Growth Pattern of Preterm Neonates with Fetal Growth Restriction: A Prospective Cohort Study

OBJECTIVES

To compare the growth of preterm neonates with fetal growth restriction (FGR) and preterm neonates born appropriate-for-gestational-age (AGA) from birth to 12-18 mo of corrected age (CA).

METHODS

In this prospective cohort study, 85 preterm neonates with FGR and 85 gestation- and gender-matched AGA neonates were followed up from birth till 12-18 mo corrected age. Anthropometric indices were compared at specific time points and the risk factors for underweight status were analyzed.

RESULTS

Mean gestational age of the cohort was 32.8 ± 2.1 wk. Mean birth weight was 1414 ± 248 g in the FGR and 1806 ± 416 g in AGA neonates. At 12-18 mo of corrected age, a significantly greater proportion of FGR infants were wasted (24.3% vs. 7.2%, P = 0.005). A greater proportion of FGR infants were underweight (27% vs. 17.4%, P = 0.11), stunted (41.9% vs. 36.2%, P = 0.30), and microcephalic (27% vs. 23.1%, P = 0.36), although the differences were not statistically significant. Significant catch-up growth from 40 wk postmenstrual age (PMA) to 12-18 mo corrected age in weight (52.8% vs. 13.1%, P <0.001) and length (37.9% vs. 8.7%, P <0.001) was observed in the FGR neonates. The z-score of weight for age at 3 mo (adjusted OR 0.65, 95% CI: 0.52-0.8; P <0.001), the median time to full feeds (aOR: 1.10, 95% CI: 1.04-1.15; P = 0.001), and hypothyroidism (aOR 2.44, 95% CI: 1.46-4.08; P = 0.001), were independent predictors of underweight status at 12-18 mo.

CONCLUSIONS

At 12-18 mo of corrected age, a significantly greater proportion of preterm FGR neonates were wasted compared to AGA ones. The former also exhibited significantly greater catch-up growth than the latter.

Evaluation of levosimendan as treatment option in a large case-series of preterm infants with cardiac dysfunction and pulmonary hypertension

Levosimendan as a calcium-sensitizer is a promising innovative therapeutical option for the treatment of severe cardiac dysfunction (CD) and pulmonary hypertension (PH) in preterm infants, but no data are available analyzing levosimendan in cohorts of preterm infants. The design/setting of the evaluation is in a large case-series of preterm infants with CD and PH. Data of all preterm infants (gestational age (GA) < 37 weeks) with levosimendan treatment and CD and/or PH in the echocardiographic assessment between 01/2018 and 06/2021 were screened for analysis. The primary clinical endpoint was defined as echocardiographic response to levosimendan. Preterm infants (105) were finally enrolled for further analysis. The preterm infants (48%) were classified as extremely low GA newborns (ELGANs, < 28 weeks of GA) and 73% as very low birth weight infants (< 1500 g, VLBW). The primary endpoint was reached in 71%, without difference regarding GA or BW. The incidence of moderate or severe PH decreased from baseline to follow-up (24 h) in about 30%, with a significant decrease in the responder group (p < 0.001). The incidence of left ventricular dysfunction and bi-ventricular dysfunction decreased significantly from baseline to follow-up (24 h) in the responder-group (p = 0.007, and p < 0.001, respectively). The arterial lactate level decreased significantly from baseline (4.7 mmol/l) to 12 h (3.6 mmol/l, p < 0.05), and 24 h (3.1 mmol/l, p < 0.01).  Conclusion: Levosimendan treatment is associated with an improvement of both CD and PH in preterm infants, with a stabilization of the mean arterial pressure during the treatment and a significant decrease of arterial lactate levels. Future prospective trials are highly warranted. What is Known: • Levosimendan as a calcium-sensitizer and inodilator is known to improve the low cardiac output syndrome (LCOS), and improves ventricular dysfunction, and PH, both in pediatric as well as in adult populations. Data related to critically ill neonates without major cardiac surgery and preterm infants are not available. What is New: • This study evaluated the effect of levosimendan on hemodynamics, clinical scores, echocardiographic severity parameters, and arterial lactate levels in a case-series of 105 preterm infants for the first time. Levosimendan treatment in preterm infants is associated with a rapid improvement of CD and PH, an increase of the mean arterial pressure, and a significant decrease in arterial lactate levels, as surrogate marker for a LCOS. • How this study might affect research, practice, or policy. As no data are available regarding the use of levosimendan in this population, our results hopefully animate the research community to conduct future prospective trails analyzing levosimendan in randomized controlled trials (RCT) and observational control studies. Additionally, our results potentially motivate clinicians to introduce levosimendan as second second-line therapy in cases of severe CD and PH in preterm infants without improvement using standard treatment strategies.

Biomarkers of renal function in preterm neonates at 72h and 3weeks of life

OBJECTIVE

Serum levels of creatinine in neonates are quite variable and suffer interference from the immature kidney and maternal creatinine concentration. The aim of this study was to measure novel biomarkers of glomerular and tubular function in healthy preterm neonates at 72h and 3 weeks of life.

METHODS

Urine samples were collected in 40 preterm neonates with 28-34 incomplete weeks of gestational age. None of the participants had comorbidities, malformations and infections. The samples were collected at 72h of life and at 3 weeks after birth. Measurements of Calbindin, Collagen IV, FABP1, αGST, IP-10, KIM-1, Osteoactivin, Renin, TFF-3, TIMP-1, α-1-Microglobulin, Albumin, Clusterin, Cystatin C, EGF, Lipocalin-2/NGAL and Osteopontin were performed using panels 1 and 2 of multiplex kits of kidney injury. Data were analyzed using the software GraphPad Prism version 6.0.

RESULTS

The preterm neonates included 55% of males with gestational age of 30±1 weeks. The most frequent maternal condition associated with preterm birth was preeclampsia (80%). Molecules related to glomerular function showed a significant increase in the concentrations obtained at 3 weeks of life compared to 72h of life. Markers related to tubular injury (KIM-1 and NGAL) also showed an increase. On the other hand, cystatin C did not change.

CONCLUSION

The elevation of molecules related to glomerular function indicates an increase of glomerular filtration rate from 72h up until 3 weeks of life, which was not clearly detected with the measurement of cystatin C.

Which long line do we use in very low birth weight neonates; umbilical venous catheter or peripherally inserted central catheter?

BACKGROUND

Umbilical venous catheters (UVC) and peripherally inserted central catheters (PICC) are commonly used in preterms. UVC is cheap, easy to insert but has shorter dwell time. UVC is replaced after 7 days due to the risk of complications. This is associated with increased cost, work, and risk of nosocomial infections. The aim of this study was to determine the antenatal and postnatal factors that predict the need for a central line for more than 7 days, thus helping select between UVC or PICC on day 1 of life in babies ≤1500 grams.

METHODS

We retrospectively collected antenatal and postnatal data of VLBW neonates over a period of 1 year who needed CL during their NICU stay. We then divided them into two cohorts. Group 1: CL ≤7 days. Group 2: CL > 7 days.

RESULTS

Sepsis and catheter complications were lower with use of a single CL or duration being ≤7 days. Birth weight, incomplete/no antenatal steroids, need for resuscitation, low Apgar's, RDS, hs-PDA, and initiation of feeds beyond 24 hours of birth were significant. The score was devised based on factors found significant that had an acceptable AUC of 0.767 on ROC analysis with a score of 1 or above having 74.8% sensitivity and 67.7% specificity for prediction of need for CL > 7 days.

CONCLUSIONS

Birth weight ≤1000 grams, incomplete steroids and need for resuscitation at birth were predictive of the need of CL beyond seven days, on day one of life.

Metabolic changes in early neonatal life: NMR analysis of the neonatal metabolic profile to monitor postnatal metabolic adaptations

BACKGROUND

A major challenge from the moment a child is delivered is the adaptation to the extrauterine life, where rapid metabolic changes take place. The study of these changes during the first days of human life may assist in the understanding of the metabolic processes that occur at this critical period, which is likely to provide significant clinical insights. To date, metabolomics has become a powerful field, ideal for the monitoring of such dynamic variations, since it offers the possibility to identify alterations in metabolic profiles, even on daily basis.

METHODS

The study included 253 healthy newborns (GA 35 to 40 weeks) from the region of Western Greece. Urine samples were collected immediately after birth and at the third day of life. NMR-based metabolomics was used to compare the metabolic urinary profiles of newborns from the first and third day of their life, assessing the impact of six perinatal factors; delivery mode, prematurity, maternal smoking, gender, nutrition and neonatal jaundice.

RESULTS

Analysis of urine metabolic fingerprint from the first and third day of life, coupled with multivariate statistics, provides insights into the details of early life metabolic profile differentiation. Αt the third day of life metabolic adaptations are evident, as many differences were noted in urine of healthy neonates within the first 72 h postpartum. Trends in differentiation of metabolites levels between the two groups, late preterm and term newborns, have been also observed.

CONCLUSIONS

Newborn's urine metabolic profiles confirmed the rapid changes in their metabolism after birth. Further, ongoing research will enable us to develop one reference model of urinary metabolomics in healthy newborns during the period of adaptation to the extra-uterine life.

Pertussis hospitalizations among term and preterm infants: clinical course and vaccine effectiveness

BACKGROUND

Pertussis causes severe disease in young unvaccinated infants, with preterms potentially at highest risk. We studied pertussis in hospitalized infants as related to gestational age (GA) and vaccination history.

METHODS

Medical record data of 0-2y old patients hospitalized for pertussis during 2005-2014 were linked to vaccination data. Multivariable logistic regression was used to study the association between GA and vaccination history on the clinical disease course. We compared vaccine effectiveness (VE) against hospitalization for pertussis between term and preterm infants (i.e., <37w GA) using the screening method as developed by Farrington.

RESULTS

Of 1187 records, medical data from 676 were retrieved. Of these, 12% concerned preterms, whereas they are 8% of Dutch birth cohorts. Median age at admission was 3 m for preterms and 2 m for terms (p < 0.001). Preterms more often had received pertussis vaccination (62% vs 44%; p = 0.01) and more often had coinfections (37% vs 21%; p = 0.01). Preterms tended more often to have complications, to require artificial respiration or to need admittance to the intensive care unit (ICU). Preterms had longer ICU stays (15d vs 9d; p = 0.004). Vaccinated preterms and terms had a lower median length of hospital stay and lower crude risks of apneas and the need for artificial respiration, additional oxygen, and ICU admittance than those not vaccinated. After adjustment for presence of coinfections and age at admittance, these differences were not significant, except the lower need of oxygen treatment in vaccinated terms. Effectiveness of the first vaccination against pertussis hospitalizations was 95% (95% CI 93-96%) and 73% (95% CI 20-91%) in terms and preterms, respectively. Effectiveness of the second dose of the primary vaccination series was comparable in both groups (86 and 99%, respectively).

CONCLUSIONS

Infants hospitalized for pertussis suffer from severe disease. Preterms were overrepresented, with higher need for intensive treatment and less VE of first vaccination. These findings stress the need for alternative prevention, in particular prenatal vaccination of mothers, to reduce pertussis in both groups.

Combined predictors of neurodevelopment in very low birth weight preterm infants

OBJECTIVE

To evaluate the combined prognostic value of neurological examination, head circumference and cranial ultrasound for neurodevelopmental delay (NDD) in very low birth weight (VLBW, <1500 g) preterm infants.

METHODS

Prospective follow-up study. Preterm infants with VLWB were assessed for NDD using the Mullen Scales of Early Learning test at 24 months of corrected age. Abnormal neurological examination (≥2 deviant items of Hammersmith neurological examination), microcephaly and major ultrasound abnormalities, each performed at term age, were evaluated as predictors of NDD in a multivariable Poisson model.

RESULTS

35/132 infants (26.5%) had NDD. In the multivariable analysis, microcephaly (RR, 3.2; 95% CI, 1.6-6.7) and major ultrasound abnormalities (RR, 2.7; 95% CI, 1.3-5.7) were associated to NDD. The combination of the two tests showed the highest positive predictive value (100%; 95% CI, 51%-100%), while the combination of normal neurological examination, no major US findings and normal head size at term showed the highest negative predictive value (89%; 95% CI, 78%-95%). The maximum under receiver operating characteristic curve area was for microcephaly or major ultrasound abnormalities (AUC 0.74 (0.65-0.83)).

CONCLUSION

The combination of head circumference, cranial ultrasound and neurological examination at term age is useful to predict NDD in VLBW preterm infants.

Development of tissue Doppler-derived predictors of hemodynamically significant patent ductus arteriosus and the ability to incorporate it in targeted neonatal echocardiography protocol

Background

Hemodynamically significant (HS) patent ductus arteriosus (PDA) is a significant cause of mortality in preterm neonates. Early detection of HS PDA and pre-symptomatic closure may help in avoiding complications. For this to happen, easily performed predictors must be available; the aim of this paper is to test the reliability and repeatability of tissue Doppler-derived parameters for prediction of HS PDA.

Methods

Preterm neonates <32 weeks were screened with echocardiography at Day 3 of life; 80 neonates with PDA were classified into HS group and hemodynamically insignificant (HIS) group based on benchmark parameter namely left ventricular outflow to superior vena caval flow ratio (LVO/SVC), and a ratio ≥4 was considered predictive of HS PDA. Tissue Doppler-derived left ventricular myocardial systolic and diastolic velocities were also performed.

Results

In total, 105 neonates (55 among HS and 60 among HIS groups) were included in the study. Septal systolic velocity (S′) proved of high sensitivity (100%) in the prediction of HS PDA; nevertheless, it proved to be more repeatable than the initially discriminating parameter (LVO/SVC) with a Kappa of 0.92.

Conclusion

This study concludes that septal S′ can be reliably used even by neonatologists for pre-symptomatic detection of HS PDA. This may also indicate the need of adding tissue Doppler parameters to the standard protocol of targeted neonatal echocardiography.

Critically ill neonates displayed stable vital parameters and reduced metabolic acidosis during neonatal emergency airborne transport in Sweden

AIM

This study evaluated the medical quality of acute airborne transports carried out by a neonatal emergency transport service in a Swedish healthcare region from 2012 to 2015.

METHODS

The transport charts and patient records of all infants transported to the regional centre were reviewed for transport indications and vital parameters and outcomes.

RESULTS

We identified 187 acute airborne transports and the main indications for referral were therapeutic hypothermia after perinatal asphyxia, extremely preterm birth and respiratory failure. There were 37 deaths, but none of these occurred during transport and none of the deaths that occurred within 24 hours after transport were found to be related to the transport per se. No differences were found in vital parameters or ventilator settings before and after transport, except for an improvement in blood pH (7.22 ± 0.13 versus 7.27 ± 0.13, mean ± SD, p < 0.01), due to a decrease in base deficit (-8.0 ± 6.8 versus -5.4 ± 6.3 mmol, p < 0.001), while the partial pressure of carbon dioxide remained unchanged.

CONCLUSION

During air transport, critically ill neonates displayed stable vital parameters and reduced metabolic acidosis. No transport-related mortality was found, but the high number of extremely preterm infants transported indicates the potential for improving in-utero transport.

Electrical velocimetry for non-invasive monitoring of the closure of the ductus arteriosus in preterm infants

Closure of a patent ductus arteriosus (PDA) in preterm infants modifies cardiac output and induces adaptive changes in the hemodynamic situation. The present study aims to analyze those changes, through a non-invasive cardiac output monitor based on blood electrical velocimetry, in preterm babies. A prospective observational study of preterm infants with a gestational age of less than 28 weeks, and a hemodynamic significant PDA, requires intravenous ibuprofen or surgical closure. All patients were monitored with electrical velocimetry before treatment and through the following 72 h. Two groups were defined, ibuprofen and surgical closure. Variations of cardiac output were analyzed from the basal situation and at 1, 8, 24, 48, and 72 h on each group. During a 12-month period, 18 patients were studied. The median gestational age in the ibuprofen group (12/18) was 26⁺⁵ weeks (25⁺⁵-27⁺³) with a median birth weight of 875 (670-1010) g. The cardiac output index (CI) value was 0.29 l/kg/min (0.24-0.34). Among the patients with confirmed ductus closure (50%), a significant CI decrease was shown (0.24 vs 0.29 l/kg/min; P 0.03) after 72 h (three ibuprofen doses). A statistically significant decrease in systolic volume (SVI) was found: 1.62 vs 1.88 ml/kg, P 0.03 with a decrease in contractility (ICON), 85 vs 140, P 0.02. The gestational age in the surgical group (6/18) was 25⁺² weeks (24-26⁺³) with a median weight of 745 (660-820) g. All patients in this group showed a decrease in the immediate postoperative CI (1 h after surgery) 0.24 vs 0.30 l/kg/min, P 0.05, and a significant decrease in contractility (ICON 77 vs 147, P 0.03). In addition, a no statistically significant decrease in SVI (1.54 vs 1.83 ml/kg, P 0.06), as well as an increase in systemic vascular resistance (10,615 vs 8797 dyn/cm², P 0.08), were detected. This deterioration was transient without significant differences in the remaining periods of time evaluated.

CONCLUSION

The surgical closure of the PDA in preterm infants causes a transient deterioration of cardiac function linked to a documented decrease in the left ventricular output. The hemodynamic changes detected after pharmacological PDA closure are similar but those patients present a better clinical tolerance to changes in the cardiac output. What is Known: • Surgical ductus closure generates acute hemodynamic changes in cardiac output and left ventricular function. What is New: • The hemodynamic changes detected after pharmacological ductus closure are similar to those found in the surgical closure. Electrical velocimetry can detect those changes.

Doppler ultrasound assessment of the splanchnic circulation in preterms with neonatal sepsis at risk for necrotizing enterocolitis

OBJECTIVE

To evaluate the role of Doppler ultrasonography in the assessment of splanchnic circulation's hemodynamic changes in septic preterms at risk of necrotizing enterocolitis.

METHODS

A total of 51 septic preterms were divided into two groups: 25 preterms with clinical signs of necrotizing enterocolitis (NEC) and 26 preterms with no clinical signs of NEC. Both groups were assessed with Doppler ultrasonography of the celiac and superior mesenteric arteries, and each septic preterm's peak systolic velocity (PSV), end-diastolic velocity (EDV), resistivity index (RI), and pulsatility index (PI) was calculated and recorded.

RESULTS

These included a statistically significant lower PSV (p: 0.001) and a lower EDV (p: 0.001) in the superior mesenteric artery in the septic group with clinical signs of NEC in comparison with the septic group with no clinical signs of NEC. A statistically significant (p < 0.001) higher PSV celiac (CA)/PSV superior mesenteric (SMA) ratio was found for the group of septic preterms with clinical signs of NEC when compared to the other group.

CONCLUSION

The study results showed that Doppler ultrasonography of the splanchnic circulation can be a tool for the early identification of NEC cases among septic preterms.

Creating religiously compliant milk banks in the Muslim world: a commentary

Human milk banks are vital for providing donor milk to infants for whom there are maternal or postnatal barriers to the mother's own milk. Although more than 35 countries have active milk banks, not one of those is a Muslim country.(1) Despite widespread support for breastfeeding across the Muslim world, religious constraints surrounding milk-sharing have created challenging barriers to the creation of milk banks. The religious objection centres around the Islamic tenet that consuming human milk builds a kinship bond between individuals who have consumed the same woman's milk which prohibits future marriage between the 'milk-brothers and sisters.' While a small-scale, experimental 'milk exchange' programme has been attempted in two Muslim countries (Kuwait and Malaysia), the only proposed milk bank in the Muslim world was a pilot programme in Turkey that was halted because of religious concerns. The problem with milk banking is the step in the process during which the milk from individual donors is pooled and de-identified, making it impossible to trace its origins and acknowledge the newly formed kinship relationship. To meet the need for Muslim children to be able to access human milk while remaining compliant with the prevalent understanding of Islamic doctrine on milk-sharing, we propose a new approach to milk banking that we term the Conditional Identified Milk Banking System (CIMBS). In this new system, both the donor's and recipient's identities are accessible to all parties through a voluntary registry, and the milk-pooling is limited to three milk donors. Based on recent survey data, we believe that there would be receptivity among practicing Muslims and religious leaders to this alternative approach.

Validity and internal consistency of the Ages and Stages Questionnaire 60-month version and the effect of three scoring methods

BACKGROUND

The Ages and Stages Questionnaire (ASQ) is currently the most used parent-completed developmental screener consisting of different age-specific questionnaires. Psychometric evaluation of the ASQ 60-month version (ASQ-60) is limited. Furthermore, it is unclear which of the available scoring methods of the ASQ is most useful in the identification of children with potential developmental problems.

AIM

To evaluate the internal consistency and construct validity of the ASQ-60 with a large sample size, and to assess the effects of three scoring-methods on this validity.

STUDY DESIGN

Parents of 394 term-born and 1063 preterm-born children from the prospective cohort-study Lollipop completed the ASQ-60 and a general questionnaire on school-problems.

OUTCOME MEASURES

Internal consistency and construct validity of the ASQ-60 were determined using the ASQ total score. Construct validity was also determined using two other types of scoring-methods based on low domain-scores ('ASQ domain score') and parental concerns ('ASQ total score with parental concerns').

RESULTS

Cronbach's alpha for total score was 0.86, confirming internal consistency. Male gender, prematurity, low paternal education, low family income and small-for-gestational-age were associated with low 'ASQ total scores,' confirming construct validity. Regarding construct validity with special education as criterion, sensitivity was best using the 'ASQ domain score' or the 'ASQ total score' with parental concerns (both 0.96). However, the specificity was best (0.93) using the ASQ total score.

CONCLUSION

The ASQ-60 has a good internal consistency and validity to screen for developmental problems in the general population. The 'ASQ total score' has the best performance, the 'ASQ domain score' is recommended in case of preferred high sensitivity.