The impact of neonatal morbidities on child growth and developmental outcomes in very low birth weight infants: a nationwide cohort study

Growth in preterm infants has long-term implications for neurodevelopmental outcomes. We aimed to estimate the nationwide growth outcomes from birth to 5 years in infants born under 1500 g and to analyze the effects of major morbidities in preterm infants on growth. In total, 2961 children born in 2013 with a birth weight under 1500 g who underwent an infant health checkup between 2013 and 2018 according to the National Health Insurance Service database were included. Checkups were conducted at 4-6, 9-12, 18-24, 30-36, 42-48, and 54-60 months of age. Information was obtained from the International Classification of Diseases-10 codes or a questionnaire administered during the check-up. At 60 months of age, the mean percentiles of weight, height, and head circumference fell within only the 30-40th percentile of normal growth values. About 30% of infants had growth parameters below the 10th percentile and showed worse neurodevelopmental outcomes. Using multiple logistic regression, infants with bronchopulmonary dysplasia showed a significantly higher incidence of growth restriction in all three categories of weight (odds ratio [OR] 1.50), height (OR 1.33), and head circumference (OR 1.36) at 60 months. Sepsis was associated with growth restriction in weight (OR 1.43) and head circumference (OR 1.33). Periventricular leukomalacia infants had relatively small head circumferences (OR 1.91) and poor developmental screening results (OR 2.89).Conclusion: Catch-up growth remains a major issue in infants born under 1500 g, especially those with some morbidities from preterm birth. Regular checkups to monitor and early intervention to achieve normal growth are essential. What is Known: • Growth in preterm infants has long-term implications for neurodevelopmental and cardiometabolic outcomes. • Data are lacking on the time-serial effects of many preterm morbidities simultaneously on long-term growth outcomes. What is New: • All growth parameters of VLBW infants, including weight, height, and head circumference, fell within the 30-40th percentile of normal growth for infants at 60 months of age, indicating that catch-up growth for VLBW infants remains an issue. • VLBW infants with major preterm morbidities, including BPD, PVL, and sepsis, showed difficulties in achieving normal catch-up growth and neurodevelopment at 60 months of age.

Systematic review and meta-analysis: the effect of bronchopulmonary dysplasia on neurodevelopment in very low birth weight premature infants

BACKGROUND

A meta-analysis was performed to study the effect of steroid intervention on the neurodevelopment of extremely low birth weight preterm infants complicated with bronchopulmonary dysplasia, and to provide a theoretical basis for clinical treatment.

METHODS

The Wanfang database, Chinese Biomedical Literature database, VIP database, Baidu Academic, CNKI database, The Cochrane Library, Medline, Embase, and PubMed database were searched by computer from establishment to 2021. Randomized controlled trials on the effect of steroids on neurodevelopment in very low birth weight preterm infants with bronchial dysplasia published from January 10, 2007 were retrieved. The included literature was evaluated for bias risk, then analyzed using RevMan 5.3 software.

RESULTS

A total of 9 studies were included, with a total of 2,453 patients. The funnel plot showed that the circles and the midline of some studies were basically symmetrical, and there was no bias in the publications. The conclusions obtained were relatively reliable. Cerebral palsy, neurodevelopmental indicators, and MRI findings of preterm infants were analyzed. The cognitive impairment of very low birth weight preterm infants complicated with bronchial dysplasia (RR =0.83, 95% CI: 0.72-0.96, P=0.01) in the treatment group was significantly different from that in the control group, while cerebral palsy (RR =0.99, 95% CI: 0.75-1.29, P=0.93), speech impairment (RR =0.75, 95% CI: 0.46-1.21, P=0.24), hearing loss requiring amplification (RR =0.60, 95% CI: 0.35-1.03, P=0.06), bilateral blindness RR =0.81, 95% CI: 0.52-1.24, P=0.32), severe intraventricular hemorrhage (IVH) (RR =0.71, 95% CI: 0.33-1.50, P=0.37), and cystic periventricular leukomalacia (RR =0.82, 95% CI: 0.43-1.57, P=0.56) had no significant differences compared with the control group.

DISCUSSION

In this meta-analysis, we found that the use of steroids in very low birth weight preterm infants complicated with bronchial dysplasia had significant effects on cognition, but no significant effects on hearing, vision, or language function.

Lack of Enteral Feeding Associated with Mortality in Prematurity and Necrotizing Enterocolitis

BACKGROUND

Necrotizing Enterocolitis (NEC) remains a significant cause of morbidity and mortality. Recently, there has been an increased recognition of the importance of intestinal immunity and the associations with antibiotics and enteral feeds in the pathophysiology of NEC. The primary purpose of this study is to examine the association of enteral feeds on the survival of premature neonates with NEC.

MATERIAL AND METHODS

A retrospective review using the Vermont Oxford Network for a Level IV NICU from January 1, 2013 through December 31, 2019 was performed. All neonates had a gestational age between 22 to 29 weeks, weighed at least 300 grams (n = 653), had a reported enteral feed status and were treated for NEC (n = 43). Data analysis utilized two-tailed t-tests for NEC and infection rates then Fisher's exact tests for survival status.

RESULTS

The incidence of NEC in the population was 6.6% (43/653). Of the 43 neonates treated for NEC, 27 were enterally fed, while the other 16 were not. All 27 neonates with NEC that were able to achieve enteral feeds survived and had an infection rate of 22.2%. Meanwhile, all 16 neonates with NEC that were unable to achieve enteral feeds died and had an infection rate of 62.5%.

CONCLUSIONS

There is a significant association between enteral feeds and NEC, survival, and infection rates in premature neonates. These findings support the importance of intestinal immunity and the microbiota in NEC. Given the limitations of the retrospective review, the profound survival advantage with enteral feeds reinforces the need for further study.

White matter alterations and cognitive outcomes in children born very low birth weight

BACKGROUND

Very low birth weight (VLBW) infants are at risk for disrupted white matter maturation, yet little is known about the contributing factors, particularly at preschool-age when cognitive difficulties begin to emerge. We examined white matter microstructure in five-year-old VLBW and full-term (FT) children, and its association with cognitive outcomes and birth weight.

METHODS

Multi-shell diffusion and MR images were obtained for 41 VLBW (mean birth weight: 1028.6 ± 256.8 g) and 26 FT (3295.4 ± 493.9 g) children. Fractional anisotropy (FA), radial diffusivity (RD), neurite orientation dispersion index (ODI) and density index (NDI) were estimated using diffusion tensor and neurite orientation dispersion and density imaging models. Between-group analyses used a general linear model with group and sex as explanatory variables. Within-group associations between white matter microstructure, cognitive outcomes and birth weight were also investigated.

RESULTS

VLBW compared to FT children showed lower FA and NDI across widespread white matter regions. Smaller clusters of atypical ODI were also found in VLBW children. Within-group analyses in FT children revealed that lower RD and higher NDI were associated with vocabulary acquisition and working memory. In VLBW children, higher FA and NDI, and lower RD and ODI, were associated with improved processing speed. In both groups, FA was positively associated with birth weight.

CONCLUSIONS

Our findings demonstrate white matter alterations in young VLBW children, including widespread reductions in axon density that may reflect sustained myelination disruptions. The associations with cognitive outcomes may also highlight which of the VLBW children are at higher risk for later cognitive difficulties.

Outcomes of neonatal hypothermia among very low birth weight infants: a Meta-analysis

BACKGROUND

Neonatal admission hypothermia (HT) is a frequently encountered problem in neonatal intensive care units (NICUs) and it has been linked to a higher risk of mortality and morbidity. However, there is a disparity in data in the existing literature regarding the prevalence and outcomes associated with HT in very low birth weight (VLBW) infants. This review aimed to provide further summary and analyses of the association between HT and adverse clinical outcomes in VLBW infants.

METHODS

In July 2020, we conducted this review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic database search was conducted in MEDLINE (PubMed), Google Scholar, ScienceDirect, World Health Organization Virtual Health Library, Cochrane Library databases, and System for Information on Grey Literature in Europe (SIGLE). We included studies that assessed the prevalence of HT and/or the association between HT and any adverse outcomes in VLBW infants. We calculated the pooled prevalence and Odds Ratio (OR) estimates with the corresponding 95% Confidence Interval (CI) using the Comprehensive meta-analysis software version 3.3 (Biostat, Engle-wood, NJ, USA; http://www.Meta-Analysis.com ).

RESULTS

Eighteen studies that fulfilled the eligibility criteria were meta-analyzed. The pooled prevalence of HT among VLBW infants was 48.3% (95% CI, 42.0-54.7%). HT in VLBW infants was significantly associated with mortality (OR = 1.89; 1.72-2.09), intra-ventricular hemorrhage (OR = 1.86; 1.09-3.14), bronchopulmonary dysplasia (OR = 1.28; 1.16-1.40), neonatal sepsis (OR = 1.47; 1.09-2.49), and retinopathy of prematurity (OR = 1.45; 1.28-1.72).

CONCLUSION

Neonatal HT rate is high in VLBW infants and it is a risk factor for mortality and morbidity in VLBW infants. This review provides a comprehensive view of the prevalence and outcomes of HT in VLBW infants.

Reduced Exercise Capacity in Adults Born Very Low Birth Weight: A Population-Based Cohort Study

RATIONALE

Population-based data regarding the consequences of very low birth weight (VLBW) and bronchopulmonary dysplasia (BPD) on adult exercise capacity is limited.

OBJECTIVES

To compare exercise capacity in a national VLBW cohort with term-born controls and explore factors contributing to the differences.

METHODS

At 26-30 years of age, 228 VLBW survivors and 100 controls underwent lung function tests, cardiopulmonary exercise testing and assessment of resting cardiac structure/function using echocardiography. Data on self-reported physical activity were collected.

MEASUREMENTS AND MAIN RESULTS

Compared with controls, VLBW adults demonstrated reduced oxygen uptake, work rate and oxygen pulse at peak exercise (9.3%, 10.7%, 10.8% lower, respectively) and earlier anaerobic threshold (all p<0.0001), with all mean values within normal range. VLBW survivors showed reduced physical activity, impaired lung function (reduced FEV1, FEV1/FVC, DLCO), altered left ventricular structure/function (reduced mass, size, stroke volume, cardiac output) and reduced right atrial/ventricular size. Adjustment for the combination of three sets of covariates (physical activity with BMI, lung function, cardiac structure/function) explained most of the exercise group-differences. Beyond the effects of physical activity and BMI, lung function and cardiac structure/function contributed approximately equally. BPD with other prematurity-related perinatal factors (ventilation, antenatal steroids, extremely low birth weight, extreme preterm) were not associated with a reduced exercise capacity.

CONCLUSIONS

Exercise capacity was significantly reduced in VLBW adults, which we speculate is from combined effects of impaired lung function, altered heart structure/function and reduced physical activity. Perinatal factors including BPD were not associated with a reduced exercise capacity.

Placental Histological Features and Neurodevelopmental Outcomes at Two Years in Very-Low-Birth-Weight Infants

BACKGROUND

We evaluated the rates of placental pathologic lesions and their relationship with two-year neurodevelopmental outcomes in very-low-birth-weight (VLBW) infants.

METHODS

This is a cohort observational study comprising 595 VLBW infants during 2007 to 2015. Neurodevelopmental assessment was carried out at 24 months corrected age.

RESULTS

In univariate analysis the rates of survival with normal neurodevelopmental outcomes were lower in pregnancies with severe histologic chorioamnionitis (38 of 43, 88.4% when compared with 305 of 450, 67.8%), severe maternal vascular malperfusion (MVM) (17 of 37, 45.9% when compared with 326/492, 66.3%), and intravillous hemorrhage (37 of 82, 45.1% when compared with 306 of 449, 68.1%). In logistic models, severe MVM (adjusted odds ratio [adj. OR] = 0.45, 95% confidence interval [CI] = 0.22 to 0.92), severe fetal vascular malperfusion (FVM) (adj. OR = 0.46, 95% CI = 0.22 to 0.45), and intravillous hemorrhage (adj. OR = 0.38, 95% CI = 0.22 to 0.62) were associated with lower rates of infant survival with normal neurodevelopmental outcome. FVM (adj. OR = 0.46, 95% CI = 0.21 to 0.97) and intravillous hemorrhage (adj. OR = 0.37, 95% CI = 0.22 to 0.62) were also the only placental lesions that were independent predictors of a lower rate of intact survival in stepwise analysis for prognostic factors of the entire cohort.

CONCLUSIONS

Placental pathologic findings such as severe MVM, FVM, and intravillous hemorrhage are significant predictors of neonatal survival and subsequent adverse neurodevelopmental outcomes. Data on the placental pathology could be useful in the neurodevelopmental follow-up of VLBW infants.

Temporal trend in early sepsis in a very low birth weight infants' cohort: an opportunity for a rational antimicrobial use

OBJECTIVE

This study aimed to evaluate annual trends of early neonatal sepsis and antimicrobial use in very low birth weight infants for 12 years, as well as to identify microbiological agents, antimicrobial sensitivity profiles, and association with early neonatal death.

METHOD

This was a retrospective cohort study including 1254 very low birth weight infants admitted from 2006 to 2017. Four groups were evaluated: culture-confirmed sepsis; presumed neonatal sepsis; ruled out neonatal sepsis group; and infants not exposed to antibiotics.

RESULTS

The medians of gestational age and birth weight were 29 weeks (27-31) and 1090g (850-1310), respectively. The rates of culture-confirmed sepsis, presumed neonatal sepsis, ruled out neonatal sepsis, and not exposed to antibiotics were 1.3, 9.0, 15.4, and 74.3%, respectively. From the initial group of newborns whose antimicrobial treatment was administered for sepsis' suspicion, it was possible to discontinue antibiotic in 44%. The culture-confirmed sepsis rates remained stable (p=0.906). Significant tendencies of decreasing presumed sepsis rates (p<0.001) and increased ruled out neonatal sepsis/not exposed to antibiotics rates (p<0.001) were observed. Streptococcus agalactiae and enteric Gram-negative rods were the predominant agents and most of them were sensitive to crystalline penicillin/ampicillin (88.2%) and to ampicillin and/or amikacin. Early death occurred in 10.8%, specifically in the culture-confirmed sepsis and presumed neonatal sepsis groups.

CONCLUSION

The confirmed sepsis rate was low and remained stable. There was a significant downward trend in the presumed neonatal sepsis rate and a significant upward trend in the ruled out neonatal sepsis group. The rate of not exposed to antibiotics infants was high, also presenting a significant downward trend. The identified bacteria were those commonly found and showed usual antimicrobial susceptibility patterns. Death predominantly occurred in groups that received antibiotic treatment.

Current obesity was associated with hypertension in children born very low birth weight

Objectives

Previous studies from the developed countries showed that children born very low birth weight have a higher risk of hypertension compared with that of the normal birth weight controls. However, studies regarding the prevalence of hypertension in such children from the developing countries are scarce. This study aimed to identify the perinatal and postnatal factors associated with hypertension in children born very low birth weight.

Results

Forty-six children aged ≥ 6 years from the VLBW cohort of Ramathibodi Hospital, Bangkok, Thailand underwent the ambulatory blood pressure monitoring. The prevalence of hypertension was 15.2% (7/46). The hypertension group had a significant higher BMI z-score at 3 years of age (0.90 ± 1.44 vs − 0.45 ± 1.47, p = 0.045) and a greater proportion of current obesity (42% vs 2.5%, p < 0.01) compared to those in the normotensive group. Multivariate analysis revealed that current obesity was associated with hypertension (OR 34.77, 95%CI 1.814–666.5). Among 36 children with normal office blood pressure, four children (11.1%) had high blood pressure uncovered by ABPM, called “masked hypertension”. Office systolic blood pressure at the 85th percentile was the greatest predictor for masked hypertension with a sensitivity of 75% and a specificity of 81.2%.

The association between restricted intra-uterine growth and inadequate postnatal nutrition in very-low-birth-weight infants and their neurodevelopmental outcomes: a 50-month follow-up study

Inadequate nutrition during a critical period of development - as is the case during gestation and the first days of life, especially in very-low-birth-weight (VLBW) infants, can impact on neurodevelopment and favour co-morbidities. In this study, we evaluate how neurodevelopment may be affected by intra-uterine growth (IUGR) restriction and by an inadequate intake of nutritional energy during the early neonatal period. A longitudinal cohort study was conducted to analyse the nutritional contributions received during the first week of life, among a population of 396 VLBW infants. Motor, cognitive, sensory and behavioural development was assessed at 14, 25, 33 and 50 months. The association between IUGR, postnatal energy restriction and neurodevelopment was examined using multivariate logistic regression techniques. Mild cognitive delay was observed in 35·6 % of neonates with IUGR and in 24 % of those with appropriate birth weight. IUGR is associated with behavioural disorder (OR 2·60; 95 % CI 1·25, 5·40) and delayed cognitive development (OR 2·64; 95 % CI 1·34, 5·20). Energy restriction during the first week of life is associated with visual deficiency (OR 2·96; 95 % CI 1·26, 6·84) and cerebral palsy (OR 3·05; CI 95 % 1·00, 9·54). In VLBW infants, IUGR is associated with behavioural disorder, while postnatal energy restriction is significantly associated with motor disorder, infantile cerebral palsy and sensory disorder.

Relationship between biparietal diameter/ventricular ratio and neurodevelopmental outcomes in non-handicapped very preterm infants

PURPOSE

Preterm infants are at high risk for brain damage and long-term neurodevelopmental problems. Cranial ultrasonography is the main neuroimaging technique for very low birth weight infants. Ventricle size and its ratio to brain volume contribute very important information about the central nervous system of preterm babies. We calculated biparietal diameter/ventricular ratio of preterm infants using cranial ultrasonography and evaluate the relationship between this ratio and neurodevelopment.

METHODS

Cranial measurements were derived using routine ultrasonographic scanning. Transverse brain length, or biparietal diameter (BPD), was considered a representation of the total brain, ventricular index (VI) and thalamo-occipital distance (TOD) length were used to represent the ventricles, and their ratio was accepted as a measure of the tissue portion of the brain. The ratio of BPD to the sum of left and right VI and TOD values was recorded as BPD/(VI+TOD) ratio.

RESULTS

Data from a total of 482 patients were analyzed. The mean gestational age was 27.6 (24-29.6) weeks and the mean birth weight was 1010 (350-1390) g. The mean BPD/(VI+TOD) ratio was 32.90 (± 2.32). At 24 months corrected age, the patients' mean MDI score was 78.64 (± 13.29) and mean PDI score was 79.49 (± 14.31). When patients with and without NDI were compared, there were significant differences between the groups in terms of BPD/(VI+TOD) ratio, MDI, and PDI (p < 0.001, p < 0.001, p < 0.001, respectively).

CONCLUSION

The BPD/ventricle ratio can be calculated using two-dimensional measurements in VLBW infants and reduced BPD/ventricle ratio was associated with poor neurodevelopmental outcomes.

TRIAL REGISTRATION

NCT02848755.

Fluconazole prophylaxis against invasive candidiasis in very low and extremely low birth weight preterm neonates: a systematic review and meta-analysis

BACKGROUND

Evidence shows that fluconazole prophylaxis is an effective treatment against invasive fungal infections in preterm neonates, however, the most efficient schedule of fluconazole prophylaxis for the colonization and mortality of invasive candidiasis (IC) is unknown.

PURPOSE

This systematic review and meta-analysis aimed to assess the efficiency of different prophylactic fluconazole schedules in controlling IC colonization, infection, and mortality in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in neonatal intensive care units.

METHODS

We searched the PubMed, Scopus, Embase, and Cochrane databases using the keywords "candida," "invasive candidiasis," "IC," "fluconazole prophylaxis," "preterm infants," "very low birth weight infants," "VLBW," "extremely low birth weight," and "ELBW."

RESULTS

Mortality was significantly decreased in a metaanalysis of studies using different fluconazole prophylaxis regimens. The meta-analysis also indicated a significant decrease in the incidence of IC-associated mortality in ELBW infants using the same fluconazole prophylaxis schedules.

CONCLUSION

Future studies should explore the effectiveness of other different fluconazole prophylaxis schedules on IC colonization, infection, and mortality.

Functional Magnetic Resonance Imaging during Visual Perception Tasks in Adolescents Born Prematurely

OBJECTIVES

Impairments in visual perception are among the most common developmental difficulties related to being born prematurely, and they are often accompanied by problems in other developmental domains. Neural activation in participants born prematurely and full-term during tasks that assess several areas of visual perception has not been studied. To better understand the neural substrates of the visual perceptual impairments, we compared behavioral performance and brain activations during visual perception tasks in adolescents born very preterm (birth weight ≤1500 g or gestational age <32 weeks) and full-term.

METHODS

Tasks assessing visual closure, discrimination of a deviating figure, and discrimination of figure and ground from the Motor-Free Visual Perception Test, Third Edition were performed by participants born very preterm (n = 37) and full-term (n = 34) at 12 years of age during functional magnetic resonance imaging.

RESULTS

Behavioral performance in the visual perception tasks did not differ between the groups. However, during the visual closure task, brain activation was significantly stronger in the group born very preterm in a number of areas including the frontal, anterior cingulate, temporal, and posterior medial parietal/cingulate cortices, as well as in parts of the cerebellum, thalamus, and caudate nucleus.

CONCLUSIONS

Differing activations during the visual closure task potentially reflect a compensatory neural process related to premature birth or lesser neural efficiency or may be a result of the use of compensatory behavioral strategies in the study group born very preterm.

Multimodal longitudinal respiratory function assessment in very low birth weight 7-year-old children

PURPOSE

Preterm birth is associated with adverse pulmonary outcomes. We aimed to evaluate respiratory morbidities and lung function of very low birth weight (VLBW) Polish children followed up at the age of 7 years old, and to compare with electrical impedance segmentography (EIS) results recorded at 4 years of age.

MATERIALS AND METHODS

VLBW children were compared with term controls using impulse oscillometry and spirometry. Perinatal data and current respiratory morbidities were analyzed and pulmonary function test results were compared with previous EIS results.

RESULTS

We included 40 VLBW children and 30 controls in the analysis. Elevated total airway resistance and forced expiratory volume in the first second below the lower limit of normal were more prevalent in VLBW children compared with term controls (15 vs 0%; 18 vs 0%). A positive bronchodilator response was more common in VLBW children (R_{5 Hz}: 46 vs 13.3%; R_5-20 ​Hz: 65 vs 36.7%). Children with bronchopulmonary dysplasia (BPD) had higher total airway resistance (R_{5 Hz}/R_{5 Hz pred}: 1.35 vs 0.95; p ​< ​0.001), large airway resistance (R_{20 Hz}/R_{20 Hz pred}: 0.89 vs 0.66; p ​= ​0.001), small airway resistance (R_5-20 ​Hz: 0.57 vs 0.34 ​kPa ​L^-1 ​s^-1; p ​= ​0.009), than controls. Strong correlation between BDR in EIS and R_{5 Hz}/R_{5 Hz pred} was observed in children with BPD (r ​= ​0.7).

CONCLUSION

VLBW school-aged children with BPD presented with substantial respiratory morbidity and persistent reduction of lung function, affecting small and large airways and lung parenchyma. EIS may be an alternative tool for lung function assessment in children with BPD.

Oral ibuprofen promoted cholestatic liver disease in very low birth weight infants with patent ductus arteriosus

OBJECTIVES

Hemodynamically significant patent ductus arteriosus (hsPDA) in very low birth weight (VLBW) infants is routinely treated in many countries with oral ibuprofen. This study retrospectively assessed whether the risk of cholestatic liver disease (CLD) increased due to oral ibuprofen administration in VLBW infants.

METHODS

A total of 122 VLBW preterm infants (26∼32 weeks, birth weight<1500g) diagnosed with patent ductus arteriosus (PDA) admitted to our neonatal intensive care unit (NICU) between September 2016 to August 2018 were included. Sixty-four infants were diagnosed with hs-PDA and received ibuprofen treatment. VLBW infants with PDA untreated with ibuprofen served as controls. Soybean oil and fat emulsions were routinely added to parenteral nutrition (PN). Once CLD was diagnosed, the fat emulsions were immediately replaced with multi-oil fat emulsion injections. To assess the independent association of treatment and duration of ibuprofen with CLD and duration of fasting and PN, binary logistic regression or multivariate linear regression analyses were conducted, adjusting for major confounders (birth weight, gestational age, Clinical Risk Index for Babies, and cholestasis-associated risk factors).

RESULTS

The duration of PN increased due to ibuprofen treatment for 6.559 days (95% CI: 1.769, 11.349; P=0.008), and the risk of prolonged fasting (cutoff>5 days) might have increased due to ibuprofen treatment (OR: 3.043, 95% CI: 0.965, 9.594; P=0.057). Furthermore, CLD was influenced by ibuprofen treatment (OR: 6.730; 95% CI: 1.279, 35.41; P=0.024), early thrombocytopenia 7 days postnatal (OR: 6.996; 95% CI: 1.769, 27.658; P=0.004), and late onset sepsis (OR: 6.976; 95% CI: 1.561, 31.169; P=0.011). Further analysis adjusting for cholestasis-associated risk factors revealed that CLD was influenced by the duration of ibuprofen treatment (OR: 2.864; 95% CI: 1.104, 7.422; P=0.030), Platlets counts 7 days postnatal (OR: 0.971; 95% CI: 0.950, 0.994; P=0.013), and duration of antibiotics (OR: 1.134; 95% CI: 1.002, 1.282; P=0.046).

CONCLUSIONS

This retrospective study indicated oral ibuprofen duration-dependently increased the risk of CLD in VLBW infants with PDA, and early thrombocytopenia served as the critical risk factor.

Comparison of the effect of continuous and standard intermittent bolus paracetamol infusion on patent ductus arteriosus

The aim of this study was to evaluate the effect of paracetamol on patent ductus arteriosus (PDA) closure and clinical outcomes in preterm infants when used as standard intermittent bolus and continuous intravenous (IV) infusion. Preterm neonates with birth weight (BW) ≤ 1500 g and gestational age (GA) ≤ 30 weeks were included in this study. During the study period, IV paracetamol therapy was given to all infants with hemodynamically significant patent ductus arteriosus (hsPDA). The patients were divided into the standard IV intermittent bolus infusion group and the continuous IV infusion group. Standard IV intermittent bolus paracetamol therapy was administered in the form of 15-mg/kg doses as 1-h infusions every 6 h for 5 days, while continuous IV paracetamol infusion therapy was administered as a 60-mg/kg/day dose continuously for 5 days. During the study period, 247 patients were evaluated, of which a total of 137 patients with hsPDA were included. There were no significant differences between the intermittent bolus and continuous infusion groups in terms of mean GA or BW. The continuous paracetamol infusion group had significantly higher rates of PDA-related morbidities, multiple paracetamol courses, and PDA ligation procedure compared with the standard intermittent bolus group.Conclusion: Our results were the first in the literature to compare IV paracetamol infusion regimens for PDA. Our results indicate that standard intermittent bolus infusion is still the most appropriate IV paracetamol regimen for the treatment of PDA.Trial registration: ClinicalTrials.gov Identifier: NCT04469413 What is Known: • Paracetamol has been proposed for the treatment of patent ductus arteriosus in preterm neonates. • There is no consensus on the duration and form of administration of paracetamol in hsPDA, and the information on this issue is insufficient. What is New: • Our study was the first in the literature to compare IV paracetamol infusion regimens for PDA. • Standard intravenous intermittent bolus paracetamol infusion was more effective in pharmacologic PDA closure compared with continuous intravenous paracetamol infusion and was associated with lower rates of PDA-related BPD, NEC, and need for ligation.

Antibiotic exposure and growth patterns in preterm, very low birth weight infants

BACKGROUND

Antibiotic exposure in term infants has been associated with later obesity. Premature, very-low-birth-weight (birth weight ≤ 1500 g) infants in the neonatal intensive care unit frequently are exposed to antibiotics. Our hypothesis was that in preterm infants, there is a positive linear and dose-dependent relationship between antibiotic exposure and growth from birth through 12 months' corrected age.

METHODS

Retrospective analysis of prospectively collected data of all antibiotic use among inborn, preterm (≤32 weeks' gestation), very-low-birth-weight infants admitted to the neonatal intensive care unit at Parkland Memorial Hospital and followed in the Low Birth Weight Clinic at Children's Medical Center, Dallas, TX. Antibiotic use was quantified by days of therapy which was compared with weight and length parameters at birth, 36 weeks' postmenstrual age, and 2, 4, 6, and 12 months' corrected age. The change in weight and length z-scores from birth to all subsequent age points was calculated. Stepwise multivariate regression analysis was performed to determine predictors of weight, length, and weight-for-length delta z-scores from birth to each subsequent age point.

RESULTS

During the 18-month study, 161 infants received a median of 11 (IQR, 5.5-19.5) antibiotic days of therapy which was not associated with weight or length delta z-scores from birth through 12 months' corrected age.

CONCLUSION

Association of prolonged antibiotic use and neonatal morbidities and mortality may override the potential association with increased weight gain in the NICU and beyond.

Portal venous gas resulting from umbilical vein catheterization in a very-low-birth-weight infant with no interruption in early feeding

Introduction

Portal venous gas (PVG) is common in necrotizing enterocolitis and occasionally occurs in neonates after umbilical vein catheterization (UVC). Therefore, determining the cause of PVG requires further clinical evaluation in these cases.

Case presentation

We report the case of a very‐low‐birth‐weight infant who underwent UVC after birth. PVG was an unexpected finding on ultrasound following catheterization. The UVC was immediately removed and replaced with a peripherally inserted central catheter. The infant’s physical examination was unremarkable. Bedside X‐ray revealed neither PVG nor pneumatosis intestinalis, which would indicate the onset of necrotizing enterocolitis. After full evaluation, breastfeeding was started on the same day. The infant did not develop feeding intolerance, necrotizing enterocolitis, or other disorders.

Conclusion

PVG occasionally occurs in neonates who undergo UVC and is considered to be caused by exogenous gases. PVG is more easily detected with ultrasound than with X‐ray and does not affect early feeding in premature infants.

Single-course antenatal corticosteroids is related to faster growth in very-low-birth-weight infant

BACKGROUND

Antenatal corticosteroids (ACS) treatment is critical to support survival and lung maturation in preterm infants, however, its effect on feeding and growth is unclear. Prior preterm delivery, it remains uncertain whether ACS treatment should be continued if possible (repeated course ACS), until a certain gestational age is reached. We hypothesized that the association of single-course ACS with feeding competence and postnatal growth outcomes might be different from that of repeated course ACS in very-low-birth-weight preterm infants.

METHODS

A multicenter retrospective cohort study was conducted in very-low-birth-weight preterm infants born at 23-37 weeks' gestation in South China from 2011 to 2014. Data on growth, nutritional and clinical outcomes were collected. Repeated course ACS was defined in this study as two or more courses ACS (more than single-course). Infants were stratified by gestational age (GA), including GA < 28 weeks, 28 weeks ≤ GA < 32 weeks and 32 weeks ≤ GA < 37 weeks. Multiple linear regression and multilevel model were applied to analyze the association of ACS with feeding and growth outcomes.

RESULTS

A total of 841 infants were recruited. The results, just in very-low-birth-weight preterm infants born at 28-32 weeks' gestation, showed both single and repeated course of ACS regimens had shorter intubated ventilation time compared to non-ACS regimen. Single-course ACS promoted the earlier application of amino acid and enteral nutrition, and higher rate of weight increase (15.71; 95%CI 5.54-25.88) than non-ACS after adjusting for potential confounding factors. No associations of repeated course ACS with feeding, mean weight and weight increase rate were observed.

CONCLUSIONS

Single-course ACS was positively related to feeding and growth outcomes in very-low-birth-weight preterm infants born at 28-32 weeks' gestation. However, the similar phenomenon was not observed in the repeated course of ACS regimen.

Evaluation of the risk factors of dental caries in children with very low birth weight and normal birth weight

Background

Health problems of premature infants can affect both general and oral health. The enamel defects, poor dietary and oral hygiene habits may predispose these children to dental caries. This study was conducted to assess the impact of very low birth weight and prematurity on caries risk in early childhood.

Methods

The study cohort consists of 189 of one year old infants. Anamnestic data were obtained from hospital records, feeding practice, bed-time sugar drinks and oral hygiene onset from questionnaires. Saliva samples of children and their mothers were collected for the detection of cariogenic pathogens.

Results

VLBW newborns had significantly shorter gestation age (29.6 vs. 38.8)) and lower mean birthweight (1124 g vs 3315 g) compared to NBW ones (p < 0.0001). Statistical significance has been found in the presence of early morbidity (p < 0.0001) and regular medication intake (p = 0.007). VLBW children got more frequently sweetened drinks during the day and night (p = 0.007). Regular oral hygiene practice was more frequent in full term group (p = 0.002). There was statistical difference in the presence of enamel hypoplasia in VLBW children (p = 0.033) but no statistical difference in the presence of hypomineralization (p = 0.0736) in comparison to NBW individuals. Proportional representation and count of S. mutans did not reveal statistical difference neither in both groups of children (p = 0.484) nor in both groups of mothers (p = 0.385).

Conclusions

The study confirmed anamnestic and medical differences between both groups. The proportional representation and count of S. mutans did not reveal statistical difference neither in VLBW and NBW children, nor in their mothers.

Perinatal factors contributing to chronic kidney disease in a cohort of Japanese children with very low birth weight

BACKGROUND

Developmental programming of chronic kidney disease (CKD) in young adults is linked to preterm birth and intrauterine growth restriction (IUGR). Which confers a higher risk of progression to chronic kidney damage in children with very low birth weight (VLBW; born weighing < 1500 g): prematurity or IUGR?

METHODS

This is a national historical cohort study of children with VLBW cared for in perinatal medical centers in Japan. Predictive factors included three latent variables (prematurity, IUGR, stress during neonatal period) and eight observed variables (gestational age, birth weight Z-score, maternal age, duration of treatment with antibiotics and diuretics, maternal smoking, late-onset circulatory collapse, kidney dysfunction) during the perinatal period. The primary endpoint was estimated glomerular filtration rate (eGFR) at age ≥ 3 years. A structural equation model was used to examine the pathologic constitution.

RESULTS

The 446 children with VLBW included 253 boys and 193 girls, of mean age 5.8 ± 2.6 years and mean eGFR 111.7 ml/min/1.73 m² at last encounter. Pathway analyses showed intrauterine malnutrition (β = 0.85) contributed more to chronic kidney damage than stress during the neonatal period (β = - 0.19) and prematurity (β = 0.12), and kidney dysfunction and late-onset circulatory collapse were important observed variables in stress during the neonatal period.

CONCLUSIONS

IUGR was more harmful to future kidneys of VLBW neonates. Neonatal kidney dysfunction and late-onset circulatory collapse were important risk factors for subsequent CKD development. This emphasizes the need for obstetricians to monitor for fetal growth restriction and neonatologists to minimize neonatal stress to prevent CKD in later life.

Reproductive risks in 35-year-old adults born very preterm and/or with very low birth weight: an observational study

Evidence suggests that increased survival over the last decades of very preterm (VPT; gestational age < 32 weeks)- and very low birth weight (VLBW; birth weight < 1500 g)-born infants is not matched by improved outcomes. The objective of our study was to evaluate the reproductive rate, fertility, and pregnancy complications in 35-year-old VPT/VLBW subjects. All Dutch VPT/VLBW infants born alive in 1983 and surviving until age 35 (n = 955) were eligible for a POPS-35 study. A total of 370 (39%) subjects completed a survey on reproductive rate, fertility problems, pregnancy complications, and perinatal outcomes of their offspring. We tested differences in these parameters between the VPT/VLBW subjects and their peers from Dutch national registries. POPS-35 participants had less children than their peers in the CBS registry. They reported more problems in conception and pregnancy complications, including a three times increased risk of hypertension during pregnancy.Conclusion: Reproduction is more problematic in 35-year olds born VPT/VLBW than in the general population, possibly mediated by an increased risk for hypertension, but their offspring have no elevated risk for preterm birth. What is known: At age 28, the Dutch national POPS cohort, born very preterm or with a very low birth in 1983, had lower reproductive rates than the general Dutch population (female 23% versus 32% and male 7% versus 22%). What is new: At age 35, the Dutch POPS cohort still had fewer children than the general Dutch population (female 56% versus 74% and male 40% versus 56%). Females in the POPS cohort had a higher risk of fertility problems and pregnancy complications than their peers in the Dutch national registries, but their offspring had no elevated risk for preterm birth.

Evaluation of urine output, lactate levels and lactate clearance in the transitional period in very low birth weight preterm infants

OBJECTIVE

To assess the association between urine output (UO), arterial lactate levels (LL) and lactate clearance with haemodynamic instability and death in very low birth weight (VLBW) preterm in the transitional period.

STUDY DESIGN

Retrospective cohort study with VLBW newborns born in 2016 and 2017, excluding those with malformations and without data. We evaluated 254 preterm infants with a total of 482 lactate levels measured in the first 72 h. Areas under the curve (AUC) were calculated for receiver-operator characteristics (ROC) curves of UO and LL (alone and combined) and of lactate clearance for prediction of haemodynamic instability and death.

RESULTS

All AUC were below 0.80. Sensitivity and specificity were also not very good. Although patients with poor outcomes had lactate levels higher than those with good outcomes, discrimination was poor.

CONCLUSION

UO and LL and lactate clearance were not good predictors of haemodynamic instability or death within 10 days of life. What is Known • It is already established that blood pressure is not a good marker for haemodynamic stability in the preterm infant. • Others clinical parameters, albeit are largely used, are not fully reliable as well. What is New • In our study we tried to determine the sensibility and specificity of urine output and arterial lactate and also the lactate clearance. • All AUC were below 0.80. Sensitivity and specificity were also not very good. Although patients with poor outcomes had lactate levels higher than those with good outcomes, discrimination was poor.

Biliary atresia in a preterm and extremely low birth weight infant: a case report and literature review

Background

Biliary atresia in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants is rarely reported, and the optimal timing of Kasai portoenterostomy (KPE) in these cases remains unclear.

Case presentation

We report a case of biliary atresia in a preterm female infant of 24 weeks of gestation who weighed 824 g. She underwent exploratory laparotomy and intraoperative cholangiography at 58 days of age (weight, 1336 g). Despite the diagnosis of biliary atresia with a type I cyst, we could only perform gallbladder drainage at that time due to the unstable intraoperative condition. While we waited for her body weight to increase, KPE was performed at 122 days of age (corrected age: 16 days), when the patient weighed 2296 g. Although she initially became jaundice-free, her liver function deteriorated due to cholangitis, and she developed decompensated cholestatic liver cirrhosis. Living donor liver transplantation was successfully performed at 117 days after KPE, and the postoperative course was uneventful. The timing of KPE is difficult to determine and a review of the relevant literature revealed that a poor prognosis in VLBW and ELBW infants with BA.

Conclusions

Early KPE and careful postoperative follow-up, including liver transplantation is important for the improvement of outcomes.

Low serum albumin concentration predicts the need for surgical intervention in neonates with necrotizing enterocolitis

PURPOSE

To investigate whether serum albumin (SA) concentration can predict the need for surgical intervention in neonates with necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all cases with NEC Bell's stage 2 and 3 that were treated in a single center between 2009 and 2015. Data on patient demographics, clinical parameters, laboratory findings and surgical status were recorded. Receiver operating characteristics analysis was used to evaluate optimal cutoffs and predictive values.

RESULTS

Overall, 151 neonates with NEC were identified. Of these, 132 (87.4%) had confirmed NEC Bell's stage 2. The median gestational age was 28.4 (range, 23.1-39.0) weeks and 69 (52.3%) had a birth weight of ≤1000 g. Sixty-eight (51.5%) underwent surgery, showing a sustained reduction in SA over time with significantly lower median SA levels compared to 64 (48.5%) cases that responded well to medical treatment (18.3 ± 3.7 g/L vs. 26.0 ± 2.0 g/L; P < 0.001). SA concentration of ≤20 g/L on day 2 of NEC diagnosis was a significant predictor for surgery (OR 3.41; P = 0.019) with a positive predictive value of 71.4%.

CONCLUSIONS

An SA concentration of ≤20 g/L on day 2 of the NEC disease process is associated with a higher likelihood for surgical intervention in neonates with NEC Bell's stage 2. SA, in combination with other clinical parameters and serological markers, may be a useful predictive tool for surgery in NEC.

LEVEL OF EVIDENCE

II.