New Ballard Score, expanded to include extremely premature infants

Effect of intrauterine growth pattern on serum visfatin concentrations in full-term infants at birth and at 6 months of life

OBJECTIVE

Visfatin is a hormone discovered in fat cells and is directly related to diabetes. We aimed to investigate the relationship between intrauterine growth pattern and serum visfatin concentrations in full-term infants at birth and at 6 months of life.

METHODS

Cord blood visfatin concentrations were assessed in 90 full-term neonates enrolled into; Group I: 30 appropriate for gestational age (AGA) neonates to healthy mothers, Group II: 30 intra-uterine growth restricted (IUGR) neonates, 19 were born to mothers with pre-eclampsia, Group III: 30 large for gestational age (LGA) neonates, 16 were infants of diabetic mothers (IDMs). Neonates were followed up at six months of age for visfatin concentrations.

RESULTS

Cord blood visfatin concentrations were increased in IUGR compared to AGA group (p = 0.002). Cord blood visfatin concentrations were increased in LGA compared to AGA and IUGR groups (P <  0.001, P <  0.001). Cord blood visfatin concentrations were positively correlated to birth weight in AGA, LGA groups (r = 0.39, p = 0.045, r = 0.449, p = 0.013 respectively). Visfatin concentrations in neonates born to mothers with pre-eclampsia and IDMs were higher than in those born to mothers without pre-eclampsia and to non-diabetic mothers (p = 0.040, p = 0.002 respectively). At six months, serum visfatin concentrations decreased compared to cord blood visfatin concentrations in IUGR and LGA groups (p <  0.001). Levels in LGA were still higher than IUGR (p = 0.004). Serum visfatin concentrations were positively correlated to cord visfatin in IUGR neonates (r = 0.497, p = 0.005).

CONCLUSION

Cord blood visfatin concentrations were increased in LGA and IUGR neonates. At six months, serum visfatin concentrations decreased compared to cord blood visfatin concentrations in LGA and IUGR groups, still higher in the former than the latter.

Breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy

BACKGROUND

Specific breastfeeding and swallowing characteristics in neonates with hypoxic-ischaemic encephalopathy (HIE) have not yet been well described in the literature. Considering the relatively high incidence of HIE in resource-poor settings, speech-language therapists should be cognisant of the feeding difficulties in this population during breastfeeding.

OBJECTIVE

To systematically describe the breastfeeding and swallowing of a single case of a neonate diagnosed with mild HIE from admission to discharge.

METHOD

A case study of a 2-day old neonate with mild HIE in a neonatal intensive care unit at an urban teaching hospital, is presented. Data were prospectively collected during four sessions in a 12-day period until the participant's discharge. Feeding and swallowing were assessed clinically, as well as instrumentally using a video-fluoroscopic swallow study.

RESULTS

After parenteral feeding, nasogastric tube feeding commenced. Breastfeeding was introduced on Day 6, as it was considered a safe option, and revealed problematic rooting, shallow latching, short sucking bursts, infrequent swallowing, and a drowsy state of arousal, with coughing and choking. No penetration or aspiration was identified instrumentally. After 13 days, the neonate was breastfeeding safely.

CONCLUSION

Although the pharyngeal stage of swallowing was intact, symptoms of oral stage dysphagia were revealed using a combination of clinical and instrumental measures. Breastfeeding difficulties were identified, exacerbated by poor state regulation, which lead to prolonged hospitalisation. The case study highlights the unexpected long duration of feeding difficulties in an infant with mild HIE and indicates further research.

Artemisinin-based combination therapy in pregnant women in Zambia: efficacy, safety and risk of recurrent malaria

Background

In Zambia, malaria is one of the leading causes of morbidity and mortality, especially among under five children and pregnant women. For the latter, the World Health Organization recommends the use of artemisinin-based combination therapy (ACT) in the second and third trimester of pregnancy. In a context of limited information on ACT, the safety and efficacy of three combinations, namely artemether–lumefantrine (AL), mefloquine–artesunate (MQAS) and dihydroartemisinin–piperaquine (DHAPQ) were assessed in pregnant women with malaria.

Methods

The trial was carried out between July 2010 and August 2013 in Nchelenge district, Luapula Province, an area of high transmission, as part of a multi-centre trial. Women in the second or third trimester of pregnancy and with malaria were recruited and randomized to one of the three study arms. Women were actively followed up for 63 days, and then at delivery and 1 year post-delivery.

Results

Nine hundred pregnant women were included, 300 per arm. PCR-adjusted treatment failure was 4.7% (12/258) (95% CI 2.7–8.0) for AL, 1.3% (3/235) (95% CI 0.4–3.7) for MQAS and 0.8% (2/236) (95% CI 0.2–3.0) for DHAPQ, with significant risk difference between AL and DHAPQ (p = 0.01) and between AL and MQAS (p = 0.03) treatments. Re-infections during follow up were more frequent in the AL (HR: 4.71; 95% CI 3.10–7.2; p < 0.01) and MQAS (HR: 1.59; 95% CI 1.02–2.46; p = 0.04) arms compared to the DHAPQ arm. PCR-adjusted treatment failure was significantly associated with women under 20 years [Hazard Ratio (HR) 5.35 (95% CI 1.07–26.73; p = 0.04)] and higher malaria parasite density [3.23 (95% CI 1.03–10.10; p = 0.04)], and still women under 20 years [1.78, (95% CI 1.26–2.52; p < 0.01)] had a significantly higher risk of re-infection. The three treatments were generally well tolerated. Dizziness, nausea, vomiting, headache and asthenia as adverse events (AEs) were more common in MQAS than in AL or DHAPQ (p < 0.001). Birth outcomes were not significantly different between treatment arms.

Conclusion

As new infections can be prevented by a long acting partner drug to the artemisinins, DHAPQ should be preferred in places as Nchelenge district where transmission is intense while in areas of low transmission intensity AL or MQAS may be used.

Patterns of admission and factors associated with neonatal mortality among neonates admitted to the neonatal intensive care unit of University of Gondar Hospital, Northwest Ethiopia

Introduction

The neonatal period is a highly vulnerable time for an infant completing many of the physiologic adjustments required for life outside the uterus. As a result, there are high rates of morbidity and mortality. The three major causes of mortality in developing countries include prematurity, infection, and perinatal asphyxia. The aim of this study was to identify the patterns of neonatal admission and factors associated with mortality among neonates admitted at the Neonatal Intensive Care Unit (NICU) of University of Gondar Hospital.

Materials and methods

A retrospective cross-sectional study was conducted among all admitted neonates in the NICU of University of Gondar referral hospital from December 1, 2015 to August 31, 2016. Information was extracted retrospectively during admission from patient records and death certificates, using a pretested questionnaire. The data were entered and analyzed using SPSS version 20, and p-values <0.05 were considered statistically significant.

Results

A total of 769 neonates was included in the study. There were 448 (58.3%) male neonates, and 398 (51.8%) neonates were rural residents. More than two-thirds of the 587 deliveries (76.3%) were performed in tertiary hospitals. Neonatal morbidity included hypothermia 546 (71%), sepsis 522 (67.9%), prematurity 250 (34.9%), polycythemia 242 (31.5%), hypoglycemia 142 (18.5), meconium aspiration syndrome 113 (14.7%), and perinatal asphyxia 96 (12.5%). The overall mortality was 110 (14.3%; 95% confidence interval [CI]: 11.9-16.9) of which 69 (62.7%) deaths occurred in the first 24 hours of age. In the multivariate analysis, mortality was associated with perinatal asphyxia (adjusted odds ratio [AOR]: 5.97; 95% CI: 3.06-11.64), instrumental delivery (AOR: 2.99; 95% CI: 1.08-8.31), and early onset neonatal sepsis (AOR: 2.66; 95% CI: 1.62-6.11).

Conclusion

Hypothermia, sepsis, and prematurity were the main reasons for NICU admission. Neonates often died within the first 24 hours of age. Implementing a better referral link and timely intervention could decrease neonatal mortality and morbidities in Gondar, Ethiopia.

Improving early identification of HIV-infected neonates with birth PCR testing in a large urban hospital in Johannesburg, South Africa: successes and challenges

Introduction: Timely diagnosis is necessary to avert early death in HIV-infected neonates. Birth PCR testing may improve early identification and facilitate access to care. We implemented a birth HIV diagnosis programme in Johannesburg, South Africa and present successes and challenges of the first two and a half years of operation.

Methods: Between June 2014 and December 2016, we sought to identify all HIV-exposed births and offer newborn HIV PCR testing before discharge after delivery. The programme identified newly delivered women who had tested positive during pregnancy and provided post-partum HIV antibody testing for women without recent negative results. HIV-positive women were required to consent for neonatal birth testing and asked to return a week later to obtain their results. Neonatal venous blood was sampled and tested at the national laboratory using Roche COBAS® TaqMan® HIV-1 Qualitative Test (Version 2.0). Non-negative results triggered active follow-up for confirmatory testing and appropriate treatment.

Results: Of 30,591 women with live births, 6864 (22.4%) were known to be HIV positive and an additional 221 women (1.4% of those tested) were identified during maternal postnatal testing. Of 7085 HIV-positive women, 6372 (89.9%) were interviewed and agreed to data collection, 6358 (99.8%) consented to birth testing for 6467 neonates and a blood sample was collected for 6377 (98.6%). If tested, 6210 (97.4%) tested negative, 91 (1.4%) positive, 57 (0.9%) revealed errors and 19 (0.3%) were indeterminate . Seven of the 19 neonates with indeterminate results and one with initial error result were found to be infected on subsequent testing yielding an intrauterine transmission rate of 1.6% (95% CI: 1.3–1.9). Sixteen (16%) of 99 infected infants were born to women (n = 221) identified during postnatal testing. With active outreach, 95/99 (96%) infected infants were initiated on antiretroviral therapy. Of 6261 neonates with negative results, 3251 (52%) returned to receive their test results.

Conclusion: Our programme successfully achieved high coverage and uptake of birth PCR testing and was able, with active tracking, to start almost all identified HIV-infected neonates on antiretroviral therapy. Implementation required additional staff for counselling, quality control and outreach. Return for negative results was low and neonates with indeterminate results required multiple repeat tests.

Oxidative stress in preeclamptic mother - newborn dyads and its correlation with early neonatal outcome - a case control study

BACKGROUND

Preeclamptic mothers are likely to have increased oxidative stress during pregnancy which can adversely affect the outcome in their neonates.

OBJECTIVES

To measure the oxidative stress in preeclamptic mother- newborn dyads and correlate it with the immediate neonatal outcome.

METHODS

This case control study conducted in a tertiary care teaching hospital, South India included 71 preeclamptic mothers - newborn dyads (cases) and 72 normal mothers - newborn dyads (controls). Biochemical parameters including total antioxidant status (TAS), protein carbonyls and malondialdehyde levels (MDA) were measured in both maternal and cord blood. Association between these oxidative stress parameters and early neonatal outcome was studied.

RESULTS

All oxidative stress markers were higher in the preeclampsia group compared to the controls. Cord blood protein carbonyl levels had significant correlation with maternal levels. Prematurity, low-birth weight, respiratory distress syndrome (RDS), early onset sepsis (EOS) and intra-uterine growth restriction (IUGR) were more among cases. Early neonatal outcomes like death, IUGR, EOS, and RDS had significant correlation with protein carbonyl levels among the cases.

CONCLUSIONS

Oxidative stress is increased in preeclamptic mother - newborn dyads. Increased protein carbonyl levels in preeclampsia correlate with adverse early neonatal outcome.

Severe Vitamin D Deficiency in Human Immunodeficiency Virus-Infected Pregnant Women is Associated with Preterm Birth

Background Low maternal vitamin D has been associated with preterm birth (PTB). Human immunodeficiency virus (HIV)-infected pregnant women are at risk for PTB, but data on maternal vitamin D and PTB in this population are scarce. Methods In a cohort of Latin American HIV-infected pregnant women from the National Institute of Child Health and Human Development International Site Development Initiative protocol, we examined the association between maternal vitamin D status and PTB. Vitamin D status was defined as the following 25-hydroxyvitamin D levels: severe deficiency (< 10 ng/mL), deficiency (10-20 ng/mL), insufficiency (21-29 ng/mL), and sufficiency (≥30 ng/mL). PTB was defined as delivery at < 37 weeks' gestational age (GA). Logistic regression was used to assess the association between maternal vitamin D status and PTB. Results Of 715 HIV-infected pregnant women, 13 (1.8%) were severely vitamin D deficient, 224 (31.3%) were deficient, and 233 were (32.6%) insufficient. Overall, 23.2% (166/715) of pregnancies resulted in PTB (median GA of PTBs = 36 weeks [interquartile range: 34-36]). In multivariate analysis, severe vitamin D deficiency was associated with PTB (odds ratio = 4.7, 95% confidence interval: 1.3-16.8]). Conclusion Severe maternal vitamin D deficiency is associated with PTB in HIV-infected Latin American pregnant women. Further studies are warranted to determine if vitamin D supplementation in HIV-infected women may impact PTB.

Prediction of 3- to 5-Month Outcomes from Signs of Acute Bilirubin Toxicity in Newborn Infants

OBJECTIVE

To evaluate the ability of the bilirubin-induced neurologic dysfunction (BIND) score to predict residual neurologic and auditory disability and to document the relationship of BIND score to total serum bilirubin (TSB) concentration.

STUDY DESIGN

The BIND score (assessing mental status, muscle tone, and cry patterns) was obtained serially at 6- to 8-hour intervals in 220 near-term and full-term infants with severe hyperbilirubinemia. Neurologic and/or auditory outcomes at 3-5 months of age were correlated with the highest calculated BIND score. The BIND score was also correlated with TSB.

RESULTS

Follow-up neurologic and auditory examinations were performed for 145/202 (72%) surviving infants. All infants with severe acute bilirubin encephalopathy (BIND scores 7-9) either died or suffered residual neurologic and auditory impairment. Of 24 cases with moderate encephalopathy (BIND 4-6), 15 (62.5%) resolved following aggressive intervention and were normal at follow-up. Three of 73 infants with mild encephalopathy (BIND scores 1-3) but severe jaundice (TSB ranging 33.5-38 mg/dL; 573-650 µmol/L) had residual neurologic and/or auditory impairment. A BIND score ≥4 had a specificity of 87.3% and a sensitivity of 97.4% for predicting poor neurologic outcomes (receiver operating characteristic analysis). BIND scores trended higher with severe hyperbilirubinemia (r² = 0.54, P < .005), but 5/39 (13%) infants with TSB ≥36.5 mg/dL (624 µmol/L) had BIND scores ≤3, and normal outcomes at 3-5 months.

CONCLUSIONS

The BIND score can be used to evaluate the severity of acute bilirubin encephalopathy and predict residual neurologic and hearing dysfunction.

Anterior Superior Iliac Spine to the Tibial Tuberosity Length: An Easier, Accurate, and Faster Method for Predicting Orogastric Tube Length in Neonates-An Observational Study

Orogastric tube (OGT) procedures are done in 20% of newborn unit cases. This study was contemplated to work out a formula to predict OGT length in terms of femur length in neonates and its agreement to existing standards. In this observational study, OGT length was estimated using NEMU (nose-ear-mid umbilicus) in 53 consecutive newborns. Their anterior superior iliac spine to tibial tuberosity length (AS-TT) was measured and equated using linear regression analysis in Stata. We further verified the accuracy of the new formula and comparison of time taken by both the methods. Strong positive correlation was seen between OGT and AS-TT (r = .88). OGT length was 10.14 + 0.88 AS-TT, which can be used in neonatal intensive care unit newborns with greater accuracy and with lesser time than the classical method. Strong agreement levels were seen. AS-TT closely relates to the femur length and can be chosen as a guide as it is faster when compared to other methods.

MANAGEMENT OF ENDOCRINE DISEASE: Growth and growth hormone therapy in short children born preterm

Approximately 15 million babies are born preterm across the world every year, with less than 37 completed weeks of gestation. Survival rates increased during the last decades with the improvement of neonatal care. With premature birth, babies are deprived of the intense intrauterine growth phase, and postnatal growth failure might occur. Some children born prematurely will remain short at later ages and adult life. The risk of short stature increases if the child is also born small for gestational age. In this review, the effects of being born preterm on childhood growth and adult height and the hormonal abnormalities possibly associated with growth restriction are discussed, followed by a review of current information on growth hormone treatment for those who remain with short stature during infancy and childhood.

Effect of Early Physical Activity Programs on Motor Performance and Neuromuscular Development in Infants Born Preterm: A Randomized Clinical Trial

Introduction: Although the survival rate of infants born preterm has increased, the prevalence of developmental problems and motor disorders among this population of infants remains the same. This study investigated the effect of physical activity programs in and out of water on motor performance and neuromuscular development of infants born preterm and had induced immobility by mechanical ventilation. Methods: This study was carried out in Al-Zahra hospital, Tabriz. 76 premature infants were randomly assigned into four groups. One group received daily passive range of motion to all extremities based on the Moyer-Mileur protocol. Hydrotherapy group received exercises for shoulders and pelvic area in water every other day. A combination group received physical activity programs in and out of water on alternating days. Infants in a containment group were held in a fetal position. Duration of study was two weeks 'from 32 through 33 weeks post menstrual age (PMA). Motor outcomes were measured by the Test of Infant Motor Performance. Neuromuscular developmental was assessed by New Ballard scale and leg recoil and Ankle dorsiflexion items from Dubowitz scale. Data were analyzed using SPSS version 13. Results: TIMP and neuromuscular scores improved in all groups. Motor performance did not differ between groups at 34 weeks PMA. Postural tone of leg recoil was significantly higher in physical activity groups post intervention. Conclusion: Physical activities and containment didn't have different effects on motor performance in infants born preterm. Leg recoil of neuromuscular development items was affected by physical activity programs.

The role of serum apelin in retinopathy of prematurity

Objective

To evaluate the role of serum apelin as a diagnostic tool in retinopathy of prematurity (ROP) disease.

Patients and methods

Thirty-eight preterm infants (60% male) with gestational age ranging from 30 to 36 weeks admitted to the neonatal intensive care unit, KJO Hospital, Saudi Arabia with proven diagnosis of ROP were included in the study. In addition, 27 preterm infants without ROP served as controls. All newborn infants in the study were subjected to adequate history taking, full clinical examination, and fundus examination by indirect ophthalmoscope (at 4–6 weeks) as well as determination of serum apelin at birth and at 4–6 weeks of age.

Results

The study revealed that oxygen therapy longer than 7 days’ duration, cesarean section (as a mode of delivery), sepsis, mechanical ventilation, blood transfusion, premature rupture of membranes, pneumothorax, perinatal asphyxia, cardiac problems, and neonatal jaundice were considered as risk factors related to development of ROP. Serum apelin levels were significantly lower in patients than controls (P<0.001) at time of diagnosis of the disease (4–6 weeks) while no significant differences were observed in levels at birth.

Conclusion

Serum apelin was found to be of significant diagnostic value in the occurrence of ROP.

Infant mortality and morbidity associated with preterm and small-for-gestational-age births in Southern Mozambique: A retrospective cohort study

Background

Preterm and small for gestational age (SGA) births have been associated with adverse outcomes during the first stages of life. We evaluated the morbidity and mortality associated with preterm and SGA births during the first year of life in a rural area of Southern Mozambique.

Methods

This is a retrospective cohort study using previously collected data from children born at the Manhiça District Hospital in two different periods (2003–2005 and 2010–2012). Newborns were classified as being preterm and/or SGA or as babies not fulfilling any of the previous conditions (term non-SGA). All children were followed up for a year for morbidity and mortality outcomes.

Results

A total of 5574 live babies were included in the analysis. The prevalence of preterm delivery was 6.2% (345/5574); the prevalence of SGA was 14.0% (776/5542) and 2.2% (114/5542) of the children presented both conditions. During the neonatal period, preterm delivery and SGA were associated with 13 (HR: 13.0, 95% CI 4.0–42.2) and 5 times (HR: 4.5, 95% CI: 1.6–12.6) higher mortality compared to term non SGA babies. Risk of hospitalization was only increased when both conditions were present (IRR: 3.5, 95%CI: 1.5–8.1). Mortality is also increased during the entire first year, although at a lower rate.

Conclusions

Neonatal and infant mortality rates are remarkably high among preterm and SGA babies in southern Mozambique. These increased rates are concentrated within the neonatal period. Prompt identification of these conditions is needed to implement interventions aimed at increasing survival of these high-risk newborns.

The Effect of Early Feeding on Initial Glucose Concentrations in Term Newborns

OBJECTIVE

To evaluate the influence of early feeding on initial glucose concentrations in healthy term newborns who were not at risk for hypoglycemia.

STUDY DESIGN

This retrospective observational study was conducted at the University of Arkansas for Medical Sciences where universal early glucose screening was standard of care for newborn infants. Plasma glucose concentrations were compared in term infants born in 2008 who were not at risk for neonatal hypoglycemia and who were fed before (early feeders) and after (late feeders) their initial glucose screens. Multiple linear regression models were built to determine whether glucose concentrations differed significantly between early vs late feeders.

RESULTS

In the 315 early and 572 late feeders, the mean (SD) age of first feeding was 0.9 (0.6) and 3.8 (2.0) hours, respectively. The age at initial glucose specimen collection was 2.2 (1.1) and 1.8 (0.8) hours, respectively. The initial glucose concentration was not higher in early vs late feeders (51.8 ± 11.9 vs 55.5 ± 13.3 mg/dL; P < .001). In linear regression analyses of all infants, the mean initial glucose concentration was 3.61 (95% CI 1.75-5.48) mg/dL lower in early vs late feeders.

CONCLUSIONS

Early feeding in otherwise healthy term newborns did not increase initial glucose concentrations compared with newborns who fed later (ie, fasted). Before direct evidence is available, these observations may be instructive for managing early asymptomatic hypoglycemia in at-risk newborns.

Reliability of transcutaneous bilirubinometry from shielded skin in neonates receiving phototherapy: a prospective cohort study

OBJECTIVE

To determine the agreement between transcutaneous bilirubin (TcB) measured from shielded skin and serum total bilirubin (STB) in infants (34 to 41 weeks of gestation) with hyperbilirubinemia receiving phototherapy (PT).

STUDY DESIGN

In this prospective cohort study, we shielded a small area of skin on sternum using a commercial photo-opaque patch (BilEclipseTM, Philips Respironics, Murrysville, PA, USA). The TcB from the shielded skin (TcBs) and STB were measured at four time points-before initiation, 12 and 24 h during and once after (12 h) cessation of PT. TcB was measured using multiwavelength transcutaneous bilirubinometer (BiliChek, Philips Children's Medical Ventures, Monroeville, PA, USA). The STB was measured in triplicate by spectrophotometry (Apel BR 5100, APEL, Japan). Bland and Altman plots were drawn to determine agreement between the TcBs and STB.

RESULTS

The gestation and birth weight of enrolled neonates were 37.0 (1.0) weeks and 2750 (458) g, respectively. The age at initiation and duration of PT were 75 (27 to 312) and 25.3 (4.4) h, respectively. Bland and Altman plot showed poor agreement between TcBs and STB at all time points. The gradient (median, range) between TcBs and STB at 0, 12, 24 h and 12 h after cessation of PT were -0.2 (-4.9 to 3.5), 1.4 (-4.7 to 4.0), 1.5 (-3.8 to 9.4) and 2 (-2.9 to 5.8) mg dl^-1. The proportions of TcBs values outside ±1.5 mg dl^-1 of STB ranged from 47 to 64% at four time points.

CONCLUSION

TcBs does not appear to be reliable for estimating serum bilirubin in late preterm and term neonates receiving PT.

Healthy Preterm Newborns Show an Increased Frequency of CD4(+) CD25(high) CD127(low) FOXP3(+) Regulatory T Cells with a Naive Phenotype and High Expression of Gut-Homing Receptors

Treg cells are crucial to prevent immune dysregulation, but little is known about the frequency of these cells in neonates, particularly in very/moderate and late preterm newborns studied as separate groups. The CD4(+) CD25(hi) CD127(lo) FOXP3(+) Treg population was phenotypically characterized to assess maturation markers and gut-homing integrins by flow cytometry in the cord blood of healthy preterm newborns born at 30-33(6/7) gestation weeks (Group 1), at 34-36(6/7) gestation weeks (Group 2) and term newborns born at 37-41 gestation weeks (Group 3), compared to healthy adults. An inverse correlation of the Treg percentage and gestational age was found, with significantly higher frequencies in Group 1 compared to Groups 2 and 3 and in Group 2 compared to Group 3, and significantly higher Treg frequencies and numbers in the neonates compared to the adults. All of the newborns exhibited increased Treg frequencies with a naive phenotype compared to adults. Cytotoxic T-lymphocyte-associated protein 4 CTLA-4 expression in the naive Treg was decreased in both preterm groups compared with those from term newborns and adults, and in the memory Treg from Group 1 compared with the other groups. The frequencies of Treg expressing α4β7 and α4β1 integrins were higher in both preterm groups, but significantly different only in Group 1, when compared with those from the term newborns and the adults. In conclusion, although a high frequency of Treg is present in newborns, an immature phenotype with a higher expression of CD45RA and α4β7/α4β1 and a lower expression of CTLA-4 is found, particularly in the very preterm group.

Factors associated with inter-institutional variations in sepsis rates of very-low-birth-weight infants in 34 Malaysian neonatal intensive care units

INTRODUCTION

This study aimed to determine whether patient loads, infant status on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis rates in very-low-birth-weight (VLBW) infants in the Malaysian National Neonatal Registry (MNNR).

METHODS

This was a retrospective study of 3,880 VLBW (≤ 1,500 g) infants admitted to 34 neonatal intensive care units (NICUs) in the MNNR. Sepsis was diagnosed in symptomatic infants with positive blood culture.

RESULTS

Sepsis developed in 623 (16.1%) infants; 61 (9.8%) had early-onset sepsis (EOS) and 562 (90.2%) had late-onset sepsis (LOS). The median EOS rate of all NICUs was 1.0% (interquartile range [IQR] 0%, 2.0%). Compared with NICUs reporting no EOS (n = 14), NICUs reporting EOS (n = 20) had significantly higher patient loads (total live births, admissions, VLBW infants, outborns); more mothers with a history of abortions, and antenatal steroids and intrapartum antibiotic use; more infants requiring resuscitation procedures at birth; higher rates of surfactant therapy, pneumonia and insertion of central venous catheters. The median LOS rate of all NICUs was 14.5% (IQR 7.8%, 19.2%). Compared with NICUs with LOS rates below the first quartile (n = 8), those above the third quartile (n = 8) used less intrapartum antibiotics, and had significantly bigger and more mature infants, more outborns, as well as a higher number of sick infants requiring ventilator support and total parenteral nutrition.

CONCLUSION

Patient loads, resuscitation at birth, status of infants on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis.

Heated Humidified High Flow Nasal Cannula versus Nasal Continuous Positive Airway Pressure as Primary Mode of Respiratory Support for Respiratory Distress in Preterm Infants

OBJECTIVE

To compare the outcomes of preterm infants with respiratory distress initiated on either Heated Humidified High Flow Nasal Cannula or Nasal Continuous Positive Airway Pressure as a primary mode of respiratory support.

STUDY DESIGN

Prospective observational cohort study.

SETTING

Tertiary care level III neonatal intensive care unit.

PARTICIPANTS

88 preterm infants between 28 to 34 weeks of gestation with mild to moderate respiratory distress within 6 hours of birth.

INTERVENTION

Eligible infants were treated either with Heated Humidified High Flow Nasal Cannula (n=46) or Nasal Continuous Positive Airway Pressure (n=42).

PRIMARY OUTCOME

Need for mechanical ventilation within 72 hrs of initiating support.

RESULTS

Baseline demographic characteristics were comparable between the two groups. There was no difference in the requirement of mechanical ventilation between Heated Humidified High Flow Nasal Cannula (19.5%) and Nasal Continuous Positive Airway Pressure (26.2%) groups [RD-0.74 (95% CI 0.34-1.62; P =0.46)]. Moderate or severe nasal trauma occurred less frequently with Heated Humidified High Flow Nasal Cannula (10.9%) in comparison to Nasal Continuous Positive Airway Pressure (40.5%) (P= 0.004).

CONCLUSIONS

Heated Humidified High Flow Nasal Cannula was comparable to Nasal Continuous Positive Airway Pressure as a primary respiratory support for preterm infants with respiratory distress, with lesser incidence of nasal trauma.

Maternal exposure to carbon monoxide and fine particulate matter during pregnancy in an urban Tanzanian cohort

Low birthweight contributes to as many as 60% of all neonatal deaths; exposure during pregnancy to household air pollution has been implicated as a risk factor. Between 2011 and 2013, we measured personal exposures to carbon monoxide (CO) and fine particulate matter (PM2.5 ) in 239 pregnant women in Dar es Salaam, Tanzania. CO and PM2.5 exposures during pregnancy were moderately high (geometric means 2.0 ppm and 40.5 μg/m3 ); 87% of PM2.5 measurements exceeded WHO air quality guidelines. Median and high (75th centile) CO exposures were increased for those cooking with charcoal and kerosene versus kerosene alone in quantile regression. High PM2.5 exposures were increased with charcoal use. Outdoor cooking reduced median PM2.5 exposures. For PM2.5 , we observed a 0.15 kg reduction in birthweight per interquartile increase in exposure (23.0 μg/m3 ) in multivariable linear regression; this finding was of borderline statistical significance (95% confidence interval 0.30, 0.00 kg; P = 0.05). PM2.5 was not significantly associated with birth length or head circumference nor were CO exposures associated with newborn anthropometrics. Our findings contribute to the evidence that exposure to household air pollution, and specifically fine particulate matter, may adversely affect birthweight.

Factors affecting efficacy of packed red blood cell transfusion in neonates

The degree of increase in haematocrit and equilibration time following packed red blood cell (PRBC) transfusion in neonates is not well studied. We evaluated change in haematocrit 15 min, 6 h and 24 h after PRBC transfusion in neonates and factors predicting this change. Among neonates receiving PRBC transfusion, we recorded pre-transfusion haematocrit and a priori identified putative variables affecting change in haematocrit following transfusion. The factors affecting change in haematocrit were analyzed by multiple linear regression analysis. Eighty-one neonates received 119 PRBC transfusions (mean volume 16 ± 4 mL/kg). Haematocrit increased from 26 ± 5 to 41 ± 5% at 15 min after PRBC transfusion (p = 0.001) and remained stable till 6 h (41 ± 5%, p = 0.11). It decreased to 40 ± 5%, at 24 h post transfusion (p < 0.001). On linear regression analysis, baseline haematocrit of the baby, donor blood haematocrit and volume of PRBC transfusion were independent determinants of increase in haematocrit.

CONCLUSION

After 16 mL/kg PRBC transfusion in neonates, haematocrit increased by 15% at 15 min post transfusion. The equilibration in haematocrit values was achieved by 15 min after transfusion. Baseline haematocrit of neonate, donor blood haematocrit and transfusion volume independently determine the rise in haematocrit. What is Known: • Rise in haematocrit following PRBC transfusion in neonates has been studied in a small number of stable infants. • Determinants of efficacy of PRBC transfusion have not been well studied in newborns. What is New: • Each milliliter/kilogramme of PRBC transfusion increases the neonate's haematocrit by approximately 1%. • Baseline haematocrit, donor blood haematocrit and transfusion volume per kilogramme body weight independently determine the rise in haematocrit.

Assessment of developmental outcome in very low birth weight infants in Southern Africa using the Bayley Scales of Infant Development (III)

OBJECTIVES

The study aimed to compare the developmental outcome of very low birth weight infants with a group of normal-term controls in a tertiary hospital in sub-Saharan Africa.

DESIGN

A group of 105 very low birth weight infants were assessed at a mean age of 17.6 months (95% CI 16.7 to 18.6) using the Bayley Scales of Infant Development, Third Edition, and compared with a group of normal-term controls at the same mean age.

RESULTS

Seven of the study infants (7%) had developmental delay (a score below 70), compared with none in the control group (p=0.04). Three of the seven study infants were delayed on all three subscales, one of whom had cerebral palsy. A further 34% of the study infants were 'at risk' of developmental delay (a score below 85). There was no difference in the mean composite score between the study group and controls for the cognitive (p=0.56), motor (p=0.57) or language (p=0.66) subscales. There was no difference in mean composite scores on all subscales between infants who were appropriate for gestational age and those who were small for gestational age. Cognitive and motor scores remained stable in paired assessments of study infants before and after 1 year of age; language scores decreased significantly (p<0.001). Mechanical ventilation was the only risk factor significantly associated with a cognitive score below 85 in study infants.

CONCLUSION

Very low birth weight infants in sub-Saharan Africa are at risk of developmental delay and require long-term neurodevelopmental follow-up.

Placental Pathology Associated with Household Air Pollution in a Cohort of Pregnant Women from Dar es Salaam, Tanzania

BACKGROUND

Smoke from the burning of biomass fuels has been linked with adverse pregnancy outcomes such as low birth weight, stillbirth, and prematurity.

OBJECTIVE

To identify potential underlying mechanisms of adverse perinatal outcomes, we explored the association of placental pathology with household air pollution in pregnant women from urban/periurban Tanzania who cook predominantly with charcoal.

METHODS

Between 2011 and 2013, we measured personal exposures to fine particulate matter (PM2.5) and carbon monoxide (CO) over 72 hr among a cohort of Tanzanian pregnant women. Placentas were collected after delivery for examination. Placental pathologies of inflammatory, hypoxic, ischemic/hypertensive, infectious and thrombotic etiologies were diagnosed, blinded to exposure levels. Using multiple logistic regression, we explored the association of PM2.5 and CO exposure with placental pathology.

RESULTS

One hundred sixteen women had personal air exposure measurements and placental histopathology available for analysis. PM2.5 and CO exposures were moderate [geometric means (GSD) were 40.5 μg/m3 (17.3) and 2.21 ppm (1.47) respectively]; 88.6% of PM2.5 measurements exceeded World Health Organization air quality guidelines. We observed an increase in the odds (per 1-unit increase in exposure on the ln-scale) of fetal thrombotic vasculopathy (FTV) both with increasing PM2.5 [adjusted odds ratio (aOR) = 5.5; 95% CI: 1.1, 26.8] and CO measurements (aOR = 2.5; 95% CI: 1.0, 6.4) in adjusted models only. FTV also was more common among pregnancies complicated by stillbirth or low birth weight.

CONCLUSIONS

Fetal thrombosis may contribute to the adverse outcomes associated with household air pollution from cook stoves during pregnancy. Larger studies are necessary for confirmation. Citation: Wylie BJ, Matechi E, Kishashu Y, Fawzi W, Premji Z, Coull BA, Hauser R, Ezzati M, Roberts D. 2017. Placental pathology associated with household air pollution in a cohort of pregnant women from Dar es Salaam, Tanzania. Environ Health Perspect 125:134-140; http://dx.doi.org/10.1289/EHP256.

Assessment of serum apolipoprotein B and apolipoprotein A-1 and their ratio in healthy full term small for gestational age newborns

BACKGROUND

Programmed changes in growth restricted fetuses can increase the risk of adulthood diseases due to elevated serum cholesterol and apolipoprotein-B (Apo-B) concentrations. Increasing evidence demonstrated the role of apoB/apoA-I ratio as a strong risk factor for cardiovascular diseases.

OBJECTIVE

To determine the concentration of cord blood lipoproteins and apolipoproteins as well as their correlation with birth weight.

METHODS

This cross-sectional study was conducted in a teaching institution in central India. Healthy full-term newborns, born out of normal vaginal deliveries, were recruited. Cases include term small for gestational age (SGA) babies while term appropriate for gestational age (AGA) babies were taken as controls. Their umbilical venous blood was collected and sent for biochemical analysis.

RESULTS

Out of 126 healthy newborns, 66 were cases and 60 were controls. Mean values of serum triglyceride (141.56±69.67 mg/dl vs. 113.67±33.38 mg/dl; p < 0.006; 95% CI = 8.31 to 47.46) and serum apo-B/apo-A-1 ratio (0.67±0.28 vs. 0.55±0.20; p < 0.007; 95% CI = 0.033 to 0.206) were significantly high and that of serum high density cholesterol (35.84±10.42 mg/dl vs. 40.73±11.70 mg/dl; p < 0.014; 95% CI = -8.79 to -0.98) and Apo-A1 [87.59±12.44 mg/dl vs. 101.87±35.07 mg/dl; p = 0.002; 95% CI = -23.39 to -5.16) were significantly low in SGA newborns. Serum cholesterol, very low-density cholesterol rlow-density cholesterol rand Apo-B did not show any significant difference. Among SGA newborns significant negative correlation was seen between birth weight and apo-B/apo-A1 and serum triglyceride, while birth weight and serum apo-A1 level showed significant positive correlation. There was no statistically significant correlation between birth weight and other parameters.

CONCLUSION

These findings further support the association of prenatal factors with lipid profile rand can serve as starting point for studying lipid transport system changes during early life in Indian population.

Intestinal Bacterial Colonization in the First 2 Weeks of Life of Nigerian Neonates Using Standard Culture Methods

OBJECTIVE

The pattern and timing of development of intestinal microflora in Nigerian infants have been scarcely researched. This study was carried out to investigate the bacteria flora in the rectum of healthy neonates in Ibadan, Nigeria.

PATIENTS AND METHODS

In this hospital-based longitudinal study, rectal swabs of 70 neonates were taken within 6-12 h of birth (day 1) and subsequently on days 3, 9, and 14. Information collected included maternal sociodemographic characteristics, antibiotic use for the neonates, and type of feeding during the first 14 days of life. Identification and speciation of gram-negative isolates were done using the Analytical Profile Index 20E® and 20NE® as appropriate. Gram-positive bacteria were identified biochemically using the catalase and coagulase tests. Data were analyzed using descriptive statistics and Chi-square at p = 0.05.

RESULTS

Majority (92.9%) of the neonates were delivered vaginally with a median gestational age of 38 weeks (range = 34-42). On the first day of life, Escherichia coli was isolated more frequently from the rectal swabs of preterm (50.0%) than term (23.1%) neonates (p = 0.031). On day 3 of life, coagulase-negative staphylococcus was the most frequently isolated bacteria from the rectal swabs of nonasphyxiated (64.4%) compared with asphyxiated (27.3%) neonates' rectal swabs (p = 0.042). Staphylococcus aureus was the most frequently isolated bacteria from the rectal swabs of nonexclusively breastfed (66.7%) than exclusively breastfed (21.3%) neonates on day 14 (p = 0.004).

CONCLUSION

Staphylococcus aureus and Escherichia coli were the predominant isolates from the rectum of Nigerian neonates, and these isolates were influenced by breastfeeding and mild-moderate asphyxia. In all, bacterial diversity in the rectum increased as the neonates got older.

Preterm newborns at Kangaroo Mother Care: a cohort follow-up from birth to six months

OBJECTIVE:

To evaluate clinical outcomes, growth and exclusive breastfeeding rates in premature infants assisted by Kangaroo Mother Care at birth, at discharge and at six months of life.

METHODS:

Prospective study of a premature infants cohort assisted by Kangaroo Mother Care in a tertiary public maternity in Northeast Brazil with birth weight ≤1750g and with clinical conditions for Kangaroo care.

RESULTS:

The sample was composed by 137 premature infants, being 62.8% female, with average birth weight of 1365±283g, average gestational age of 32±3 weeks and 26.2% were adequate for gestational age. They have been admitted in the Kangaroo Ward with a median of 13 days of life, weighing 1430±167g and, at this time, 57.7% were classified as small for corrected gestational age. They were discharged with 36.8±21.8 days of chronological age, weighing 1780±165g and 67.9% were small for corrected gestational age. At six months of life (n=76), they had an average weight of 5954±971g, and 68.4% presented corrected weight for gestational age between percentiles 15 and 85 of the World Health Organization (WHO) weight curve. Exclusive breastfeeding rate at discharge was 56.2% and, at six months of life, 14.4%.

CONCLUSIONS:

In the studied sample, almost two thirds of the children assisted by Kangaroo Mother Care were, at six months of life, between percentiles 15 and 85 of the WHO weight curves. The frequency of exclusive breastfeeding at six months was low.

Preterm birth: Case definition & guidelines for data collection, analysis, and presentation of immunisation safety data

Preterm birth is commonly defined as any birth before 37 weeks completed weeks of gestation. An estimated 15 million infants are born preterm globally, disproportionately affecting low and middle income countries (LMIC). It contributes directly to estimated one million neonatal deaths annually and is a significant contributor to childhood morbidity. However, in many clinical settings, the information available to calculate completed weeks of gestation varies widely. Accurate dating of the last menstrual period (LMP), as well as access to clinical and ultrasonographic evaluation are important components of gestational age assessment antenatally. This case definition assign levels of confidence to categorisation of births as preterm, utilising assessment modalities which may be available across different settings. These are designed to enable systematic safety evaluation of vaccine clinical trials and post-implementation programmes of immunisations in pregnancy.

Early Discharge of Preterm Infants- An Indian Perspective

INTRODUCTION

Early home discharge of preterm infants is a priority in developing countries due to bed shortage and poor socio-economic status. There is wide variation in home discharge policies for preterm infants. Limited data exists on optimal timing for discharging such infants. In view of the socio-economic and medico-legal importance of the issue, we aimed to study the outcomes of our ex-preterm infants discharged home 'early', to guide our clinical practice.

AIM

To study the rates of re-admissions/mortality within 4 weeks after discharge in preterm (born <34 weeks) infants.

MATERIALS AND METHODS

This was an analysis of retrospectively collected data on all ex-preterm infants (gestation <34 weeks at birth) discharged home from our Neonatal Intensive Care Unit (NICU) during the study period. Infants enrolled were stratified based on their gestation age: Group I (n=54): 26-29 weeks, Group II (n=181): 30-34 weeks. Data on demographic characteristics, hospital course and outcomes were analysed for infants meeting inclusion criteria. Re-admission and/or mortality within 4 weeks after discharge were studied.

RESULTS

The mean±(SD) duration of stay was 42±19 vs. 19±14 days in group I vs. II infants. Five (2.7%) infants were re-admitted within the first four weeks after discharge in group II; none in group I.

CONCLUSION

Early home discharge for preterm infants born <34 weeks was feasible and safe in our set-up. Large prospective studies are required to confirm these benefits.

Neurodevelopment of preterm infants born after in vitro fertilization and spontaneous multiple pregnancy

BACKGROUND

The aim of this study was to compare perinatal, neonatal characteristics and neurodevelopmental prognosis of preterm infants born after in vitro fertilization (IVF) and spontaneous multiple pregnancy, and to evaluate the factors affecting neurodevelopmental outcome at 24-36 months.

METHODS

A total of 125 preterm infants, 65 from spontaneous and 60 from IVF multiple pregnancy were evaluated in terms of neurodevelopmental outcome at the age of 24-36 months. Mean maternal age, chronic maternal disease, birthweight, gestational week, gender, APGAR score, neonatal intensive care unit admission, presence of congenital anomalies, referral to follow up, rehospitalization and socioeconomic status were investigated. Gross Motor Function Classification System and Denver II Developmental Screening Test were carried out. Local ethics committee approved the study (12.10.2010; no: 305).

RESULTS

Mean maternal age, chronic maternal illness, pregnancy-related diseases, 5 min APGAR score, rate of cesarean delivery and referral to follow up were significantly higher in the IVF group (P < 0.05). Neurological examination identified increased muscle tone in two children (1.6%); only one infant in the IVF group had cerebral palsy. A total of 26 subjects (20.8%; spontaneous group, n =17, 26.2%; IVF group, n = 9, 15%) had abnormal Denver II findings, mostly in language (8.8%) and personal-social (8.0%) development.

CONCLUSION

Morbidity, length of hospitalization and neurodevelopmental outcome of preterm infants born after spontaneous and IVF multiple pregnancy are similar. Delays in language and personal-social development were the most common neurodevelopmental abnormalities. Even within similar socioeconomic status, parents in the IVF group were more compliant with follow up.

ABM Clinical Protocol #10: Breastfeeding the Late Preterm (34-36 6/7 Weeks of Gestation) and Early Term Infants (37-38 6/7 Weeks of Gestation), Second Revision 2016

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Assessment of Adequacy of Supplementation of Vitamin D in Very Low Birth Weight Preterm Neonates: A Randomized Controlled Trial

OBJECTIVES

To compare the effect of 400 IU and 1000 IU vitamin D for 6 weeks in very low birth weight preterm neonates.

DESIGN

Randomized, double-blinded controlled trial in a teaching hospital.

PARTICIPANTS

Fifty very low birth weight preterm neonates.

INTERVENTION

Vitamin D 400 IU/day (Group 1) or 1000 IU/day (Group 2).

OUTCOME MEASURES

Change in serum calcium, phosphate, alkaline phosphatase (ALP), 25-hydroxy vitamin D (25-OHD), parathormone, incidence of skeletal hypomineralization and growth.

RESULTS

After 6 weeks of supplementation, the mean serum calcium and 25-OHD levels were significantly higher (p  <  0.001 each), while ALP and parathormone levels significantly lower (p  <  0.001 each) in group 2. Skeletal hypomineralization was lesser and growth better in group 2.

CONCLUSION

Vitamin D supplementation in a dose of 1000 IU/day is more effective in maintaining serum calcium, phosphate, ALP, 25-OHD and parathormone levels with lower incidence of skeletal hypomineralization and better growth.

Red Palm Oil Supplementation: A Feasible Diet-Based Approach to Improve the Vitamin A Status of Pregnant Women and Their Infants

This double-blinded, randomized, controlled study was designed to study the effect of dietary supplementation with red palm oil during pregnancy on maternal and neonatal vitamin A status. A total of 170 women were recruited at 16 to 24 weeks of gestation and randomly assigned to an experimental group that received red palm oil to supply approximately one recommended dietary amount (RDA) (2,400 μg) of β-carotene or to a control group that received an equivalent volume of groundnut oil. The women received the oils for a period of 8 weeks, starting at 26 to 28 weeks of gestation and extending to 34 to 36 weeks of gestation. The mean postintervention (34 to 36 weeks) levels of serum retinol were 1.20 ± 0.22 (SD) μmol/L (95% CI, 1.15–1.25) in women receiving red palm oil and 0.73 ± 0.15 μmol/L (95% CI, 0.69–0.77) in their infants; these levels were significantly higher than those in women receiving groundnut oil (1.07 ± 0.26 μmol/L; 95% CI, 1.01–1.13; p < .01) and their infants (0. 62 ± 0.17 μmol/L; 95% CI, 0.57–0.67; p < .001). A significantly lower proportion of women in the red palm oil group than in the control group had vitamin A deficiency (serum retinol levels < 0.7 μmol/L) after intervention (1.5% vs. 9.7%). The proportion of women having anemia was significantly lower (p < .01) in the red palm oil-supplemented group (80.6%) than in the control group (96.7%). The mean birthweight and gestational age of the infants did not differ significantly between the two groups. An increased risk of low birthweight (p = . 003) and preterm delivery (p = . 000) was observed with decreasing serum retinol levels in the third trimester of pregnancy. These results show that red palm oil supplementation significantly improved maternal and neonatal vitamin A status and reduced the prevalence of maternal anemia. Maternal vitamin A status in the later part of pregnancy is significantly associated with fetal growth and maturation. Hence red palm oil, a rich source of bioavailable vitamin A, could be used as a diet-based approach for improving vitamin A status in pregnancy.

Utilizing Infant Cry Acoustics to Determine Gestational Age

OBJECTIVES/HYPOTHESIS

The date of last menstruation period and ultrasonography are the most commonly used methods to determine gestational age (GA). However, if these data are not clear, some scoring systems performed after birth can be used. New Ballard Score (NBS) is a commonly used method in estimation of GA. Cry sound may reflect the developmental integrity of the infant. The aim of this study was to evaluate the connection between the infants' GA and some acoustic parameters of the infant cry.

STUDY DESIGN

A prospective single-blind study was carried out.

METHODS

In this prospective study, medically stable infants without any congenital craniofacial anomalies were evaluated. During routine blood sampling, cry sounds were recorded and acoustic analysis was performed. Step-by-step multiple linear regression analysis was performed.

RESULTS

The data of 116 infants (57 female, 59 male) with the known GA (34.6 ± 3.8 weeks) were evaluated and with Apgar score of higher than 5. The real GA was significantly and well correlated with the estimated GA according to the NBS, F0, Int, Jitt, and latency parameters. The obtained stepwise linear regression analysis model was formulized as GA=(31.169) - (0.020 × F0)+(0.286 × GA according to NBS) - (0.003 × Latency)+(0.108 × Int) - (0.367 × Jitt). The real GA could be determined with a ratio of 91.7% using this model.

CONCLUSIONS

We have determined that after addition of F0, Int, Jitt, and latency to NBS, the power of GA estimation would be increased. This simple formula can be used to determine GA in clinical practice but validity of such prediction formulas needs to be further tested.

trans Fatty Acids in Colostrum, Mature Milk and Diet of Lactating Adolescents

The purpose of this study was to investigate the trans fatty acids (TFA) content and distribution in colostrum, mature milk, and diet of adolescent mothers, after TFA declaration in food labels became mandatory in Brazil. Participants were healthy adolescents (n 54, 15-19 years, 1-90 days postpartum) practicing exclusive breastfeeding. Milk samples were collected 3 days after delivery (colostrum) and in the third month postpartum (mature milk) by hand expression. The fatty acid composition of the milk samples was determined by gas chromatography. TFA intake corresponded to 1.23 % of total energy value. Total 18:2 TFA accounted for less than 0.5 % of the energy intake. The amount of total 18:1 TFA (mean ± SEM) was 1.9 % ± 0.14 in colostrum and 1.5 % ± 0.2 in mature milk. The total content of n-3 PUFA was inversely correlated with the total content of 18:1 TFA in colostrum. Both in colostrum and in mature milk, vaccenic acid (11t-18:1) was found to be the most abundant 18:1 trans isomer, followed by elaidic acid (9t-18:1), whereas rumenic acid (9c,11t-18:2 CLA) was the predominant 18:2 trans isomer. In conclusion, the levels of TFA of industrial sources found in the mother's diet and breast milk (colostrum and mature milk) showed a decrease in relation to those observed in studies conducted prior to the TFA labeling resolution in Brazil. However, the current low intake levels of n-3 LCPUFA and DHA content in the milk of lactating adolescents may be insufficient for supporting adequate neurological development of the infants.

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns

OBJECTIVE

To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants.

METHOD

Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed.

RESULTS

560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications.

CONCLUSION

Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room.

Repercussions of preterm birth on symptoms of asthma, allergic diseases and pulmonary function, 6-14 years later

BACKGROUND

Prevalence of allergic diseases and impaired pulmonary function may be high in children born prematurely. This study aimed to assess pulmonary function and prevalence of asthma, atopic diseases and allergic sensitisation in these patients.

METHODS

A cross-sectional study was conducted with children aged 6-14 years who were born prematurely with birth weight <2000g from January 2008 to May 2011. Exclusion criteria were: major malformations, or acute respiratory disorders. The International Study of Asthma and Allergies in Childhood questionnaire was applied followed by allergic skin prick test and spirometry.

RESULTS

The study included 84 children aged 9.3±2.3 years born at mean gestational age of 31.8±2.4 weeks. The prevalence of current asthma was 25%, more severe asthma was 15.5%; rhinitis was 38.1%; flexural eczema was 8.3%; and a positive skin-prick test was 69.6%. Frequencies of children with values <80% of predicted were: FVC (8.3%), FEV₁ (22.6%), and FEV₁/FVC ratio (16.7%). Prevalence of children with FEF_25-75% <70% of the predicted value was 32.4%, positive bronchodilator response was observed in 20.5% of cases, and altered pulmonary function in 42.9%. Factors associated with altered pulmonary function were oxygen dependency at 28 days of life (OR: 4.213, p=0.021), the presence of wheezing in childhood (OR: 5.979, p=0.014) and infant's height (OR: 0.945, p=0.005).

CONCLUSIONS

There was a high prevalence of severe asthma, allergic sensitisation, and altered pulmonary function among children and adolescents born prematurely. Bronchopulmonary dysplasia and a history of wheezing were risk factors for altered pulmonary function.

Comparison of gestational dating methods and implications for exposure-outcome associations: an example with PM2.5 and preterm birth

OBJECTIVES

Estimating gestational age is usually based on date of last menstrual period (LMP) or clinical estimation (CE); both approaches introduce potential bias. Differences in methods of estimation may lead to misclassification and inconsistencies in risk estimates, particularly if exposure assignment is also gestation-dependent. This paper examines a 'what-if' scenario in which alternative methods are used and attempts to elucidate how method choice affects observed results.

METHODS

We constructed two 20-week gestational age cohorts of pregnancies between 2000 and 2005 (New Jersey, Pennsylvania, Ohio, USA) using live birth certificates: one defined preterm birth (PTB) status using CE and one using LMP. Within these, we estimated risk for 4 categories of preterm birth (PTBs per 10⁶ pregnancies) and risk differences (RD (95% CIs)) associated with exposure to particulate matter (PM_2.5).

RESULTS

More births were classified preterm using LMP (16%) compared with CE (8%). RD divergences increased between cohorts as exposure period approached delivery. Among births between 28 and 31 weeks, week 7 PM_2.5 exposure conveyed RDs of 44 (21 to 67) for CE and 50 (18 to 82) for LMP populations, while week 24 exposure conveyed RDs of 33 (11 to 56) and -20 (-50 to 10), respectively.

CONCLUSIONS

Different results from analyses restricted to births with both CE and LMP are most likely due to differences in dating methods rather than selection issues. Results are sensitive to choice of gestational age estimation, though degree of sensitivity can vary by exposure timing. When both outcome and exposure depend on estimate of gestational age, awareness of nuances in the method used for estimation is critical.

An epigenetic clock for gestational age at birth based on blood methylation data

Background

Gestational age is often used as a proxy for developmental maturity by clinicians and researchers alike. DNA methylation has previously been shown to be associated with age and has been used to accurately estimate chronological age in children and adults. In the current study, we examine whether DNA methylation in cord blood can be used to estimate gestational age at birth.

Results

We find that gestational age can be accurately estimated from DNA methylation of neonatal cord blood and blood spot samples. We calculate a DNA methylation gestational age using 148 CpG sites selected through elastic net regression in six training datasets. We evaluate predictive accuracy in nine testing datasets and find that the accuracy of the DNA methylation gestational age is consistent with that of gestational age estimates based on established methods, such as ultrasound. We also find that an increased DNA methylation gestational age relative to clinical gestational age is associated with birthweight independent of gestational age, sex, and ancestry.

Conclusions

DNA methylation can be used to accurately estimate gestational age at or near birth and may provide additional information relevant to developmental stage. Further studies of this predictor are warranted to determine its utility in clinical settings and for research purposes. When clinical estimates are available this measure may increase accuracy in the testing of hypotheses related to developmental age and other early life circumstances.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-016-1068-z) contains supplementary material, which is available to authorized users.

Maternal and Cord Blood Hepcidin Concentrations in Severe Iron Deficiency Anemia

BACKGROUND

The present study was conducted to assess the maternal and cord blood hepcidin concentrations in severe iron deficiency anemia (IDA) and to find out its correlation with other iron status parameters.

METHODS

This prospective observational study was carried out in 30 mothers with severe IDA (hemoglobin < 70 g/L and serum ferritin < 12 μg/L), and 15 healthy nonanemic (hemoglobin ≥ 110 g/L) mothers, who delivered live singleton neonates at term gestation. Mothers and neonates with infection/inflammatory conditions were excluded. Quantitative estimation of complete blood count, serum iron, ferritin, total iron binding capacity (TIBC), and transferrin saturation (Tfsat) was done in maternal and cord blood immediately after delivery by an auto analyzer. Serum hepcidin concentrations were measured by double-antibody sandwich enzyme-linked immunosorbent assay using a Human Hepcidin-25 kit. Data were analyzed by statistical software SPSS 16.0.

RESULTS

The serum iron and ferritin concentrations in severe IDA were 6.7 ± 1.8 μmol/L and 4.1 ± 1.4 μg/L in maternal blood, and 9.5 ± 2.6 μmol/L and 55.4 ± 19.7 μg/L in cord blood, respectively, significantly lower than nonanemic controls (p < 0.001). The corresponding serum hepcidin concentrations were 76.6 ± 22.7 μg/L and 110.5 ± 11.8 μg/L, respectively (p < 0.05). The proportion of cord blood/maternal blood hepcidin concentration was similar in both anemic (1.4:1) and nonanemic (1.3:1) mothers. Significant correlation was observed among maternal and cord blood hepcidin concentrations and other iron status parameters.

CONCLUSION

Even in the presence of low serum iron and ferritin, maternal and cord blood hepcidin concentrations remained high in severe anemia. Failure of this proportional suppression of hepcidin indicates poor systemic bioavailability of iron to the mother and poor placental transport.

Scheduled Intermittent Screening with Rapid Diagnostic Tests and Treatment with Dihydroartemisinin-Piperaquine versus Intermittent Preventive Therapy with Sulfadoxine-Pyrimethamine for Malaria in Pregnancy in Malawi: An Open-Label Randomized Controlled Trial

BACKGROUND

In Africa, most plasmodium infections during pregnancy remain asymptomatic, yet are associated with maternal anemia and low birthweight. WHO recommends intermittent preventive therapy in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). However, sulfadoxine-pyrimethamine (SP) efficacy is threatened by high-level parasite resistance. We conducted a trial to evaluate the efficacy and safety of scheduled intermittent screening with malaria rapid diagnostic tests (RDTs) and treatment of RDT-positive women with dihydroartemisinin-piperaquine (DP) as an alternative strategy to IPTp-SP.

METHODS AND FINDINGS

This was an open-label, two-arm individually randomized superiority trial among HIV-seronegative women at three sites in Malawi with high SP resistance. The intervention consisted of three or four scheduled visits in the second and third trimester, 4 to 6 wk apart. Women in the IPTp-SP arm received SP at each visit. Women in the intermittent screening and treatment in pregnancy with DP (ISTp-DP) arm were screened for malaria at every visit and treated with DP if RDT-positive. The primary outcomes were adverse live birth outcome (composite of small for gestational age, low birthweight [<2,500 g], or preterm birth [<37 wk]) in paucigravidae (first or second pregnancy) and maternal or placental plasmodium infection at delivery in multigravidae (third pregnancy or higher). Analysis was by intention to treat. Between 21 July 2011 and 18 March 2013, 1,873 women were recruited (1,155 paucigravidae and 718 multigravidae). The prevalence of adverse live birth outcome was similar in the ISTp-DP (29.9%) and IPTp-SP (28.8%) arms (risk difference = 1.08% [95% CI -3.25% to 5.41%]; all women: relative risk [RR] = 1.04 [95% CI 0.90-1.20], p = 0.625; paucigravidae: RR = 1.10 [95% CI 0.92-1.31], p = 0.282; multigravidae: RR = 0.92 [95% CI 0.71-1.20], p = 0.543). The prevalence of malaria at delivery was higher in the ISTp-DP arm (48.7% versus 40.8%; risk difference = 7.85%, [95% CI 3.07%-12.63%]; all women: RR = 1.19 [95% CI 1.07-1.33], p = 0.007; paucigravidae: RR = 1.16 [95% CI 1.04-1.31], p = 0.011; multigravidae: RR = 1.29 [95% CI 1.02-1.63], p = 0.037). Fetal loss was more common with ISTp-DP (2.6% versus 1.3%; RR = 2.06 [95% CI 1.01-4.21], p = 0.046) and highest among non-DP-recipients (3.1%) in the ISTp-DP arm. Limitations included the open-label design.

CONCLUSIONS

Scheduled screening for malaria parasites with the current generation of RDTs three to four times during pregnancy as part of focused antenatal care was not superior to IPTp-SP in this area with high malaria transmission and high SP resistance and was associated with higher fetal loss and more malaria at delivery.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201103000280319; ISRCTN Registry ISRCTN69800930.

Serial serum alkaline phosphatase as an early biomarker for osteopenia of prematurity

Metabolic bone disease of prematurity is a condition characterized by reduction in bone mineral content (osteopenia). It is a problem faced by very low birth weight (VLBW) infants because of lack of fetal mineralization during the last trimester. Our aim was to assess serum alkaline phosphatase (ALP) level as an early biomarker for osteopenia in premature infants and to estimate an optimal cutoff value of serum ALP at which osteopenia is detected radiologically in premature newborns.This prospective study was conducted on a cohort of 120 newborn infants of both sex of ≤34 weeks' gestational age and <1500 g birth weight. Two blood samples, from each infant on at least 2 consecutive weeks, were reported for calcium, phosphorus, and ALP. Evidence of osteopenia was evaluated radiologically by performing wrist/knee x-ray.Sixteen infants (13.3%) had evidence of osteopenia in x-ray, whereas 104 infants (86.7%) were nonosteopenic and all the osteopenic infants were <1000-g birth weight. Birth weight and gestational age were significantly inversely related to serum ALP levels. Both samples showed statistically significantly higher mean ALP level in osteopenic than nonosteopenics (P < 0.001, and P < 0.001 respectively). There was no constant value of serum ALP related to radiologic evidence of osteopenia. However, the optimal cutoff value of serum ALP at which osteopenia is detected is 500 IU/L with 100% sensitivity and 80.77% specificity.High levels of ALP can be considered a reliable biomarker to predict the status of bone mineralization and the need for radiological evaluation in premature infants particularly those <1000-g birth weight and <32 weeks' gestation.

Multivariate Longitudinal Analysis with Bivariate Correlation Test

In the context of multivariate multilevel data analysis, this paper focuses on the multivariate linear mixed-effects model, including all the correlations between the random effects when the dimensional residual terms are assumed uncorrelated. Using the EM algorithm, we suggest more general expressions of the model's parameters estimators. These estimators can be used in the framework of the multivariate longitudinal data analysis as well as in the more general context of the analysis of multivariate multilevel data. By using a likelihood ratio test, we test the significance of the correlations between the random effects of two dependent variables of the model, in order to investigate whether or not it is useful to model these dependent variables jointly. Simulation studies are done to assess both the parameter recovery performance of the EM estimators and the power of the test. Using two empirical data sets which are of longitudinal multivariate type and multivariate multilevel type, respectively, the usefulness of the test is illustrated.