences between groups, due to higher length and weight increments in AGA infants between 0 and 6 months (p < 0.0001 and p = 0.002, respectively). Genome-wide analysis showed no epigenetic differences between LGA and AGA infants. Overall, LGA infants had slower growth in early infancy, being anthropometrically similar to AGA infants by 6 months of age. In addition, differences between AGA and LGA newborns were not associated with epigenetic changes.

First-borns have greater BMI and are more likely to be overweight or obese: a study of sibling pairs among 26,812 Swedish women

BACKGROUND

A number of large studies have shown phenotypic differences between first-borns and later-borns among adult men. In this study, we aimed to assess whether birth order was associated with height and BMI in a large cohort of Swedish women.

METHODS

Information was obtained from antenatal clinic records from the Swedish National Birth Register over 20 years (1991-2009). Maternal anthropometric data early in pregnancy (at approximately 10-12 weeks of gestation) were analysed on 13,406 pairs of sisters who were either first-born or second-born (n=26,812).

RESULTS

Early in pregnancy, first-born women were of BMI that was 0.57 kg/m(2) (2.4%) greater than their second-born sisters (p<0.0001). In addition, first-borns had greater odds of being overweight (OR 1.29; p<0.0001) or obese (OR 1.40; p<0.0001) than second-borns. First-borns were also negligibly taller (+1.2 mm) than their second-born sisters. Of note, there was a considerable increase in BMI over the 18-year period covered by this study, with an increment of 0.11 kg/m(2) per year (p<0.0001).

CONCLUSIONS

Our study corroborates other large studies on men, and the steady reduction in family size may contribute to the observed increase in adult BMI worldwide.

A high birth weight is associated with increased risk of type 2 diabetes and obesity

BACKGROUND

The association between low birth weight and adult disease is well known. Less is known on long-term effects of high birth weight.

OBJECTIVE

This study aims to investigate whether a high birth weight increases risk for adult metabolic disease.

METHODS

Swedish term single births, 1973-1982 (n = 759,999), were studied to age 27.5-37.5 years using Swedish national registers. Hazard ratios (HRs) were calculated in relation to birth weight for type 2 diabetes, obesity, hypertension and dyslipidaemia.

RESULTS

Men with birth weights between 2 and 3 standard deviation score (SDS) had a 1.9-fold increased risk (HR 1.91, 95% confidence interval [CI] 1.25-2.90) of type 2 diabetes, whereas those with birth weights above 3 SDS had a 5.4-fold increased risk (HR 5.44, 95% CI 2.70-10.96) compared to men with birth weights between -2 and 2 SDS. The corresponding HRs for women were 0.60 (95% CI 0.40-0.91) and 1.71 (95% CI 0.85-3.43) for birth weights 2-3 SDS and >3 SDS, respectively. Men with birth weights between 2 and 3 SDS had a 1.5-fold increased risk (HR 1.47, 95% CI 1.22-1.77) of obesity. The corresponding risk for women was 1.3-fold increased (HR 1.32, 95% CI 1.19-1.46). For men and women with birth weights above 3 SDS, the risks of adult obesity were higher, HR 2.46 (95% CI 1.63-3.71) and HR 1.85 (95% CI 1.44-2.37), respectively.

CONCLUSIONS

A high birth weight, particularly very high, increases the risk of type 2 diabetes in male young adults. The risk of obesity increases with increasing birth weight in both genders.

Gene Expression in Placentas From Nondiabetic Women Giving Birth to Large for Gestational Age Infants

Gestational diabetes, obesity, and excessive weight gain are known independent risk factors for the birth of a large for gestational age (LGA) infant. However, only 1 of the 10 infants born LGA is born by mothers with diabetes or obesity. Thus, the aim of the present study was to compare placental gene expression between healthy, nondiabetic mothers (n = 22) giving birth to LGA infants and body mass index-matched mothers (n = 24) giving birth to appropriate for gestational age infants. In the whole gene expression analysis, only 29 genes were found to be differently expressed in LGA placentas. Top upregulated genes included insulin-like growth factor binding protein 1, aminolevulinate δ synthase 2, and prolactin, whereas top downregulated genes comprised leptin, gametocyte-specific factor 1, and collagen type XVII α 1. Two enriched gene networks were identified, namely, (1) lipid metabolism, small molecule biochemistry, and organismal development and (2) cellular development, cellular growth, proliferation, and tumor morphology.

Energy substrate metabolism in pyruvate dehydrogenase complex deficiency

Pyruvate dehydrogenase (PDH) deficiency is an inherited disorder of carbohydrate metabolism, resulting in lactic acidosis and neurological dysfunction. In order to provide energy for the brain, a ketogenic diet has been tried. Both the disorder and the ketogenic therapy may influence energy production. The aim of the study was to assess hepatic glucose production, lipolysis and resting energy expenditure (REE) in an infant, given a ketogenic diet due to neonatal onset of the disease. Lipolysis and glucose production were determined for two consecutive time periods by constant-rate infusions of [1,1,2,3,3-²H₅]-glycerol and [6,6-²H²]-glucose. The boy had been fasting for 2.5 h at the start of the sampling periods. REE was estimated by indirect calorimetry. Rates of glucose production and lipolysis were increased compared with those of term neonates. REE corresponded to 60% of normal values. Respiratory quotient (RQ) was increased, indicating a predominance of glucose oxidation. Blood lactate was within the normal range. Several mechanisms may underlie the increased rates of glucose production and lipolysis. A ketogenic diet will result in a low insulin secretion and reduced peripheral and hepatic insulin sensitivity, leading to increased production of glucose and decreased peripheral glucose uptake. Surprisingly, RQ was high, indicating active glucose oxidation, which may reflect a residual enzyme activity, sufficient during rest. Considering this, a strict ketogenic diet might not be the optimal choice for patients with PDH deficiency. We propose an individualised diet for this group of patients aiming at the highest glucose intake that each patient will tolerate without elevated lactate levels.

Perioperative nutrition in extremely preterm infants undergoing surgical treatment for patent ductus arteriosus is suboptimal

AIM

To evaluate perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriosus (PDA).

METHODS

This is a population-based study of extremely preterm infants born in Sweden during 2004-2007 and operated on for PDA. Data on perioperative nutrition were obtained from hospital records. All enteral and parenteral nutrients and blood products were used to calculate daily nutritional intakes, starting 3 days before and ending 3 days after surgery. Data are mean (95% confidence intervals).

RESULTS

Study infants (n = 140) had a mean gestational age (GA) of 24.8 weeks, and mean birth weight was 723 g. Energy and macronutrient intakes were below minimal requirements before, during and after PDA surgery. On the day of surgery, energy intake was 78 (74-81) kcal/kg/day, protein 2.9 (2.7-3.2) g/kg/day, fat 2.5 (2.3-2.7) g/kg/day and carbohydrate intake 10.7 (10.2-11.2) g/kg/day. Nutrition did not vary in relation to GA, but infants operated early (0-6 days after birth) received poorer nutrition than infants operated at older age. Fluid intake was 164 (159-169) mL/kg/day, and it did not vary during the week of surgery.

CONCLUSION

Perioperative nutrition in extremely preterm infants undergoing PDA surgery in Sweden is suboptimal and needs to be improved. The significance of malnutrition for outcome after PDA surgery remains unclear and requires further investigation.

Nutrient intakes independently affect growth in extremely preterm infants: results from a population-based study

AIM

To explore associations between energy and macronutrient intakes and early growth in extremely low gestational age (ELGA) infants.

METHODS

Retrospective population-based study of all ELGA infants (<27 weeks) born in Sweden during 2004-2007. Detailed data on nutrition and anthropometric measurements from birth to 70 days of postnatal age were retrieved from hospital records.

RESULTS

Study infants (n = 531) had a mean ± SD gestational age of 25.3 ± 1.1 weeks and a birth weight of 765 ± 170 g. Between 0 and 70 days, average daily energy and protein intakes were 120 ± 11 kcal/kg and 3.2 ± 0.4 g/kg, respectively. During this period, standard deviation scores for weight, length and head circumference decreased by 1.4, 2.3 and 0.7, respectively. Taking gestational age, baseline anthropometrics and severity of illness into account, lower energy intake correlated with lower gain in weight (r = +0.315, p < 0.001), length (r = +0.215, p < 0.001) and head circumference (r = +0.218, p < 0.001). Protein intake predicted growth in all anthropometric outcomes, and fat intake was positively associated with head circumference growth.

CONCLUSION

Extremely low gestational age infants received considerably less energy and protein than recommended and showed postnatal growth failure. Nutrient intakes were independent predictors of growth even after adjusting for severity of illness. These findings suggest that optimized energy and macronutrient intakes may prevent early growth failure in these infants.

Insulin resistance, a link between maternal overweight and fetal macrosomia in nondiabetic pregnancies

BACKGROUND/AIMS

During the last decades the number of large for gestational age infants delivered by nondiabetic mothers has increased. Our aim was to investigate to what extent fetal growth in nondiabetic pregnant women can be explained by rates of maternal energy substrate production and resting energy expenditure.

METHODS

Twenty nonsmoking pregnant women without impaired glucose tolerance and with a wide range of fetal weights (0.2-2.7 SDS) were investigated at 36 weeks of gestation. Maternal lipolysis, glucose production, resting energy expenditure, body composition and insulin resistance were assessed.

RESULTS

Median (range) glucose production rate was 805 (653-1,337) μmol/min and that of glycerol, reflecting lipolysis, was 214 (110-576) μmol/min. Multiple linear regression analysis showed that maternal fat mass explained 36% of the variation in insulin resistance, accounting for 62% of the variation in glucose production. Further, glucose production explained 31% of the variation in fetal weight. Resting energy expenditure explained 51% of the variation in estimated fetal weight.

CONCLUSION

Fetal weight is dependent on maternal glucose production, which is in turn determined by the degree of insulin resistance, induced in part by the maternal fat mass. The variation in maternal resting energy expenditure is closely related to fetal weight.

Gestational diabetes and offspring body disproportion

AIM

It has been demonstrated that females born large for gestational age (LGA) in weight but not length are at increased risk of being obese at childbearing age. We addressed the question whether women with gestational diabetes mellitus (GDM) are at increased risk of giving birth to such infants.

METHODS

Birth characteristics of 884,267 infants of non-diabetic mothers and 7817 of mothers with GDM were analysed. LGA was defined as birth weight or birth length >2 standard deviation scores for gestational age. Multiple logistic regression analysis was performed.

RESULTS

The odds ratio (OR) for a woman with GDM to give birth to an LGA infant that was heavy alone was four times increased (OR: 3.71, 95% CI: 3.41-4.04). Furthermore, in the population of mothers giving birth to LGA infants, the proportion heavy alone was 68% in the group of women with GDM compared with 64.4% in the group of non-diabetic women. The risks were independent of gender of the foetus.

CONCLUSION

Women with GDM have an almost four times higher risk of delivering an LGA infant that is heavy alone. The noted disproportion between weight and length in infants of such mothers may have an impact on the risk of later obesity.

Females born large for gestational age have a doubled risk of giving birth to large for gestational age infants

AIM

To analyse if females born large for gestational age (LGA) have an increased risk to give birth to LGA infants and to study anthropometric characteristics in macrosomic infants of females born LGA.

METHODS

The investigation was performed as an intergenerational retrospective study of women born between 1973 and 1983, who delivered their first infant between 1989 and 1999. Birth characteristics of 47,783 females, included in the Swedish Birth Register both as newborns and mothers were analysed. LGA was defined as >2 SD in either birth weight or length for gestational age. The infants were divided into three subgroups: born tall only, born heavy only and born both tall and heavy for gestational age. Multiple logistic and linear regression analyses were performed.

RESULTS

Females, born LGA with regard to length or weight, had a two-fold (adjusted OR 1.96, 95% Cl 1.54-2.48) increased risk to give birth to an LGA infant. Females, born LGA concerning weight only, had a 2.6 (adjusted OR 2.63, 95%, 1.85-3.75) fold increased risk of having an LGA offspring heavy only and no elevated risk of giving birth to an offspring that was tall only, compared to females born not LGA. In addition, maternal obesity was associated with a 2.5 (adjusted OR 2.56, 95%, 2.20-2.98) fold increased risk of having an LGA newborn, compared to mothers with normal weight.

CONCLUSION

Females, born LGA, have an increased risk to give birth to LGA infants, compared to mothers born not LGA. Maternal overweight increases this risk even further.

Energy substrate production in infants born small for gestational age

AIM

To investigate energy substrate production and its hormonal regulation in infants born small for gestational age.

METHODS

Eleven infants, aged 24.4 +/- 5.3 hour, were studied following a fast of 4.0 +/- 0.6 hour. Gestational age was 35.4 +/- 2.8 weeks and birth weight 1804 +/- 472 g (<-2 SD). Rates of glucose production and lipolysis were analyzed using [6,6-(2)H(2)]-glucose and [2-(13)C]-glycerol.

RESULTS

Plasma levels of glucose and glycerol were 4.1 +/- 1.1 mmol x L(-1) and 224 +/- 79 micromol x L(-1), respectively. Glucose appearance averaged 30.3 +/- 8.2 and glucose production rate 21.1 +/- 6.1 micromol x kg(-1) x minutes(-1). Glycerol production rate was 5.6 +/- 1.6 micromol x kg(-1) x minutes(-1), correlating strongly to birth weight (r = 0.904, p < 0.001). Of the glycerol produced, 55 +/- 22% was converted to glucose, corresponding to 8 +/- 3% of the glucose production.

CONCLUSIONS

Even though the infants could produce energy substrates, lipolysis was reduced and the glucose production was in the low end of the normal range compared with infants born appropriate for gestational age. The correlation between glycerol production and birth weight indicates that lipolysis depends on the amount of stored fat. Data on insulin and insulin-like growth factor binding protein 1 support the view that insulin sensitivity in these infants is reduced in the liver but increased peripherally.

Treatment of extreme hyperglycemia monitored with intracerebral microdialysis

OBJECTIVE

Description of a pediatric patient with hyperosmolar hyperglycemic nonketotic syndrome where the treatment was monitored with intracerebral microdialysis.

DESIGN

Case report.

SETTING

Intensive care unit at a university hospital.

PATIENT

An 11-yr-old boy with new-onset diabetes who presented with a blood glucose concentration of 100 mmol/L (1800 mg/dL) and a serum osmolality of 448 mOsm/kg.

INTERVENTIONS

Interventions included intracerebral and subcutaneous microdialysis as well as intracranial pressure monitoring during correction of the hyperosmolar condition. The strategy was to decrease osmolality by 1 mOsm.kg(-1).hr(-1) and blood glucose by 1.5 mmol.L(-1).hr(-1) (27 mg/dL).

MEASUREMENTS AND MAIN RESULTS

The concentrations of glucose in the subcutaneous dialysates corresponded to the blood glucose concentrations. The brain/subcutaneous glucose ratio varied between 0.20 and 1.28 (mean, 0.43; median, 0.4). When the blood glucose decreased quickly after steady state, the brain/subcutaneous ratio increased sharply, demonstrating that the normalization of glucose in the brain was slower than that in blood.

CONCLUSIONS

Microdialysis can be used to monitor the brain/subcutaneous glucose ratio in patients with extreme hyperglycemia. A rapid decrease in blood glucose increases the brain/subcutaneous glucose ratio, which may be a potential risk factor for osmotic brain edema. Microdialysis may prove to be a valuable tool in treatment management. The child made a full recovery.

Influence of perinatal factors on the onset of puberty in boys and girls: implications for interpretation of link with risk of long term diseases

The authors examined the hypothesis that perinatal factors influence the onset of puberty. Children born as singletons in Uppsala, Sweden, in 1973-1977 were followed for height development before and during their school years (through 16 years of age). In all, 62 children born after preeclampsia, 129 born prematurely, 90 born small for gestational age, 175 born large for gestational age, 49 born short for gestational age, and 38 born tall for gestational age were compared with 688 "normal" children. Differences in age and height at puberty onset and age at menarche were analyzed using the t test and analyses of covariance. For boys, the mean age at puberty onset did not differ between normal boys and those with perinatal factors. Boys born small or short for gestational age were 4 cm shorter than normal boys, and those born large for gestational age were 3 cm taller than normal boys. Among girls, patterns for differences in height were similar. Girls born small for gestational age were 5 months younger than normal girls at the onset of puberty and menarche. Patterns of early childhood growth seemed to explain the relations between these perinatal factors and height and age at puberty. The authors conclude that body size at birth affects stature at puberty; in girls, smallness for gestational age is associated with earlier puberty. Associations between intrauterine exposures and disease risk may be confounded by, or mediated through, effects on adolescence.