Longitudinal growth and post-discharge mortality and morbidity among extremely low birth weight neonates

Need for Repeat-Hospitalization in Very Low Birth Weight or Very Preterm Infants: A Prospective Cohort Study

OBJECTIVE

To determine the incidence of repeat-hospitalization amongst neonates with gestation <32 wk or birth weight <1500 g within 6 mo of birth.

METHODS

All live births with gestation <32 wk or birth weight <1500 g born at a level-III NICU were prospectively enrolled and followed up through routine visits, multimedia and telephonically, fortnightly for re-hospitalization details till 6 mo of postnatal age. Main outcome measures were incidence, causes and risk factors for repeat-hospitalization.

RESULTS

Of the 131 neonates enrolled, incidence and incidence density of repeat-hospitalization were 16% (95% CI 10.2-23.4) and 3.6 per 100 person-months, respectively. The most common causes for repeat-hospitalizations were pneumonia (n = 8; 29.6%), sepsis (n = 5, 18.5%), gastroenteritis (n = 3, 11.1%) and severe anemia (n = 2, 7.4%). Majority of repeat-hospitalizations (92.6%; 95% CI 74.1-98.5) occurred within 2 mo of discharge. The median hospital stay during repeat-hospitalizations was 4 d (IQR 1-21). On multivariate analysis, lower socioeconomic status was significantly associated with repeat-hospitalization (aOR 5.9, 1.3-23). Death after discharge occurred in 3 (2.3%) infants and were due to sudden infant death syndrome, complex cyanotic heart disease and pneumonia with multiple co-morbidities (one each). All deaths occurred at home.

CONCLUSIONS

Nearly one-sixth of very low birth weight (VLBW) or very preterm infants required repeat-hospitalization after discharge, primarily within 2 mo of discharge. Infections, especially pneumonia, being the most common reason. A comprehensive follow-up package of post-discharge care for prevention of morbidities and timely hospital care for ongoing morbidities is required for optimal long-term survival of these infants.

Clinical Profile of Neonates Getting Readmitted to Neonatal Intensive Care Unit (NICU) after Discharge from Hospital

OBJECTIVES

To estimate the proportion of neonates getting readmitted to neonatal intensive care unit (NICU), after discharge from the hospital. Secondary objectives were to describe the clinical characteristics, reason for readmission and outcome of neonates getting readmitted.

METHODS

A retrospective descriptive study was conducted to identify neonates getting readmitted to NICU within 28 d of birth and/or before 40 wk post-menstrual age (PMA). Details of neonates who were readmitted to NICU were identified and data extracted in predesigned proforma from digitalized case records (July 2021-June 2023), and outcomes were analyzed.

RESULTS

Out of 26,403 live-births, 5175 neonates required NICU admission (19.6%). Readmissions accounted for 5.9% (95% CI: 5.3-6.6%) of NICU admissions (305/5175) and 1.2% (95% CI: 1.0-1.3%) of live-births. Mean gestational age and birthweight were 36.8 (2.9) wk (range 25-41) and 2584 (713) g (range = 650-4900). Ninety-six (31.5%) were preterm. One hundred and three (33.8%) were high risk neonates. Median age at readmission was 17 d (range: 3-150). Infections (n = 109, 35.7%), infection-related complications (n = 18, 5.9%), feeding problems (n = 63, 20.6%), and jaundice (n = 42, 13.7%) were commonest reasons for readmission. Median duration of hospital stay was 5 d (range: 1-120). Two hundred and ninety four (96.4%) were discharged, and 10 (3.2%) neonates expired.

CONCLUSIONS

Readmissions accounted for 5.9% of total NICU admissions. Infections, jaundice and feeding related issues accounted for 76% of all the readmissions.

Fortification of Breast Milk With Preterm Formula Powder vs Human Milk Fortifier in Preterm Neonates: A Randomized Noninferiority Trial

IMPORTANCE

Fortification of expressed breast milk (EBM) using commercially available human milk fortifiers (HMF) increases short-term weight and length in preterm very low-birth-weight (VLBW) neonates. However, the high cost and increased risk of feed intolerance limit their widespread use. Preterm formula powder fortification (PTF) might be a better alternative in resource-limited settings.

OBJECTIVE

To demonstrate that fortification of EBM by preterm formula powder is noninferior to fortification by HMF, in terms of short-term weight gain, in VLBW neonates.

DESIGN, SETTING, AND PARTICIPANTS

Open-label, noninferiority, randomized trial conducted from December 2017 to June 2019 at a level 3 neonatal unit in India. The trial enrolled preterm (born at or before 34 weeks of gestation) VLBW neonates receiving at least 100 mL/kg/d of feeds and consuming 75% of milk or more as EBM.

INTERVENTIONS

Neonates were randomly assigned to receive fortification by either PTF or HMF. Calcium, phosphorus, iron, vitamin D, and multivitamins were supplemented in PTF and only vitamin D in the HMF group to meet the recommended dietary allowances.

MAIN OUTCOMES AND MEASURES

The primary outcome was the weight gain until discharge from the hospital or 40 weeks' postmenstrual age, whichever was earlier; the prespecified noninferiority margin was 2 g/kg/d. Secondary outcomes included morbidities such as necrotizing enterocolitis, feed intolerance, and extrauterine growth restriction (<10th percentile on the Fenton chart at 40 weeks' postmenstrual age).

RESULTS

Of the 123 neonates enrolled, 60 and 63 were randomized to the PTF and HMF groups, respectively. The mean gestation (30.5 vs 29.9 weeks) and birth weight (1161 vs 1119 g) were comparable between the groups. There was no difference in the mean (SD) weight gain between the PTF and HMF groups (15.7 [3.9] vs 16.3 [4.0] g/kg/d; mean difference, -0.5 g/kg/d; 95% CI, -1.9 to 0.7). The lower bound of 95% CI did not cross the noninferiority margin. The incidence of feed intolerance was lower in the PTF group (1.4 vs 6.8 per 1000 patient-days; incidence rate ratio 0.19; 95% CI, 0.04 to 0.95), and fewer neonates required withholding of fortification for 24 hours or more (5% vs 22%; risk ratio, 0.22; 95% CI, 0.07 to 0.75). The incidence of necrotizing enterocolitis stage II or more (0 vs 5%) and extrauterine growth restriction (73% vs 81%) was comparable between the groups.

CONCLUSIONS AND RELEVANCE

Fortification with preterm formula powder is not inferior to fortification with human milk fortifiers in preterm neonates. Given the possible reduction in feed intolerance and lower costs, preterm formula might be a better option for fortification, especially in resource-restricted settings.

TRIAL REGISTRATION

Clinical Trial Registry, India Identifier: CTRI/2017/11/010593.

Longitudinal Growth of Extremely Low Birth Weight Infants at 5 years

This prospective cohort study assessed longitudinal growth of Extremely low birth weight (ELBW) infants at 5 y of age. ELBW infants discharged alive during 2009-2011 were prospectively followed till 5 y of age. Forty-five matched controls were enrolled. The weight, length, and occipitofrontal circumference were recorded and Z-scores were calculated using the WHO software. The primary outcome was the comparison of growth parameters of the ELBW cohort with controls. Forty-seven ELBW and 45 controls were assessed at 5 y. In ELBW cohort, 17 (36.2%) were underweight, 13 (27.7%) were stunted, 11 (23.4%) were wasted, and 6 (15.7%) had microcephaly at 5 y. As compared to controls, the proportion of underweight and stunting was significantly higher among ELBW infants (p < 0.001). There was no significant difference in Z-scores at 2 and 5 y. ELBW infants have significant undernutrition at 5 y of age and there is no catch-up growth beyond 2 y.

Early anemia and neonatal morbidity in extremely low birth-weight preterm infants

Background: Extremely low birth-weight (ELBW) preterm infants remain at high risk for mortality and major morbidities, and nearly all need packed red blood cell transfusions within their first weeks of life. The overall objective of this study was to assess the association between anemia at admission to neonatal intensive care unit (NICU) with the neonatal morbidity and mortality in ELBW infants.Methods: This retrospective study was conducted on 106 patients with ELBW admitted at our level III NICU from January 2006 to December 2015. The subjects were divided into two groups: (1) patients with anemia at admission and (2) patients without anemia. Their characteristics and outcomes were compared. Statistical analysis was performed using the Statistical Package for the Social Sciences software, version 24.0 (IBM New York, USA), and a value of p < 0.05 was considered statistically significant.Results: Of the 106 ELBW, 34 (32%) presented with anemia at admission and 72 (68%) without anemia. Anemia-naive presented mean hemoglobin at the admission of 12.8 ± 1.5 g/dl and nonanemic 16.8 ± 2.1 g/dl, p < .001). The anemic group presented a lower gestational age (26 ± 2 vs. 27 ± 2 SD weeks, p = .025), greater need for inotropic support (52.9 vs. 31.9%, p = .041), longer period of invasive mechanical ventilation (9 vs. 2 days, p = .012), higher FiO₂ need (0.8 vs. 0.4, p < .001), more frequent hemodynamically significant patent ductus arteriosus (HS-PDA) (64.7 vs. 41.7%, p = .006) and severe intra-periventricular hemorrhage (IPVH) (41.2 vs. 16.7%, p = 0.005). The multivariate analysis confirmed an association between anemia at admission and HS-PDA (OR = 3.2; 95% CI: 1.1-9.5, p = 0.044) and severe IPVH (OR = 3.3; 95% CI: 1.0-9.9, p = .038). In anemic infants, ionotropic support and IPVH >2 were considered independent factors for mortality.Conclusion: In this ELBW series, the presence of anemia at admission to the NICU was associated with HS-PDA and severe IPVH. Preventive strategies for early anemia must be encouraged.

Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study

BACKGROUND

Despite global efforts, stunting remains a public health problem in several developing countries. The prevalence of stunting among 0- to 5-year-old children in Armenia has increased from 17% in 2000 to 19% in 2010. A baseline study was conducted among preschool children in Berd, a region near the northeastern border of Armenia that has experienced intermittent military tension for over 20 years.

METHODS

We conducted a cross-sectional study including 594 children aged 6-month- 6 years old and their caregivers in our analysis, to assess the prevalence and determinants of stunting. We calculated the anthropometric measurements and hemoglobin levels of children; analyzed children's stool and conducted a survey with children's caregivers. We employed the hierarchical logistic regression model to explore the predictors of stunting among 25-72 months old children and multivariable logistic regression models to investigate the predictors of stunting among 6-24 months old children. Individual and residence level variables were included in the models including anemia, minimum dietary diversity, mothers' height, the overall duration of breastfeeding, birthweight, child's history of diarrhea and mean socio-economic score.

RESULTS

The prevalence of stunting was significantly higher among the 6-24 months old children (13.3%) compared to the children aged 25-72 months old (7.8%). We did not find any differences in the prevalence of stunting by place of residence in either age group. The 6-24 months old children who consumed at least four food groups during the previous day (minimum dietary diversity) had 72% lower odds of being stunted (p < 0.05). Each kilogram increase in birthweight was associated with 76% lower odds of being stunted (OR = 0.24, p < 0.01). Mother's height significantly decreased the odds of stunting among the children 25-72- months old (OR = 0.86, p < 0.001). BMI was also a significant predictor of stunting among both age-groups.

CONCLUSIONS

The study results highlight the significance of mother's height, birthweight, and adequate complementary feeding to reduce stunting. Further studies are needed to determine the possible association of anemia and stunting with the ongoing conflict in the region, as well as socioeconomic conditions and food insecurity in the region.

Neurodevelopmental Outcome of Extremely Low Birth Weight Children at Corrected Age of Two Years

OBJECTIVE

To assess the neurodevelopmental, cognitive and behavioral function of extremely low birth weight babies (ELBW) till corrected age of two years.

METHODS

79 ELBW babies were enrolled and followed at 1 year (n=50), 18 months (n=47) and 2 years (n=36). Adverse composite outcome was defined as death or moderate-to-severe neurodevelopmental impairment (defined as either cerebral palsy or DQ score <70 or deafness or blindness).

RESULTS

At 1 year, 24% were neurologically abnormal. At 18 months, average score (>85) was seen in 25 (54%) children in motor and 8 (17%) in mental development. Abnormal behavioral score (?12) was seen in 89% children. Adverse composite outcome was present in 28 (35.4%) babies.

CONCLUSIONS

ELBW neonates are at a high risk of neurodevelopmental and behavioral impairment.

Prevalence, Demographic Characteristics and Associated Risk Factors of Malnutrition Among 0-5 Aged Children: A Cross-Sectional Study From Van, Eastern Turkey

Malnutrition in childhood is a dramatic indicator of poor socio-economical status worldwide. To recognize and reveal the socio-demographic features is crucial, especially for developing countries. Our aim was to investigate the prevalence and association with sociodemographic variables of malnutrition in 0-5 years old children in Van, Turkey. A total of 702 children are included in this cross-sectional study. Demographic features of subject including age, gender, family characteristics and other data were obtained. Nutritional assessment was done using anthropometric indices including weight-for-age, height-for-age, weight-for-height, head circumference and body mass index-for-age. Multivariate logistic regressions were carried out to assess malnutrition-associated factors. Prevalence of underweight, stunting and wasting were 19.7, 17.7 and 16.2%, respectively. Socio-demographic variables that statistical significantly in association with malnutrition were low monthly family income, educational level and employment status of father, parental consanguinity, number of pregnancies, regular intake of vitamin D and history of prematurity. The prevalence of children with head circumference-z score ≤2SD and body mass index-for-age ≤2SD were 9.8 and 16.3%, respectively. Multivariate analysis detected following risk factors for these indices; low monthly family income, history of prematurity, unemployed father and the period between pregnancies (1-2 years). We found that prevalence of malnutrition in the city of Van, was still higher than more developed regions of Turkey. The associated risk factors of malnutrition should be specifically interpreted by health professionals and also by government authorities that are responsible for making practical politics of public health.

Risk factors associated with growth failure in the follow-up of very low birth weight newborns

OBJECTIVE

To determine risk factors during neonatal hospital stay and follow-up associated with failure to thrive in the first year of life of very low birth weight newborns.

METHODS

Study of preterm very low birth weight newborns followed from 2006 to 2013 in a public institutional hospital program. The study included newborns that attended at least one appointment in each of the three periods: Period I, up to 3 months of corrected age (CA); Period II, 4-6 months of CA; and Period III, 7-12 months of CA. The variables were analyzed by logistic regression with XLSTAT 2014 software (Microsoft®, WA, USA). Failure to thrive (Z-score below -2 SD) was classified as a dichotomous dependent variable (0 - failure/1 - success), while the other variables were classified as explanatory variables for the hospitalization periods and for each of the follow-up periods (I, II, and III).

RESULTS

Children born adequate for gestational age increased the chance of Z-score for weight at discharge>-2 SD (OR=10.217; 95% CI: 1.117-93.436). Metabolic bone disease and retinopathy of prematurity in Period I, as well as hospital readmissions in Periods II and III during follow-up increased the chance of Z-score<-2 SD.

CONCLUSION

Failure to thrive is influenced by intrauterine factors and, subsequently, by several morbidities, both in the birth and hospitalization period, as well as in the post-discharge period and thus, such variables should be prioritized in the follow-up.

Head growth of undernourished children in rural Nepal: association with demographics, health and diet

BACKGROUND

Brain development in early childhood is a key determinant of later cognition, social achievement and educational success. Head circumference (HC) measurements are a simple method to assess brain growth, yet reports of these measurements are uncommon in nutritional surveys of undernourished children.

OBJECTIVE

To evaluate HC measurements in a population of rural Nepali children and relate these measurements to demographics, health and diet.

METHODS

An observational study of head growth was nested within a longitudinal evaluation of a livestock-based agricultural intervention in rural Nepal. Between 538 and 689 children (aged 6 months to 8 years) were measured (height, weight, HC) at each of six survey visits. A total of 3652 HC measurements were obtained. Results were converted to Z-scores (WHO Anthro).

RESULTS

Mean head circumference Z-scores (HCZ) diminished progressively over the first 4 years of life; a decline of 30% occurred between 3 and 4 years of age (-1.73 to -2.45, P < 0.0001). Overall, 56% of HCZ were <-2. Gender-adjusted HCZ (but not other measurements) were significantly lower for girls than boys [mean (SD) -2.31 (1.0) vs -1.99 (0.094), P < 0.0001]; girls more often had microcephaly (61% vs 50%, P < 0.0001). For children <3 years of age, HCZ were better in those who had eaten two or more animal-source foods (ASFs) within the previous 24 h [-1.69 (.05) vs -2.08 (0.10), P = 0.001] than in those who had eaten none or only one; HCZ correlated with the number of ASFs consumed (P < 0.001). Regression analyses demonstrated that the main determinants of HCZ were age, weight-for-age Z-scores (WAZ) and gender; 43% of the variance in HCZ in younger children was explained by WAZ and ASF consumption.

CONCLUSION

HCs reflect brain size in young children; brain size is linked to cognitive function. Poor head growth represents another facet of the 'silent emergency' of child undernutrition. Routine HCZ assessments may contribute to better understanding of the links between poverty and cognitive development.