New Ballard Score, expanded to include extremely premature infants

Survival and morbidity among two cohorts of extremely low birth weight neonates from a tertiary hospital in northern India

This study was conducted to compare the survival and morbidity of extremely low birth weight neonates born during two different time periods (2009-10 and 2001-02) at a Level III referral neonatal unit in Northern India. All consecutive intramural extremely low birth weight neonates (<1000g), irrespective of gestation, and admitted to Intensive Care were enrolled. 149 and 123 neonates were enrolled during 2009-10 and 2001-02, respectively. The baseline characteristics were comparable except for mean birth weight, which was lower during 2009-10 (843±108g vs 885±126g, P=0.003). Surfactant therapy (54% vs 18%, P<0.001), non-invasive ventilation (28% vs 6%, P<0.001), high frequency ventilation (24% vs 4%, P=0.001), IVH (52% vs 25%, P<0.001) and PDA (34% vs 18%, P=0.004) were significantly more during 2009-10. Culture positive sepsis (33% vs 51%, P=0.003) and ROP rates (7% vs 23%, P=0.042) were significantly higher during 2001-02. Overall survival was similar; however, neonates between 28-30 weeks gestation had better survival (63%) during 2009-10 compared to 2001-02 (38%), P=0.009. Survival in neonates 28-30 weeks improved during this period while overall survival remained the same.

Gestational age assessment in malaria pregnancy cohorts: a prospective ultrasound demonstration project in Malawi

Background

Malaria during pregnancy is associated with an increased risk for low birth weight (<2500 grams). Distinguishing infants that are born premature (< 37 weeks) from those that are growth-restricted (less than the 10th percentile at birth) requires accurate assessment of gestational age. Where ultrasound is accessible, sonographic confirmation of gestational age is more accurate than menstrual dating. The goal was to pilot the feasibility and utility of adding ultrasound to an observational pregnancy malaria cohort.

Methods

In July 2009, research staff (three mid-level clinical providers, one nurse) from The Blantyre Malaria Project underwent an intensive one-week ultrasound training to perform foetal biometry. Following an additional four months of practice and remote image review, subjects from an ongoing cohort were recruited for ultrasound to determine gestational age. Gestational age at delivery established by ultrasound was compared with postnatal gestational age assessment (Ballard examination).

Results

One hundred and seventy-eight women were enrolled. The majority of images were of good quality (94.3%, 509/540) although a learning curve was apparent with 17.5% (24/135) images of unacceptable quality in the first 25% of scans. Ultrasound was used to date 13% of the pregnancies when menstrual dates were unknown and changed the estimated gestational age for an additional 25%. There was poor agreement between the gestational age at delivery as established by the ultrasound protocol compared to that determined by the Ballard examination (bias 0.8 weeks, limits of agreement -3.5 weeks to 5.1 weeks). The distribution of gestational ages by Ballard suggested a clustering of gestational age around the mean with 87% of the values falling between 39 and 41 weeks. The distribution of gestational age by ultrasound confirmed menstrual dates was more typical. Using ultrasound confirmed dates as the gold standard, 78.5% of preterm infants were misclassified as term and 26.8% of small-for gestational age infants misclassified as appropriately grown by Ballard.

Conclusion

Ultrasound should be strongly considered in prospective malaria studies with obstetric endpoints to confirm gestational age and avoid misclassification of infants as premature or growth-restricted. The use of ultrasound does require a significant investment of time to maintain quality image acquisition.

Avaliação de fatores que interferem na amamentação na primeira hora de vida

Objetivo: Investigar como o passo 4 da Iniciativa Hospital Amigo da Criança foi aplicado, avaliar a prevalência da amamentação na primeira hora após o nascimento e analisar os fatores associados à não amamentação neste período de vida. Métodos: Estudo transversal conduzido em alojamento conjunto de maternidade de alto risco na cidade do Rio de Janeiro, com entrevista com amostra de 403 puérperas. A Razão de Prevalência, com seu respectivo intervalo de confiança de 95%, foi estimada a partir de modelo com função de ligação complementar log log, através do programa SPSS15® . Resultados: A prevalência de amamentação na primeira hora após o nascimento foi de 43,9%. A análise multivariada evidenciou que foram protegidas contra a não amamentação na primeira hora de vida as mulheres de cor não preta (RP = 0,62; IC 95%: 0,42-0,90), multíparas (RP = 0,66; IC 95%: 0,47-0,93), que fizeram pré-natal (RP = 0,23; IC 95%: 0,08-0,67), com parto normal (RP = 0,41; IC 95%: 0,28-0,60), cujos bebês tiveram peso ao nascer igual ou superior a 2.500g (RP = 0,31; IC 95%: 0,11-0,86) e que receberam ajuda da equipe de saúde para amamentar na sala de parto (RP = 0,51; IC 95%: 0,36-0,72). Conclusão: A ajuda prestada pela equipe de saúde à amamentação ao nascimento, que se constitui no “Passo 4 da Iniciativa Hospital Amigo da Criança”, bem como a cor materna não preta, a multiparidade, a realização de pré-natal, o parto normal e o peso adequado ao nascer contribuíram para o inicio do aleitamento materno na primeira hora de vida.

Universal screening of newborns to detect hearing impairment--is it necessary?

BACKGROUND

In contrast to the recommendations of the Joint Committee on Infant Hearing, neonatal hearing screening programs are still not universally available.

OBJECTIVES

To prospectively evaluate the presence of hearing loss in all newborn babies delivered in our hospital during study period using the transient evoked otoactoustic emission as the primary screening tool followed by confirmation with brainstem evoked response audiometry before six months of age and to determine risk factors responsible for hearing loss.

DESIGN

A prospective study of nonrandomized cohort.

SETTING

Nursery, Postnatal ward and NICU of Tertiary care center.

PARTICIPANTS

500 neonates (439: not at risk; 61: at risk) from a total of 610 neonates born in between 2009 and 2010.

MEASUREMENTS

Incidence of hearing impairment in the "at risk" and "no risk" group was compared, using proportion test.

MAIN OUTCOME MEASURE(S)

Incidence of hearing loss in newborns both "at risk" and in "no risk" group, risk factors responsible for hearing loss, importance of universal newborn hearing screening.

RESULTS

The overall incidence of hearing impairment was 8 per 1000 screened. The incidence in "no risk" and "at risk" group was 2.27 per 1000 screened and 49.18 per 1000 screened respectively. Statistically significant difference in the incidence of hearing impairment between the two groups. (P<0.05; Proportion Test) was seen. Common risk factors identified were culture positive postnatal infections, birth asphyxia, low birth weight, and prematurity.

CONCLUSIONS

A high incidence of hearing impairment warrants the implementation of universal newborn hearing screening. Considering the economic limitations of our country we may employ screening of "at risk" groups initially.

Risk factors for cognitive impairment in school-age children born preterm: application of a hierarchical model

The purpose was to analyze factors associated with cognitive impairment in very low birth weight (VLBW) children born preterm. A prospective cohort of 65 VLBW children was assessed at the age of eight years using the Wechsler Intelligence Scale for Children. A model for the relationship of variables with the cognitive impairment outcome attributed hierarchical levels: distal (socioeconomic variables), intermediate I and II (perinatal and neonatal variables, post-neonatal variables) and proximal (child health and psychosocial stimulation). A multivariate logistic regression was performed. In the multivariate hierarchical logistic regression, the maternal education (OR=0.77, 95%CI 0.63-0.94) and number of prenatal visits (OR=0.73, 95%CI 0.54-0.99) showed a protective association, but the male (OR=7.3, 95%CI 1.54-35.3) was associated with worse results. The VLBW children cognitive performance in the age of eight years benefits from more educated mothers, better prenatal care, and the baby gender as female.

Does mesenchymal stem cell population in umbilical cord blood vary at different gestational periods?

OBJECTIVE

To identify and quantitatively determine Mesenchymal stem cells (MSCs) in the umbilical cord blood (UCB) of neonates born at different gestational periods.

METHODS

UCB was collected at birth in neonates of three different gestational groups. The mononuclear cells (MNCs) were phenotypically analyzed by flow cytometer.

RESULTS

The yield of total MNCs did not differ much with gestation; the average values were 22.6 ± 6.48 × 106 cells/ml. The MSCs were significantly higher in the lower gestation group. These were 0.0219 ± 0.012 %, 0.0044 ± 0.003 % and 0.0022 ± 0.003 % in 28 to 31 wk, 32 to 35 wk and >36 wk, respectively (P = 0.00). There was a significant inverse correlation between the gestational age and the presence of MSCs with a correlation co-efficient of -0.54 (P = 0.0001).

CONCLUSIONS

The MSCs population was significantly higher in infants born at lesser gestation than those born at term gestation.

Exposure to organochlorines and mercury through fish and marine mammal consumption: associations with growth and duration of gestation among Inuit newborns

BACKGROUND

Several studies have reported negative associations of polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB) and mercury (Hg) with duration of gestation and fetal growth in fish eating populations. Docosahexaenoic acid (DHA) from fish, seafood and marine mammal intake has been reported to be positively related with pregnancy duration and fetal growth. So far, it remains unclear, however, if the associations of environmental contaminants (ECs) with growth are direct or mediated through their relation with the duration of gestation and the degree to which DHA intake during pregnancy attenuates the negative association of ECs with fetal growth.

OBJECTIVES

To investigate direct and indirect associations of in utero exposure to ECs with fetal growth and pregnancy duration while taking into account the possible positive effects of DHA.

METHODS

Pregnant Inuit women (N=248) from Arctic Quebec were recruited and cord blood samples were analyzed for PCBs, HCB, Hg and DHA. Anthropometric measurements were assessed at birth. Path models were used to evaluate direct and indirect associations.

RESULTS

Cord concentrations of PCB 153, HCB and Hg were significantly associated with shorter duration of pregnancy (β varying from -0.17 to -0.20, p<0.05). Path models indicated that the associations of PCBs, HCB and Hg with reduced fetal growth (β varying from -0.09 to -0.13, p<0.05) were mediated through their relations with shorter gestation duration. Cord DHA was indirectly related to greater growth parameters (β varying from 0.17 to 0.20, p<0.05) through its positive association with gestation duration.

CONCLUSION

Prenatal exposure to ECs was associated with reduced gestation duration, which is a recognized determinant of fetal growth. DHA intake during pregnancy appeared to have independent positive association with fetal growth by prolonging gestation. Whether these associations are causal remains to be elucidated.

Growth velocity of extremely low birth weight preterms at a tertiary neonatal unit in South Africa

INTRODUCTION

There is wide variation in the feeding practices of extreme low birth weight (ELBW) preterms often guided by tradition and resources. The feeding regimen at Groote Schuur Hospital (GSH) nursery, a tertiary neonatal unit, follows a restricted use of parenteral nutrition and concentrates on early introduction of breast milk. There is a need to determine whether this approach achieves acceptable growth velocity.

OBJECTIVES

This study aims to describe the growth velocity of ELBW babies at GSH.

DESIGN

This was a retrospective cohort study.

METHODOLOGY

Infant hospital records of all ELBW babies born at GSH from 1 March to 31 August 2010 were accessed from a previously collected database and relevant data extracted. Growth data were collected from birth to 8 weeks postnatal age or discharge, whichever came first.

RESULTS

Ninety-one ELBW babies were born during the study period. Forty were excluded from the study. Thirty died before discharge, and 10 were excluded for other reasons. The mean (SD) gestation of the cohort was 28.5 (1.6) weeks, and the median (range) birth weight was 875 (640-995) g. The overall mean (SD) growth velocity was 14 (2.9) g/kg/day. There was no statistically significant association between the growth velocity and the type of feed given, days to establishing full enteral feeds, time to regaining birth weight, HIV exposure status, intra-uterine growth restriction or exposure to antenatal steroids.

CONCLUSION

In our cohort of ELBW infants, growth velocity was within the range currently deemed acceptable by international consensus.

Failure of early nasal continuous positive airway pressure in preterm infants of 26 to 30 weeks gestation

OBJECTIVE

To identify variables associated with early nasal continuous positive airway pressure (ENCPAP) failure in preterm neonates less than 30 weeks gestational age.

STUDY DESIGN

Multicenter prospective study including 131 preterm newborns, over a period of 2 years. Patients and respiratory variables were assessed using univariate analysis.

RESULT

Variables associated with ENCPAP failure were: the need of resuscitation with a FiO(2)>0.30; a CPAP pressure of 6.4±1.2 cm H(2)O; the need of a FiO(2) of 0.40 in the first 4 h of life; male gender maintaining the need of a FiO(2)>0.25 in the first 4 h of life; and respiratory distress syndrome with criteria for surfactant administration.

CONCLUSION

The need for oxygen in resuscitation and maintained in first hours of life, male gender, a CPAP pressure over 5 cm H(2)O and surfactant need are predictors of ENCPAP failure in preterm neonates 26 to 30 weeks gestational age.

Respiratory function in healthy late preterm infants delivered at 33-36 weeks of gestation

OBJECTIVE

To compare pulmonary function testing including respiratory compliance (Crs) and time to peak tidal expiratory flow to expiratory time (TPTEF:TE) at term corrected age in healthy infants born at 33-36 weeks of gestation versus healthy infants delivered at term.

STUDY DESIGN

We performed a prospective cohort study of late preterm infants born at 33-36 weeks without clinical respiratory disease (<12 hours of >0.21 fraction of inspired oxygen) and studied at term corrected age. The comparison group was term infants matched for race and sex to the preterm infants and studied within 72 hours of delivery. Crs was measured with the single breath occlusion technique. A minimum of 50 flow-volume loops were collected to estimate TPTEF:TE.

RESULTS

Late preterm infants (n = 31; mean gestational age 34.1 weeks, birth weight 2150 g) and 31 term infants were studied at term corrected age. The late preterm infants had decreased Crs (1.14 vs 1.32 mL/cm H(2)O/kg; P < .02) and decreased TPTEF:TE (0.308 vs 0.423; P < .01) when compared with the term infants. Late preterm infants also had an increased respiratory resistance (0.064 vs 0.043 cm H(2)O/mL/s; P < .01).

CONCLUSIONS

Healthy late preterm infants (33-36 weeks of gestation) studied at term corrected age have altered pulmonary function when compared with healthy term infants.

Longitudinal growth of very low birth weight neonates during first year of life and risk factors for malnutrition in a developing country

AIMS

To study growth of very low birth weight neonates (VLBW) during first year and identify risk factors for malnutrition.

METHODS

Neonates ≤34 weeks and ≤1500 g enrolled in a human milk fortification trial were prospectively followed till 1 year corrected age (CA). Anthropometry was plotted on WHO charts. Risk factors were compared between well nourished and underweight infants.

RESULTS

One hundred and thirty-two, 127, 110, 99 and 101 neonates were followed at CA of 40 weeks, 3, 6, 9 and 12 months. Weight (Mean Z score -2.3 ± 1.2 to -1.7 ± 1.4; p = 0.005) and length (-2.1 ± 1.5 to -1.5 ± 1.3; p = 0.004) improved significantly, from 40 weeks to one year while head circumference declined (-0.92 ± 1.1 to -1.2 ± 1.1; p < 0.001). Incidence of underweight, stunting, microcephaly and wasting changed from 63%, 53%, 13% and 52% neonates at 40 weeks to 41%, 32%, 21% and 27% at one year. Growth between fortified and unfortified or small for gestational age (SGA) and appropriate for gestational age (AGA) groups were similar, while extremely low birth weight (ELBW) neonates showed poorer growth. Z score of weight at 3 months emerged as an independent predictor of malnutrition at one year.

CONCLUSION

VLBW neonates, especially the ELBW group remained growth retarded at CA of one year. Z score of weight at 3 months was a significant risk factor for malnutrition at one year.

Efeitos da inalação de beclometasona e furosemida sobre a função pulmonar e índice de oxigenação de recém-nascidos prematuros

O objetivo deste estudo foi avaliar a função pulmonar e o índice de oxigenação de recém-nascidos pré-termo submetidos à inalação endotraqueal de beclometasona e furosemida. Foram avaliados 30 recém-nascidos pré-termo com idade gestacional <36 semanas, sob ventilação mecânica convencional por pelo menos 12 horas. Três inalações sequenciais com as respectivas medicações foram realizadas, com intervalo de três horas entre as mesmas. Foram coletadas amostras de sangue arterial para análise dos gases sanguíneos; após aspiração endotraqueal, a mensuração das variáveis respiratórias foi realizada em dois momentos, antes e após duas horas da última inalação. A complacência dinâmica, assim como o índice de oxigenação, não apresentou diferença estatística significativa entre os momentos antes e após as medicações; no entanto, a resistência de vias aéreas demonstrou redução no grupo beclometasona entre os momentos antes e após a intervenção (p=0,03). Diante desses resultados, não podemos afirmar que a beclometasona e a furosemida inalatória exercem influência significativa na função pulmonar e oxigenação dos recém-nascidos estudados.

Preterm birth trends in Greece, 1980-2008: a rising concern

OBJECTIVE

To identify preterm birth trends in Greece.

DESIGN

Retrospective epidemiological study.

SETTING

Women giving birth in Greece from 1980 to 2008.

POPULATION

Live births beyond the 24th gestational week.

METHODS

Data acquisition from the Hellenic Vital Statistics records. Statistical analysis of preterm birth rate among neonates estimated for each year.

MAIN OUTCOME MEASURES

Total number of births and preterm births, as well as rate of preterm birth by gestational week. Stillbirth rates by gestational age.

RESULTS

3 218 463 births occurred during the period under study, 151 594 (4.7%) of which were preterm. A steep rise in preterm births was noted during the final years of the study, reaching 9.6% in 2008. This was mainly due to the "late preterm" sub-group (34(+0) -36(+6) gestational weeks). The rates of stillbirth fell in a constant way regardless of the maturity index.

CONCLUSIONS

Although preterm birth etiology is multifactorial, the selective rise in the "late preterm" group possibly was due to an increase in medical reasons necessitating a preterm delivery, changes in obstetric practice, or both. Further studies are needed to estimate the precise effect of each contributing factor.

Oxygen saturation of healthy term neonates during the first 30 minutes of life

BACKGROUND

The purpose of this study was to document the oxygen saturation (SpO(2) ), general physical signs and laboratory characteristics during the first 30 min of life.

METHODS

Forty healthy singleton full-term neonates delivered vaginally (n = 33) or by cesarean section (n = 7) were included in this prospective observational study. After delivery, the SpO(2) levels of the upper (right hand; 'preductal') and lower (dorsum of the right foot; 'postductal') extremities of the neonates lying on the servo-controlled radiant heater in the delivery room were measured simultaneously with oximeter probes (Oxiprobe BM-270) placed at 1, 5, 10, 15, 20, 25, and 30 min. The correlation between pre- and postductal SpO(2) level and different variables (vital signs, capillary refill time recorded at 1 and 15 min, cord pH and hemoglobin values, and Apgar scores at 1 and 5 min) was examined.

RESULTS

The 1 min pre- and postductal SpO(2) were 82.3 ± 7.34% and 79.08 ± 8.16% (P > 0.05), respectively. The preductal values at 5, 10, and 15 min were statistically higher than the postductal values (89.73 ± 6.01%, 93.43 ± 4.06%, and 94.53 ± 3.19% vs 85.53 ± 6.92%, 89.9 ± 4.91%, 92.83 ± 3.92%, respectively). SpO(2) was the same regardless of the mode of delivery. No correlations were found between pre- and postductal SpO(2) and other variables.

CONCLUSIONS

Oxygen saturation was not affected by mode of delivery, was independent of Apgar score, cord hemoglobin, cord pH, vital signs, and capillary refill time in the first few minutes of life, and did not reach 90% in the first 5 min of life in healthy full-term neonates.

Organochlorine pesticide residues in maternal blood, cord blood, placenta, and breastmilk and their relation to birth size

There is a growing concern that persistent organic pollutants like organochlorine pesticides (OCPs) can impair fetal growth and affect birth size. However, currently available epidemiological evidence is inconclusive. In this case-control study, we examined the association between exposure to hexachlorocyclohexane (HCH) and its isomers (α-HCH, β-HCH and γ-HCH), dichlorodiphenyltrichloroethane (DDT) and dichlorodiphenyldichloroethylene (DDE) and birth size. We recruited 60 infant-mother pairs, comprising of 30 term, small for gestational age babies with their mothers (Case group), and another 30 term, appropriate for gestational age babies with their mothers (Control group). This study was conducted in a tertiary hospital in Delhi, India, between March, 2009 and February 2010. Organochlorine pesticides were estimated in maternal blood, cord blood, placenta and breastmilk samples, using gas-liquid chromatography. Transplacental and transmammary transfer of OCPs was assessed by correlating the maternal blood OCP levels with those in cord blood and breastmilk by simple linear regression. The birthweight, crown heel length, head circumference, mid-arm circumference and ponderal index of the neonates was correlated with OCP levels in the maternal blood, cord blood, placenta and breastmilk. The OCP estimates were compared between samples of the case and control group. There was a significant (P<0.001) transplacental transfer of all OCPs, however the transmammary transfer was insignificant for most OCPs except α-HCH. The OCP levels in the case group were higher than the control group; these were significantly more for t-HCH in cord blood and breastmilk; β-HCH in maternal blood, cord blood and breastmilk; DDE in placenta and DDT in breastmilk. There was a significant negative correlation between birthweight and t-HCH levels in maternal blood (P=0.022), cord blood (P<0.001), placenta (P=0.008) and breastmilk (P=0.005); β-HCH in cord blood (P<0.001) and placenta (P=0.020); γ-HCH in placenta (P=0.045); and DDT (P=0.009). Length at birth had a significant negative correlation with t-HCH in cord blood (P=0.014) and breastmilk (P<0.001); β-HCH in cord blood (P=0.016) and breastmilk (P=0.012); DDE in placenta (P=0.016); and DDT in breastmilk (P=0.006). Similarly, OCP levels were also found to be negatively correlated with head circumference, ponderal index and chest circumference in neonates. We conclude that prenatal exposure to some OCPs could impair the anthropometric development of the fetus, reducing the birthweight, length, head circumference, chest circumference and ponderal index.

Assessment of gestational age using cerebellar measurements at cranial ultrasound: what is the best approach?

BACKGROUND AND AIMS

Clinical assessment of gestational age (GA) in preterm infants can be challenging. Several ultrasound approaches for estimating GA using cerebellar measurements are reported, claiming to be simpler and more accurate than clinical assessment, but they are not widely used. We aimed to compare the accuracy of four previously described measurements and compare their use in preterm infants.

METHODS

We studied infants <32weeks of GA defined by in-vitro fertilization date or early fetal ultrasound, excluding infants with neurological problems. Vermis anterior-posterior diameter (VAPD), vermis height (VH), and transverse cerebellar diameter via anterior (TCDa) and mastoid fontanelles (TCDm) were measured.Estimated PMA was calculated using published equations, and compared to known PMA using intraclass correlation coefficient (ICC). Intra and inter-observer reliability were determined.

RESULTS

We studied 80 infants (mean GA 28.5weeks [range 24-32], mean post-natal age 5.7days). ICC was 0.761 (VAPD), 0.632 (VH), 0.115 (TCDa) and 0.825 (TCDm). The TCDm equation gave the best estimate of GA (mean estimate -2days; 95% CI±13.8days). TCDa and TCDm absolute measurements were similar for each infant. Accuracy for estimating GA was similar for appropriately grown and small-for-gestation infants. Inter and intra-observer reliability was very good for all measurements.

CONCLUSIONS

Three previously described equations for estimating GA from cerebellar measurements gave good estimates of GA in preterms. The equation described for TCDm gave the narrowest 95% CI. We recommend the TCDm equation for the estimation of GA in VLBW infants but the TCD measurement can be made via either the anterior or mastoid fontanelle.

HIV transmission to extremely low birth weight infants

BACKGROUND

Prematurity increases the perinatal HIV transmission rate compared with term infants. There is sparse literature documenting the risk of transmission of HIV to extremely low birth weight (ELBW) infants.

OBJECTIVE

To determine the risk of perinatal transmission of HIV to ELBW infants in a tertiary neonatal unit in South Africa.

METHODS

A prospective database was maintained on all inborn ELBW infants over a 1-year period from March 2010 to February 2011. Survival and DNA HIV polymerase chain reaction results at 6 weeks were recorded.

RESULTS

Of the 180 ELBW infants, 51 (28%) of these babies were HIV exposed. Of these 51 infants, 37 survived until 6 weeks of age. Polymerase chain reaction testing revealed 1 HIV-positive infant for a rate of 2.7% (95% confidence interval: 0.7-14.1%). Twenty-six (72%) of the 36 mothers received antiretroviral drugs, but only 16 (44%) had been treated for more than 1 month.

CONCLUSIONS

The rate of HIV transmission in this cohort of ELBW infants is very low despite only 44% of the mothers receiving adequate antiretroviral drugs. We postulate that this is due to our high (89%) cesarean section rate, universal (100%) infant prophylactic antiretroviral drugs and the use of pasteurized breast milk.

Effect of intermittent kangaroo mother care on weight gain of low birth weight neonates with delayed weight gain

OBJECTIVE

To evaluate intermittent Kangaroo Mother Care (KMC) with additional opportunities to breastfeed on weight gain of low birth weight (LBW) neonates with delayed weight gain.

METHODS

40 LBW neonates were followed to see whether KMC with additional opportunities to breastfeed improved weight gain.

RESULTS

In the KMC group, the mean age of regaining birth weight was significantly less (15.68 vs. 24.56 days) and the average daily weight gain was significantly higher (22.09 vs. 10.39 g, p < .001) than controls.

CONCLUSION

KMC with additional opportunities to breastfeed was found to be an effective intervention for LBWs with delayed weight gain and should be considered to be an effective strategy.

Mortality and morbidity in extremely low birth weight (ELBW) infants in a neonatal intensive care unit

OBJECTIVE

To determine the morbidity and mortality in ELBW babies till discharge from a Neonatal Intensive Care Unit (NICU).

METHODS

This study was a prospective observational study conducted in a 40 bed well equipped level III care NICU between 01.12.2006 and 30.04.2008. All ELBW babies admitted during this period were assessed for morbidities and interventions required during NICU stay and for their outcome like survival or death.

RESULTS

The survival rate of 87 ELBW babies admitted during this period was 56.1 %. Pulmonary hemorrhage was the commonest cause of death (25 %) followed by respiratory distress syndrome (22.5 %), intraventricular hemorrhage (22.5 %) and sepsis (20 %). Significantly higher number of non-survivors were <750 g at birth (p = 0.0001) and <28 wk gestation (p = 0.0001). Small for gestational babies had better chances of survival compared to those appropriate for gestational age (p = 0.005). RDS (67.8 %), probable sepsis (62.1 %) and hyperbilirubinemia (59.8 %) were the most frequent morbidities. Conventional ventilation (72.4 %) and nasal CPAP(48.3 %) were the commonest respiratory interventions. Surfactant replacement therapy was required in 47.1 % babies.

CONCLUSIONS

ELBW babies have a major contribution to mortality in a NICU. Babies with birth weight <750 g and gestation <28 wk have poor survival. RDS, pulmonary hemorrhage, IVH and sepsis are the common causes of death while RDS, sepsis and hyperbilirubinemia are the most common morbidities.

Poor zinc status in early infancy among both low and normal birth weight infants and their mothers in Delhi

BACKGROUND

Low birth weight (LBW) infants are at high risk of zinc deficiency, but there is a paucity of data on their zinc status.

OBJECTIVE

To evaluate zinc status of LBW (BW <2,500 g) and normal birth weight (NBW; BW ≥ 2,500 g) infants at birth and in early infancy.

METHODS

A total of 339 infants (LBW, n = 220; NBW, n = 119) were enrolled, and venous blood samples of mother-infant dyad were taken within 48 h of birth. Infants' levels were repeated between 2 and 10 months of age. Serum zinc levels were estimated using an inductively coupled plasma mass spectrometer. Primary outcome was zinc deficiency, defined as serum zinc <65 µg/dl.

RESULTS

Zinc results were available for 182 LBW and 103 NBW infants at birth and for 100 LBW and 66 NBW infants at follow-up with a median postnatal age of 14 and 15.5 weeks, respectively. Median zinc levels were low and comparable at birth as well as at follow-up, with zinc deficiency being present in 51.0% of LBW and 42.4% of NBW infants at birth and in 79.0% of LBW and 66.7% of NBW infants at follow-up. Zinc levels decreased significantly in both groups from birth to follow-up, irrespective of zinc multivitamin supplementation. Zinc levels of infants with BW <2,000 g at follow-up were significantly lower compared to infants with higher BW.

CONCLUSION

Zinc status was poor in many infants at birth irrespective of BW. Zinc status worsened significantly during early infancy, with infants with BW <2,000 g having the lowest zinc levels.

Inflammatory and haematological markers in the maternal, umbilical cord and infant circulation in histological chorioamnionitis

BACKGROUND

The relationship between histological chorioamnionitis and haematological and biochemical markers in mothers and infants at delivery, and in infants postnatally, is incompletely characterised. These markers are widely used in the diagnosis of maternal and neonatal infection. Our objective was to investigate the effects of histological chorioamnionitis (HCA) on haematological and biochemical inflammatory markers in mothers and infants at delivery, and in infants post-delivery.

METHODS

Two hundred and forty seven mothers, delivering 325 infants, were recruited at the only tertiary perinatal centre in Western Australia. Placentae were assessed for evidence of HCA using a semi-quantitative scoring system. Maternal high sensitivity C-reactive protein (hsCRP), procalcitonin, and umbilical cord hsCRP, procalcitonin, white cell count and absolute neutrophil count were measured at delivery. In infants where sepsis was clinically suspected, postnatal CRP, white cell count and absolute neutrophil count were measured up to 48 hours of age. The effect of HCA on maternal, cord and neonatal markers was evaluated by multivariable regression analysis.

RESULTS

The median gestational age was 34 weeks and HCA was present in 26 of 247 (10.5%) placentae. Mothers whose pregnancies were complicated by HCA had higher hsCRP (median 26 (range 2-107) versus 5.6 (0-108) mg/L; P<0.001). Histological chorioamnionitis was associated with higher umbilical cord hsCRP (75(th) percentile 2.91 mg/L (range 0-63.9) versus 75(th) percentile 0 mg/L (0-45.6); P<0.001) and procalcitonin (median 0.293 (range 0.05-27.37) versus median 0.064 (range 0.01-5.24) ug/L; P<0.001), with a sustained increase in neonatal absolute neutrophil count (median 4.5 (0.1-26.4)×10(9)/L versus 3.0 (0.1-17.8)×10(9)/L), and CRP up to 48 hours post-partum (median 10 versus 6.5 mg/L) (P<0.05 for each).

CONCLUSION

Histological chorioamnionitis is associated with modest systemic inflammation in maternal and cord blood. These systemic changes may increase postnatally, potentially undermining their utility in the diagnosis of early-onset neonatal infection.

Impact of changes in perinatal care on neonatal respiratory outcome and survival of preterm newborns: an overview of 15 years

Survival and outcomes for preterm infants with respiratory distress syndrome (RDS) have improved over the past 30 years. We conducted a study to assess the changes in perinatal care and delivery room management and their impact on respiratory outcome of very low birth weight newborns, over the last 15 years. A comparison between two epochs was performed, the periods before and after 2005, when early nasal continuous positive airway pressure (NCPAP) and Intubation-SURfactant-Extubation (INSURE) were introduced in our center. Three hundred ninety-five clinical records were assessed, 198 (50.1%) females, gestational age 29.1 weeks (22–36), and birth weight 1130 g (360–1498). RDS was diagnosed in 247 (62.5%) newborns and exogenous surfactant was administered to 217 (54.9%). Thirty-three (8.4%) developed bronchopulmonary dysplasia (BPD), and 92 (23%) were deceased. With the introduction of early NCPAP and INSURE, there was a decrease on the endotracheal intubation need and invasive ventilation (P < 0.0001), oxygen therapy (P = 0.002), and mortality (P < 0.0001). The multivariate model revealed a nonsignificant reduction in BPD between the two epochs (OR = 0.86; 95% CI 0.074–9.95; P = 0.9). The changes in perinatal care over the last 15 years were associated to an improvement of respiratory outcome and survival, despite a nonsignificant decrease in BPD rate.

Inflammatory and haematological markers in the maternal, umbilical cord and infant circulation in histological chorioamnionitis

Background

The relationship between histological chorioamnionitis and haematological and biochemical markers in mothers and infants at delivery, and in infants postnatally, is incompletely characterised. These markers are widely used in the diagnosis of maternal and neonatal infection. Our objective was to investigate the effects of histological chorioamnionitis (HCA) on haematological and biochemical inflammatory markers in mothers and infants at delivery, and in infants post-delivery.

Methods

Two hundred and forty seven mothers, delivering 325 infants, were recruited at the only tertiary perinatal centre in Western Australia. Placentae were assessed for evidence of HCA using a semi-quantitative scoring system. Maternal high sensitivity C-reactive protein (hsCRP), procalcitonin, and umbilical cord hsCRP, procalcitonin, white cell count and absolute neutrophil count were measured at delivery. In infants where sepsis was clinically suspected, postnatal CRP, white cell count and absolute neutrophil count were measured up to 48 hours of age. The effect of HCA on maternal, cord and neonatal markers was evaluated by multivariable regression analysis.

Results

The median gestational age was 34 weeks and HCA was present in 26 of 247 (10.5%) placentae. Mothers whose pregnancies were complicated by HCA had higher hsCRP (median 26 (range 2–107) versus 5.6 (0–108) mg/L; P<0.001). Histological chorioamnionitis was associated with higher umbilical cord hsCRP (75^th percentile 2.91 mg/L (range 0–63.9) versus 75^th percentile 0 mg/L (0–45.6); P<0.001) and procalcitonin (median 0.293 (range 0.05–27.37) versus median 0.064 (range 0.01–5.24) ug/L; P<0.001), with a sustained increase in neonatal absolute neutrophil count (median 4.5 (0.1–26.4)×10⁹/L versus 3.0 (0.1–17.8)×10⁹/L), and CRP up to 48 hours post-partum (median 10 versus 6.5 mg/L) (P<0.05 for each).

Conclusion

Histological chorioamnionitis is associated with modest systemic inflammation in maternal and cord blood. These systemic changes may increase postnatally, potentially undermining their utility in the diagnosis of early-onset neonatal infection.

A prospective study of twinning and perinatal mortality in urban Guinea-Bissau

Background

Despite twinning being common in Africa, few prospective twin studies have been conducted. We studied twinning rate, perinatal mortality and the clinical characteristics of newborn twins in urban Guinea-Bissau.

Methods

The study was conducted at the Bandim Health Project (BHP), a health and demographic surveillance site in Bissau, the capital of Guinea-Bissau. The cohort included all newborn twins delivered at the National Hospital Simão Mendes and in the BHP study area during the period September 2009 to August 2011 as well as singleton controls from the BHP study area. Data regarding obstetric history and pregnancy were collected at the hospital. Live children were examined clinically. For a subset of twin pairs zygosity was established by using genetic markers.

Results

Out of the 5262 births from mothers included in the BHP study area, 94 were twin births, i.e. a community twinning rate of 18/1000. The monozygotic rate was 3.4/1000. Perinatal mortality among twins vs. singletons was 218/1000 vs. 80/1000 (RR = 2.71, 95% CI: 1.93-3.80). Among the 13783 hospital births 388 were twin births (28/1000). The hospital perinatal twin mortality was 237/1000.

Birth weight < 2000g (RR = 4.24, CI: 2.39-7.51) and caesarean section (RR = 1.78, CI: 1.06-2.99) were significant risk factors for perinatal twin mortality. Male sex (RR = 1.38, CI: 0.97-1.96), unawareness of twin pregnancy (RR = 1.64, CI: 0.97-2.78) and high blood pressure during pregnancy (RR = 1.77, CI: 0.88-3.57) were borderline non-significant. Sixty-five percent (245/375) of the mothers who delivered at the hospital were unaware of their twin pregnancy.

Conclusions

Twins had a very high perinatal mortality, three-fold higher than singletons. A birth weight < 2000g was the strongest risk factor for perinatal death, and unrecognized twin pregnancy was common. Urgent interventions are needed to lower perinatal twin mortality in Guinea-Bissau.

Cord blood triglycerides are associated with IGF-I levels and contribute to the identification of growth-restricted neonates

OBJECTIVE

The aim of this study was to investigate whether readily available laboratory tests may aid in the identification of growth-restricted neonates.

DESIGN

Cord serum levels of 15 chemical analytes, including insulin-like growth factor I (IGF-I) and insulin-like growth factor binding protein 3 (IGFBP-3) were measured in newborns ≥36 weeks gestational age (GA). Based on the number of anthropometric indices (out of four) with values ≤25th centile for GA, the babies were allocated into three groups, i.e., Group(25)0, Group(25)1 and Group(25)2 corresponding to neonates with 0, 1 and 2 or more indices, respectively, that were ≤25th centile for GA. Furthermore, two composite variables were developed: A25 (Group(25)0 and Group(25)1) and B25 (Group(25)0 and Group(25)2). The data were evaluated by the Mann-Whitney test and multiple regression analyses.

RESULTS

Cord serum triglycerides and total cholesterol levels were significantly higher in Group(25)2 compared to Group(25)0 (p values 0.004 and 0.0009, respectively). The triglycerides almost doubled the power of the variable B25 for predicting IGF-I levels and were found to have a highly significant, negative association with the IGF-I levels (p<0.0001). The IGF-I along with the IGFBP-3 levels explained almost one third of the variation of triglycerides.

CONCLUSION

Cord serum triglycerides can assist in the identification of growth-restricted neonates. The novel finding of the association of triglycerides with IGF-I calls for further research as this can illuminate unknown aspects of the fetal lipid metabolism.

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

OBJECTIVE

To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death.

STUDY DESIGN

Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24  h of life.

RESULT

Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions.

CONCLUSION

In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.

Effects of aggressive parenteral nutrition on growth and clinical outcome in preterm infants

BACKGROUND

The goal of nutrition in the preterm infant is to achieve postnatal growth approximating normal fetal growth. During the early postnatal period, protein intake must be sufficient to achieve normal postnatal growth in extremely low-birthweight infants. The aim of this study was to test the hypothesis that giving higher amounts of amino acids and lipids to infants born at <34 gestational weeks (GW) may improve growth at the 40th week of gestation and have a positive preventive effect on development of retinopathy of prematurity (ROP).

METHODS

Fifty-three neonates born at <34 GW and hospitalized in the neonatal intensive care unit (NICU) were included in this prospective study. They were randomly divided into two groups. Group 1 received aggressive parenteral nutrition (PN) (amino acids 3 g/kg per day and lipids 2 g/kg per day on first day of life). Group 2 received conventional PN (amino acids 1.5 g/kg per day and lipids 1 g/kg per day on first day of life). The anthropometric measurements, clinical outcomes and serum levels of insulin-like growth factor-I (IGF-I), IGF binding protein (IGFBP) and thyroid hormones were compared between groups.

RESULTS

At 40 weeks of gestation, height, head circumference and serum IGF-I and IGFBP3 were statistically higher in the group receiving aggressive PN. Thyroid hormones were not affected by aggressive PN. The lower levels of IGF-I and IGFBP3 in the group receiving conventional PN were negatively correlated with development of ROP.

CONCLUSION

Aggressive PN seems to positively affect neonates' anthropometric measurements at the 40th gestational week and the development of ROP. These effects may be related to high levels of IGF-I and IGFBP3.

Confiabilidade dos dados de uma população de muito baixo peso ao nascer no Sistema de Informações sobre Nascidos Vivos 2005-2006

O objetivo do presente estudo foi avaliar a completitude e a concordância entre informações do Sistema de Informação sobre Nascidos Vivos (SINASC) e registros hospitalares em uma situação de elevado risco neonatal. Foi realizado o relacionamento probabilístico entre dados de uma Unidade de Cuidados Intensivos Neonatal pública e do SINASC (2005-2006), o que tornou possível analisar os dados de 170 nascidos vivos, com muito baixo peso ao nascer (500g - 1.499g) presentes em ambas as bases. As variáveis analisadas foram: idade materna, número de consultas de pré-natal, tipo de parto, sexo, peso ao nascer, Apgar 1º e 5º minutos e idade gestacional. A completitude no SINASC variou de 91,8% (Apgar 1º minuto) a 100% (sexo, parto e idade materna). Para avaliação da concordância foram utilizados o coeficiente kappa para variáveis dicotômicas, o coeficiente kappa ponderado para variáveis ordinais, e o coeficiente de correlação intraclasse (ICC) e a abordagem gráfica de Bland-Altman para variáveis contínuas. A concordância foi considerada boa a excelente para Apgar 1º minuto (kappa = 0,98), tipo de parto (kappa = 0,96), idade materna (ICC 0,95), Apgar 5º minuto (kappa = 0,93), sexo (kappa = 0,92) e consultas de pré-natal (kappa = 0,76); mas apenas razoável para idade gestacional (kappa = 0,50) e peso ao nascer (ICC = 0,57). Embora o peso ao nascer possa ser mais susceptível a erros de registro em uma população de risco neonatal elevado, a elevada confiabilidade observada na maioria das variáveis analisadas corrobora a importância do SINASC como fonte de informações para estudos de epidemiologia perinatal, mesmo para situações de elevado risco neonatal.

Early abnormal amplitude-integrated electroencephalography (aEEG) is associated with adverse short-term outcome in premature infants

BACKGROUND

In preterm infants with IVH the electrocortical background activity is affected and there is a correlation between the severity of cerebral injury to the degree of depression, however the usefulness of the early aEEG recordings has hardly been determined.

AIM

To identify early aEEG features that could be used as prognostic markers for severe brain injury in prematures.

METHODS

In 115 infants, 25-32 wk GA, aEEG recordings during the first 72 h of life were correlated with head ultrasound findings. Continuity (Co), sleep-wake cycling (Cy) and amplitude of the lower border (LB) of the aEEG were evaluated by semi-quantitative analysis.

RESULTS

The infants were divided into four groups based on head ultrasound findings: A (n=72, normal), B [n=16, grades 1-2 intraventricular hemorrhage (IVH)], C (n=21, grades 3-4 IVH) and D (n=6, periventricular leukomalacia). 18 infants (16 of group C and 2 of group D) died during hospitalization. Significantly lower values of all aEEG features were found in group C infants. The presence of pathological tracings (burst-suppression, continuous low-voltage, flat trace) or discontinuous low-voltage (DLV), the absence of Cy and LB<3 μV in the initial aEEG displayed a sensitivity of 88.9%, 63% and 51.9% respectively, for severe brain injury. Logistic regression of aEEG features and GA to the presence or absence of severe injury revealed that only Co was significantly correlated to outcome. Using this feature 83.19% of cases were correctly classified.

CONCLUSION

Pathological tracings or DLV in the initial aEEG is predictive for poor short-term outcome in premature neonates.

Maternal preeclampsia is associated with increased risk of necrotizing enterocolitis in preterm infants

BACKGROUND

Necrotizing enterocolitis (NEC) is an important cause of mortality and morbidity in preterm infants.

AIMS

To evaluate the effect of maternal preeclampsia on the development and severity of NEC in premature infants.

STUDY DESIGN

Prospective observational study in a tertiary neonatal intensive care unit.

SUBJECTS

The preterm infants of ≤ 37 gestational age who were consecutively hospitalized were enrolled. The study group contained preterm infants born to a preeclamptic mother and the comparison group contained preterm infants born to a normotensive mother.

OUTCOME MEASURES

The primary outcome was to determine the association between preeclampsia and NEC.

RESULTS

A total of 88 infants had NEC diagnosis. The incidence of NEC in infants born to preeclamptic mothers (22.9%) was significantly higher compared with those born to normotensive mothers (14.6%). According to NEC stages, NEC was more advanced in preeclamptic mother infants. NEC developed significantly earlier in infants with NEC in the study group. The duration of NEC was also significantly longer in infants born to preeclamptic mothers. In multiple logistic regression model, preeclampsia was found to be predictive of NEC with an odds ratio of 1.74 (95% confidence interval 0.64-0.92).

CONCLUSIONS

Maternal preeclampsia may be an important risk factor for the development of NEC in premature infants as NEC incidence and severity of NEC were found to be significantly higher in premature infants born to preeclamptic mothers. The onset of NEC was significantly earlier and duration of NEC was longer in these infants.

Insulin-like growth factor binding protein-3 in preterm infants with retinopathy of prematurity

BACKGROUND

Retinopathy of prematurity (ROP) is the main cause of visual impairment in preterm newborn infants.

OBJECTIVE

This study was conducted to determine whether insulin-like growth factor binding protein -3 (IGFBP-3) is associated with proliferative ROP and has a role in pathogenesis of the disease in premature infants.

MATERIALS AND METHODS

A total of 71 preterm infants born at or before 32 weeks of gestation participated in this study. Studied patients consisted of 41 neonates without vaso-proliferative findings of ROP as the control group and 30 preterm infants with evidence of severe ROP in follow up eye examination as the case group. Blood samples obtained from these infants 6-8 weeks after birth and blood levels of IGFBP-3 were measured using enzyme-linked immunosorbent assay (ELISA).

RESULTS

The mean gestation age and birth weight of the studied patients were 28.2 ± 1.6 weeks and 1120.7 ± 197 gram in the case group and 28.4 ± 1.6 weeks and 1189.4 ± 454 gram in the control group (P=0.25 and P=0.44 respectively). The infants in the case group had significantly lower Apgar score at first and 5 min after birth. Insulin-like growth factor binding protein -3 (IGFBP-3) was significantly lower in the patients with proliferative ROP than the patients without ROP [592.5 ± 472.9 vs. 995.5 ± 422.2 ng/ml (P=0.009)]. Using a cut-off point 770.45 ng/ml for the plasma IGFBP-3, we obtained a sensitivity of 65.9% and a specificity of 66.7% in the preterm infants with vasoproliferative ROP.

CONCLUSION

Our data demonstrated that the blood levels IGFBP-3 was significantly lower in the patients with ROP and it is suspected that IGFBP-3 deficiency in the premature infants may have a pathogenetic role in proliferative ROP.

Extended interval dosing of gentamicin in premature neonates ≤ 28-week gestation

AIM

To evaluate an extended interval dosing (EID) regimen of gentamicin in neonates ≤28-week gestation.

METHODS

In 2008, an EID regimen for gentamicin was introduced for all neonates admitted to the NICU in Calgary. The dosing interval was based on a 22 h level after the first dose of 5mg/kg. We conducted an observational study in 33 infants ≤28-week gestation on the EID regimen from the first day of life and compared gentamicin peak and trough levels with a historical control of 34 infants who received gentamicin in a dose of 2.5 mg/kg every 24 h (TID, traditional interval dosing).

RESULTS

In the EID group, based on the 22 h level, dosing interval was 36 h in 20 neonates and 48 h in 13 neonates. All neonates, except one, achieved therapeutic peak and trough levels. Compared to the TID group, the EID group had higher peak levels (median 9.8 μg/mL vs. 4.6 μg/mL, p < 0.001) with no difference in trough levels. With target peak levels of 5-12 μg/mL and trough levels of <2 μg/mL, a higher proportion of neonates in the TID group would need dose adjustment.

CONCLUSION

In neonates ≤ 28-week gestation, an EID regimen from day one of life, using a single level 22 h after the first dose for dosing interval, achieves therapeutic peak and trough levels and more optimum peak levels as compared to a TID regimen.

Restrictive guideline reduces platelet count thresholds for transfusions in very low birth weight preterm infants

BACKGROUND AND OBJECTIVES

Platelet transfusions are performed almost entirely according to expert experience. This study assessed the effectiveness of a restrictive guideline to reduce platelet transfusions in preterm infants.

METHODS

A retrospective cohort of preterm infants with a birth weight of <1500 g had been born in 2 periods. In Period 1, a transfusion was indicated for a platelet count of <50,000/ml in clinically stable neonates or <100,000/ml in bleeding or clinically unstable infants. In Period 2, the indications were restricted to <25,000/ml in clinically stable neonates, or <50,000/ml in newborns who were either on mechanical ventilation, subject to imminent invasive procedures, within 72 h following a seizure, or extremely premature and <7 days old. A count of <100,000/ml was indicated for bleeding or major surgery.

RESULTS

Periods 1 and 2 comprised 121 and 134 neonates, respectively. The rates of ventricular haemorrhage and intrahospital death were similar in both periods. The percentage of transfused infants, the odds of receiving a platelet transfusion, the mean platelet count before transfusion and the percentage of transfusions with a platelet count >50,000/ml were greater in Period 1. Among thrombocytopenic neonates, the percentage of transfused neonates and the number of transfusions were similar in both groups.

CONCLUSION

The restrictive guideline for platelet transfusions reduced the platelet count thresholds for neonatal transfusions without increasing the rate of ventricular haemorrhage.

Background rates of adverse pregnancy outcomes for assessing the safety of maternal vaccine trials in sub-Saharan Africa

Background

Maternal immunization has gained traction as a strategy to diminish maternal and young infant mortality attributable to infectious diseases. Background rates of adverse pregnancy outcomes are crucial to interpret results of clinical trials in Sub-Saharan Africa.

Methods

We developed a mathematical model that calculates a clinical trial's expected number of neonatal and maternal deaths at an interim safety assessment based on the person-time observed during different risk windows. This model was compared to crude multiplication of the maternal mortality ratio and neonatal mortality rate by the number of live births. Systematic reviews of severe acute maternal morbidity (SAMM), low birth weight (LBW), prematurity, and major congenital malformations (MCM) in Sub-Saharan African countries were also performed.

Findings

Accounting for the person-time observed during different risk periods yields lower, more conservative estimates of expected maternal and neonatal deaths, particularly at an interim safety evaluation soon after a large number of deliveries. Median incidence of SAMM in 16 reports was 40.7 (IQR: 10.6–73.3) per 1,000 total births, and the most common causes were hemorrhage (34%), dystocia (22%), and severe hypertensive disorders of pregnancy (22%). Proportions of liveborn infants who were LBW (median 13.3%, IQR: 9.9–16.4) or premature (median 15.4%, IQR: 10.6–19.1) were similar across geographic region, study design, and institutional setting. The median incidence of MCM per 1,000 live births was 14.4 (IQR: 5.5–17.6), with the musculoskeletal system comprising 30%.

Interpretation

Some clinical trials assessing whether maternal immunization can improve pregnancy and young infant outcomes in the developing world have made ethics-based decisions not to use a pure placebo control. Consequently, reliable background rates of adverse pregnancy outcomes are necessary to distinguish between vaccine benefits and safety concerns. Local studies that quantify population-based background rates of adverse pregnancy outcomes will improve safety assessment of interventions during pregnancy.

NIDCAP improves brain function and structure in preterm infants with severe intrauterine growth restriction

OBJECTIVE

The effect of NIDCAP (Newborn Individualized Developmental Care and Assessment Program) was examined on the neurobehavioral, electrophysiological and neurostructural development of preterm infants with severe intrauterine growth restriction (IUGR).

STUDY DESIGN

A total of 30 infants, 27-33 weeks gestation, were randomized to control (C; N=17) or NIDCAP/experimental (E; N=13) care. Baseline health and demographics were assessed at intake; electroencephalography (EEG) and magnetic resonance imaging (MRI) at 35 and 42 weeks postmenstrual age; and health, growth and neurobehavior at 42 weeks and 9 months corrected age (9 months).

RESULTS

C and E infants were comparable in health and demographics at baseline. At follow-up, E infants were healthier, showed significantly improved brain development and better neurobehavior. Neurobehavior, EEG and MRI discriminated between C and E infants. Neurobehavior at 42 weeks correlated with EEG and MRI at 42 weeks and neurobehavior at 9 months.

CONCLUSION

NIDCAP significantly improved IUGR preterm infants' neurobehavior, electrophysiology and brain structure. Longer-term outcome assessment and larger samples are recommended.

Frequency and risk factors of fetal malnutrition among liveborn singleton term neonates using a computerised perinatal database, 2000-2006

AIM

The aim of this study was to determine the frequency, risk factors and anthropometric measurements of fetally malnourished, liveborn singleton term neonates.

METHODS

The computed delivery room data of 11.741 liveborn singleton term neonates was used to compare malnourished and nourished newborns.

RESULTS

Of the total subjects, 577 (4.9%) were malnourished. There were no differences between the groups with regard to gender distribution, Apgar scores, maternal parity, smoking during pregnancy and type of delivery. Maternal age and neonatal gestational age (GA) were significantly lower in malnourished newborns (P < 0.001). Birthweight (BW), birth length (BL) and head circumference (HC) were significantly lower in the malnourished group compared with well-nourished group (P < 0.001). Mean BW (g) was 2724.7 ± 17.0 in the malnourished group versus 3234.3 ± 3.8 in the well-nourished group; BL (cm) was 47.8 ± 0.1 in malnourished versus 49.5 ± 0.0 in well-nourished neonates; HC (cm) was 33.25 ± 0.1 in the malnourished versus 34.3 ± 0.0 in the well-nourished group. Between the groups, there were significant differences in the ratio of small, appropriate and large for GA (P < 0.001). Of the malnourished newborns, 35.5% were small for GA, 63.3% were appropriate for GA and 1.2% were large for GA.

CONCLUSION

Fetal malnutrition (FM) still exists despite the advances in current obstetric care. Neonates of adolescent mothers and of low GA are particularly at risk for FM. The BW, BL and HC of fetally malnourished neonates are lower than that of well-nourished neonates. Like term singleton appropriate and small for GA neonates, term singleton large for GA neonates could also have been fetally malnourished.

The effects of environmental noise and infant position on cerebral oxygenation

PURPOSE

To assess how different infant positions and peak sound levels affected cerebral oxygen saturation over time.

SUBJECTS

Twenty-four premature infants who were born less than 32 weeks' gestational age without congenital cardiac, neurologic, and gastrointestinal anomalies.

DESIGN

Repeated-measures design with the first observation between 2 and 48 hours of life; once again between 49 and 96 hours of life; on day of life 7; and every 7 days thereafter until discharge home, transfer to another hospital, or 40 weeks postmenstrual age, whichever came first.

METHODS

Continuous sound levels (decibels) were obtained and 2 infant positions were performed while measuring cerebral oxygen saturation during 40-minute observation periods.

MAIN OUTCOME MEASURES

Effect of peak sound and differences in infant position on cerebral oxygen saturation.

RESULTS

Peak sound levels 5 dB above the average ambient sound level did not significantly change cerebral oxygen saturation values. Differences in cerebral oxygenation were significantly less when infants were changed from a supine, head midline position to a right lateral, 15° head elevation compared with a left lateral, 0° elevation position.

CONCLUSIONS

Aspects of the current neonatal intensive care unit environment do not appear to affect cerebral oxygen saturation.

Size at birth and insulin-like growth factor-I and its binding protein-1 among infants of diabetic mothers

OBJECTIVE

to estimate the association between intrauterine fetal growth, evaluated by anthropometric measurements, and biochemical growth factors; IGF-I and IGBP-1 among IDMs.

METHODS

Cross-sectional study carried out on 69 full term IDMs who was admitted to neonatal intensive care units, Ain Shams University Hospitals. Clinical examination including anthropometric measurements; birth weight, length, head circumference, mid-arm circumference, skinfold thickness at triceps and subscapular areas and placental weight. Laboratory investigations included maternal HbA(1c) and cord blood IGF-I and IGBP-1. They were classified into three groups: 20 small for gestational age (SGA), 25 appropriate for gestational age (AGA) and 24 large for gestational age (LGA).

RESULTS

Most of SGA neonates were born to mothers with type I diabetes, while most of AGA and LGA were born to mothers with gestational diabetes. According to maternal HbA(1c), SGA and LGA neonates were born to metabolically uncontrolled mothers while AGA neonates were born to well-controlled diabetic mothers. Anthropometric measurements had significant positive correlations with IGF-I and negative correlations with IGFBP-1.

CONCLUSIONS

Good control of diabetes during pregnancy is essential to improve fetal growth. There is an opposing effect of cord blood IGF-I and IGFBP-1 on anthropometric measurements.

A new scoring system for evaluation of multiple organ dysfunction syndrome in premature infants

BACKGROUND

The Neonatal Multiple Organ Dysfunction (NEO-MOD) scoring system is used to predict mortality in infants with multiple organ dysfunction syndrome (MODS). The NEOMOD scoring system was extended to include involvement of the microvascular system. This modified scoring system was developed to enable more accurate and earlier diagnosis of MODS in premature infants.

OBJECTIVE

To evaluate the modified NEOMOD scoring system in preterm infants with MODS and compare its effectiveness with the NEOMOD scoring system.

METHODS

This prospective study was performed in a tertiary neonatal intensive care unit. A total of 198 premature infants were enrolled. Infants were evaluated for development of MODS by using the modified NEOMOD scoring system until discharge or death according to clinical and laboratory findings. Infants who had organ dysfunction in 2 or more organ systems had MODS diagnosed.

RESULTS

In the 160 infants (80.8%) with MODS, the gastrointestinal system, respiratory system, and hematologic system were involved most often. The gastrointestinal system, respiratory system, and acid-base metabolism were involved initially in 99.4%, 86.3%, and 26.3% of infants, respectively. The mean modified NEOMOD score for the infants who died in the first 28 days after birth was significantly higher than the mean score for infants who survived. The number of systems involved was also higher in infants who died.

CONCLUSIONS

The modified NEOMOD scoring system is a safe and accurate tool for determining both mortality rate and dysfunction of multiple organ systems affecting mortality in pre-term infants.

Plasma soluble α-klotho protein levels in premature and term neonates: correlations with growth and metabolic parameters

OBJECTIVE

α-Klotho (α-KL), a protein with antiaging properties, regulates phosphate, calcium, and bone metabolism, induces resistance to oxidative stress, and may participate in insulin signaling. The role of α-KL in neonates, known to be prone to metabolic disturbances and oxidative stress, is not known. The aim of this study was to evaluate circulating soluble α-KL concentrations in preterm and full-term neonates and unravel possible correlations with growth, metabolism, and indices of oxidative stress.

DESIGN

Prospective study.

METHODS

Plasma-soluble α-KL levels were determined by specific ELISA in 50 healthy neonates (25 preterm, mean (s.d.) gestational age (GA) 33.7 (1.1) weeks, and 25 full-term infants) at days 14 and 28 of life. Associations of α-KL with anthropometric, metabolic parameters, and indices of oxidative stress were examined.

RESULTS

α-KL levels were significantly higher in full-term than in preterm infants at both days 14 (1099 (480) pg/ml vs 884 (239) pg/ml respectively; P<0.05) and 28 (1277 (444) pg/ml vs 983 (264) pg/ml respectively; P<0.01). In both preterm and full-term infants, α-KL levels increased significantly from day 14 to 28 of life (P<0.001). Circulating α-KL concentrations correlated with GA (β=0.32, P=0.001), body weight (β=0.34, P=0.001), body length (β=0.33, P=0.001), 1,25-dihydroxy-vitamin D level (β=0.24, P<0.05), and malondialdehyde level (β=0.20, P<0.05) but not with glucose, insulin, or homeostasis model assessment index of insulin resistance values.

CONCLUSIONS

Soluble α-KL levels rise as GA and postnatal age advance in neonates and may have an impact on vitamin D metabolism and oxidative stress. Whether α-KL may have a role in the regulation of infants' growth should be further studied.

Curvas de crescimento e perfil dietético de recém-nascidos pré-termo com peso adequado para a idade gestacional durante a hospitalização

OBJETIVO: Elaborar curvas de crescimento e estabelecer o perfil dietético de recém-nascidos pré-termo com peso adequado para a idade gestacional (AIG) durante a internação após o nascimento. MÉTODOS: Estudo coorte retrospectivo e descritivo de recém-nascidos pré-termo AIG, nascidos entre janeiro de 2006 e dezembro de 2007, internados em um hospital de Viçosa, Minas Gerais, Brasil. Foram coletadas informações sobre as medidas antropométricas ao nascer e sua evolução (peso diário e comprimento, perímetro cefálico e torácico semanal) e sobre a evolução diária da dieta. A partir dos dados coletados foram construídas curvas de crescimento referentes às medidas ao nascer e àquelas no pós-natal, em função da idade gestacional, as quais foram comparadas às referências nacionais e internacionais. Além da análise descritiva, foram feitos ajustes por funções polinomiais de terceiro grau para modelação das curvas de crescimento. RESULTADOS: Foram incluídos no estudo 68 recém-nascidos pré-termo AIG, com idade gestacional média de 33,2±2,6 semanas. Observou-se uma grande concordância entre as curvas do percentil 50 das quatro medidas antropométricas ao nascer em estudo e as curvas do percentil 50 de crescimento intrauterino. Entretanto, as curvas do percentil 50 das medidas antropométricas no período pós-natal foram similares às curvas do percentil 10 ou -2 desvios-padrão de crescimento intrauterino. Durante a internação, 84,6% das crianças receberam leite materno; entretanto, a mediana encontrada do percentual dos dias de uso do leite materno em função do tempo de internação foi de somente 50% (2 a 100%). CONCLUSÕES: Os ganhos antropométricos durante o período de internação não reproduzem o ganho intrauterino. Observou-se a necessidade de maior oferta do leite materno durante o período de internação.

Frequency of Premature Infant Engagement and Disengagement Behaviors During Two Maternally Administered Interventions

Although sensitive maternal behaviors improve later quality of mother-infant interaction and subsequently infant development, little is known regarding how an intervention might promote early premature infant social interactive behavior. This study compared the frequency of premature infant engagement and disengagement behaviors during two maternally administered interventions, the multi-sensory auditory, tactile, visual and vestibular intervention (ATVV) and kangaroo care (KC) for 26 infants between 31 and 46 weeks PMA. The ATVV intervention elicited more disengagement (M = 24 vs. 12, p = .0003), trended toward more engagement (M = 21 vs. 15.7, p = .06) and more potent engagement (M = 24 vs. 12, p = .0003), subtle disengagement (M = 25 vs. 11.9, p < .0001), and potent disengagement (M = 22.9 vs. 14, p = . 006) behaviors than did KC. The ATVV intervention may be an intervention to promote the infant's learning how to regulate engagement and disengagement behaviors.

Decreased leptin concentration in neonates is associated with enhanced postnatal growth during the first year

Leptin regulates maternal metabolism and fetal growth by reducing food intake and increasing energy expenditure, particularly during the third trimester. In this study, we investigated the relationships between leptin and growth, and explored the longitudinal change of leptin in early postnatal life. A total of 58 infants were categorized according to gestational length and birth weight. Arterial blood samples were taken within 24 hours (Day 1), and on Days 4 and 7 of life. Plasma leptin levels were measured by commercial human leptin enzyme immunometric assay. The average serum leptin level declined in the first week of life. There was a positive correlation between leptin level and body weight on Day 4. Neonates with leptin decrease between Day 1 and Day 4 had better weight gain at one year old, and the hospital stay day was shorter. Furthermore, the full feeding days and the duration of feeding priming and full feeding days in the leptin decrease group were less than in the leptin increase group. Serum leptin was significantly decreased and positively correlated with neonates' body weight gain in the first week of life. A rapid decline in serum leptin after birth is associated with greater future weight gain and physiological advantage for infants' life.

Malaria prevalence among pregnant women in two districts with differing endemicity in Chhattisgarh, India

Background

In India, malaria is not uniformly distributed. Chhattisgarh is a highly malarious state where both Plasmodium falciparum and Plasmodium vivax are prevalent with a preponderance of P. falciparum. Malaria in pregnancy (MIP), especially when caused by P. falciparum, poses substantial risk to the mother and foetus by increasing the risk of foetal death, prematurity, low birth weight (LBW), and maternal anaemia. These risks vary between areas with stable and unstable transmission. The specific objectives of this study were to determine the prevalence of malaria, its association with maternal and birth outcomes, and use of anti-malarial preventive measures for development of evidence based interventions to reduce the burden of MIP.

Methods

A cross-sectional study of pregnant women presenting to antenatal clinics (ANC) or delivery units (DU), or hospitalized for non-obstetric illness was conducted over 12 months in high (Bastar) and low (Rajnandgaon) transmission districts in Chhattisgarh state. Intensity of transmission was defined on the basis of slide positivity rates with a high proportion due to P. falciparum. In each district, a rural and an urban health facility was selected.

Results

Prevalence of peripheral parasitaemia was low: 1.3% (35/2696) among women at ANCs and 1.9% at DUs (19/1025). Peripheral parasitaemia was significantly more common in Bastar (2.8%) than in Rajnandgaon (0.1%) (p < 0.0001). On multivariate analysis of ANC participants, residence in Bastar district (stable malaria transmission) was strongly associated with peripheral parasitaemia (adjusted OR [aOR] 43.4; 95% CI, 5.6-335.2). Additional covariates associated with parasitaemia were moderate anaemia (aOR 3.7; 95% CI 1.8-7.7), fever within the past week (aOR 3.2; 95% CI 1.2-8.6), and lack of formal education (aOR 4.6; 95% CI 2.0-10.7). Similarly, analysis of DU participants revealed that moderate anaemia (aOR 2.5; 95% CI 1.1-5.4) and fever within the past week (aOR 5.8; 95% CI 2.4-13.9) were strongly associated with peripheral and/or placental parasitaemia. Malaria-related admissions were more frequent among pregnant women in Bastar, the district with greater malaria prevalence (51% vs. 11%, p < 0.0001).

Conclusions

Given the overall low prevalence of malaria, a strategy of enhanced anti-vector measures coupled with intermittent screening and targeted treatment during pregnancy should be considered for preventing malaria-associated morbidity in central India.

Increased incidence of bronchopulmonary dysplasia in preterm infants exposed to preeclampsia

OBJECTIVE

The aims of the study were to determine the effect of preeclampsia on bronchopulmonary dysplasia (BPD) development in preterm infants and to investigate the possible association between BPD severity and preeclampsia.

METHODS

The study group involved preterm infants (≤32 gestational week) born to a preeclamptic mother with no co-existing medical condition, whereas the comparison group involved preterm infants born to a normotensive mother. BPD was defined as requirement for supplemental oxygen for the first 28 days of life and classified as mild, moderate and severe.

RESULTS

There were a total of 117 and 215 premature infants that were born to a preeclamptic mother and a normotensive mother, respectively. The incidence of BPD in preterm infants born to preeclamptic mothers (38.5%) was significantly higher than those born to normotensive mothers (19.5%). Frequencies of moderate and severe BPD were significantly higher in the infants born to preeclamptic mothers. Moderate and severe BPD was also significantly higher in infants born to a mother with severe preeclampsia compared with a mother with mild preeclampsia. In logistic regression model, preeclampsia was found to be predictive of BPD.

CONCLUSIONS

Preeclampsia was found to be an important risk factor for BPD development in preterm infants. The incidence of both moderate and severe BPD was significantly higher in infants born to preeclamptic mothers. These findings might be associated with altered angiogenesis in the preeclamptic mother which might be shared by the fetus.