Part 1: a matter of size: evaluating the growth-restricted neonate

Anterior fontanel size in Korean nursery newborns and clinical implications of large anterior fontanel: A retrospective cohort, observational study

Anterior fontanel (AF) sizes in newborns are influenced by ethnicity, gender, genetics, nutrition, and other pathological conditions. However, AF sizes in recent Korean newborns have not been reported yet. Thus, this study aimed to understand variation in AF size and clinical implications of large AF sizes in newborns. This cohort study was conducted on nursery newborns born at a University Hospital between September 2019 and August 2020. AF size was measured at 24 to 48 hours after birth. Newborns with a large AF (> 3.6cm) were examined for other pathological reasons using radiological and laboratory tests. Demographic data were analyzed in relation to AF size. A total of 573 newborns were investigated. Their mean gestational age was 38.5 ± 1.2 weeks at birth and their mean birth weight was 3140 ± 450 g. Their mean AF size was 1.85 ± 0.83 cm (90 and 97-percentile of AF size were 2.96 and 3.65 cm, respectively). Among demographic factors, small for gestational age (SGA) weight, SGA head circumference, and multiple births were correlated with larger AF size. Among 18 infants with a large AF, 2 had intracranial abnormalities and 11 had vitamin D deficiency. This is the first recent study on AF sizes of Korean newborn infants. Their mean AF size was the smallest so far. For the largest AF size, a cutoff of 3.65 cm met the 97-percentile of the cohort. Both SGA weight and head circumference were risk factors for large AF size. For the largest AF size, intracranial lesions and vitamin D deficiency as well as SGA presented clinical implications.

Multistrain Probiotic Increases the Gut Microbiota Diversity in Obese Pregnant Women: Results from a Randomized, Double-Blind Placebo-Controlled Study

BACKGROUND

Maternal obesity is associated with adverse pregnancy outcomes. Probiotic supplementation during pregnancy may have positive effects on blood glucose, gestational weight gain (GWG), and the risk of gestational diabetes mellitus [GDM and glycated hemoglobin (HbA1c)].

OBJECTIVES

This feasibility study involved a daily probiotic intervention in obese pregnant women from the early second trimester until delivery. The primary aim was to investigate the effect on GWG and maternal glucose homeostasis (GDM and HbA1c). Secondary aims were the effect on infant birth weight, maternal gut microbiota, and other pregnancy outcomes.

METHODS

We carried out a randomized double-blinded placebo-controlled study in 50 obese pregnant women. Participants were randomly allocated (1:1) to multistrain probiotic (4 capsules of Vivomixx®; total of 450 billion CFU/d) or placebo at 14-20 weeks of gestation until delivery. Participants were followed with 2 predelivery visits at gestational week 27-30 and 36-37 and with 1 postdelivery visit. All visits included blood and fecal sampling. An oral-glucose-tolerance test was performed at inclusion and gestational week 27-30.

RESULTS

Forty-nine participants completed the study. Thirty-eight participants took >80% of the capsules (n = 21), placebo (n = 17). There was no significant difference in GWG, GDM, HbA1c concentrations, and infant birth weight between groups. Fecal microbiota analyses showed an overall increase in α-diversity over time in the probiotic group only (P = 0.016).

CONCLUSIONS

Administration of probiotics during pregnancy is feasible in obese women and the women were willing to participate in additional study visits and collection of fecal samples during pregnancy. Multistrain probiotic can modulate the gut microbiota in obese women during pregnancy. A larger study population is needed to uncover pregnancy effects after probiotic supplementation. This trial was registered at clincaltrials.gov as NCT02508844.

Growth Measurement Practices from a National Survey of Neonatal Nurses

PURPOSE

To describe neonatal nurses' growth measurement practices, attitudes, knowledge, bases of practice knowledge, and barriers and facilitators for changing practice; and to identify differences in practices and knowledge by nursing organization, unit type, education, and experience.

DESIGN AND METHODS

A cross-sectional online survey of U.S. neonatal nurses was distributed through two neonatal nursing organizations.

RESULTS

The survey was completed by 301 nurses. Some evidence-based practices (EBPs) were infrequently reported including recording frontal-occipital head circumference (FOC) and length using 0.1 cm increments (17.9% and 17.6%, respectively); measuring FOC, weight, and length more than once before recording (61.9%, 27.2%, and 39.6%, respectively); and for length, using a length board instead of tape measure (19.4%), with a second person assisting (25.1%), with Frankfort plane head positioning (3.3%), and measuring from crown to heels of both feet (19.1%). Most nurses perceived their measurements as accurate or highly accurate (96.7% for FOC, 99.3% for weight, and 87.1% for length). The mean percentage correct on knowledge items was 68.1%. NICU nurses scored slightly better than well-newborn nurses (mean 69.3% correct vs. 65.1% correct, p = .04). Most based measurement practices on clinical practice guidelines (86.6%) and unit policies and procedures (85.9%). Team culture (33.3%) and insufficient resources (32.6%) were the most common barriers to EBP. The support of nurse managers (70.0%) and unit educators (68.5%) were common facilitators.

CONCLUSIONS AND IMPLICATIONS

Knowledge gaps and practice improvement areas were identified. Results can inform interventions to improve the accuracy and reliability of neonatal growth measurement practices.

Anterior Fontanelle Size in Healthy Indian Late Preterm and Full Term Newborns

OBJECTIVE

To measure the size of the anterior fontanelle (AF) in healthy late-preterm and term newborns and correlate it with birth weight, gestational age, gender, occipito-frontal circumference, small for gestational age status and birth weight z-score.

METHODS

This was an observational study carried out from October 2013 through April 2015 at a tertiary care hospital. Newborns ≥ 34 wk gestation were enrolled. Fontanelle edge was palpated with index finger and size calculated by adding anterior-posterior and transverse diameters and dividing by two.

RESULTS

A total of 1010 neonates were enrolled. The mean AF size was 2.23 ± 0.52 cm (mean ± SD). There was a significant decrease in the size of the AF with advancing gestational maturity on one-way ANOVA (F = 31.30) (P < 0.001) and also by increasing birth weight (F = 20.34) (P < 0.001). There was no significant difference in the mean AF size between males; 2.21 ± 0.54 cm and females; 2.25 ± 0.55 cm (mean ± SD) (P = 0.575). There was a strong correlation between AF size with increasing birth weight; correlation (r) = 0.985. In small for gestational age neonates the AF was larger, 2.27 ± 0.55 (mean ± SD) and a strong correlation between birth weight z-score and AF size was noted (r = 1.012).

CONCLUSIONS

The mean AF size in late-preterm and term Indian newborns in a mixed community hospital was 2.23 ± 0.52. A strong correlation was found between AF size with increasing birth weight and with birth weight z-score in small for gestational age babies.

Foetal growth restriction in mice modifies postnatal airway responsiveness in an age and sex-dependent manner

Epidemiological studies demonstrate an association between intrauterine growth restriction (IUGR) and asthma; however the underlying mechanism is unknown. We investigated the impact of maternal hypoxia-induced IUGR on airway responsiveness in male and female mice during juvenility and adulthood. Pregnant BALB/c mice were housed under hypoxic conditions for gestational days 11-17.5 and then returned to normoxic conditions for the remainder of pregnancy. A control group was housed under normoxic conditions throughout pregnancy. Offspring were studied at 2 weeks (juveniles) and 8 weeks (adults), where lung volume was assessed by plethysmography, airway responsiveness to methacholine determined by the forced oscillation technique and lungs fixed for morphometry. IUGR offspring were lighter at birth, exhibited "catch-up growth" by 2 weeks, but were again lighter in adulthood. IUGR males were "hyper-responsive" at 2 weeks and "hypo-responsive" as adults, in contrast with IUGR females who were hyper-responsive in adulthood. IUGR males had increased inner and total wall thickness at 2 weeks which resolved by adulthood, while airways in IUGR females were structurally normal throughout life. There were no differences in lung volume between Control and IUGR offspring at any age. Our data demonstrate changes in airway responsiveness as a result of IUGR that could influence susceptibility to asthma development and contribute to sexual dimorphism in asthma prevalence which switches from a male dominated disease in early life to a female dominated disease in adulthood.

Assessment, Management, and Health Implications of Early-Onset Preeclampsia

Early-onset preeclampsia is a serious condition of pregnancy with the potential for adverse maternal and fetal health outcomes. A strong body of evidence supports the need for postpartum follow-up and health counseling, because these women and their offspring are at risk for future cardiovascular disease; nurses play a key role in this education. An understanding of the diagnosis, risk screening for, pathogenesis, and management of severe preeclampsia and its sequelae, such as intrauterine growth restriction and pulmonary edema, enables nurses to develop a comprehensive plan of care that will support women and their families through this challenging and dynamic complication of pregnancy.

Representativeness of participants in a lifestyle intervention study in obese pregnant women - the difference between study participants and non-participants

OBJECTIVE

To examine the representativeness of participants attending a lifestyle intervention study addressing obese pregnant women.

METHODS

Retrospective comparison of baseline data, attendance to oral glucose tolerance test (OGTT) during pregnancy, and pregnancy outcome in eligible women stratified according to study participation. Of 750 eligible women with a self-reported BMI > 30 kg/m(2), and a live singleton pregnancy, 510 were eligible for inclusion and 425 were randomized to either active intervention (n= 284) or to standard obstetric care (n= 141) including two standard OGTT. The 85 women who declined participation or were excluded due to competing diseases and 240 women who did not respond to the initial invitation received the same standard care.

RESULTS

The randomized women had similar BMI but a lower parity and age, and were more frequently non-smokers, born in Denmark and married or cohabitating with their partner than the non-participants. Women participating in the trial had a higher compliance to the second OGTT compared to non-participants, also after correcting for age and nationality. There was no difference in pregnancy outcome, i.e., fetal weight and length, gestational age as well as mode of delivery.

CONCLUSION

Women declining participation in a randomized lifestyle intervention study in pregnancy have characteristics indicating they are those who might benefit the most from lifestyle intervention.

Current pattern of Ponderal Indices of term small-for-gestational age in a population of Nigerian babies

BACKGROUND

Small-for-gestational age (SGA) newborns constitute a special group of neonates who may have suffered varying degrees of intrauterine insults and deprivation. Variations in birth weight, length and Ponderal Index (PI) depend on the type and degree of intrauterine insults the babies were exposed to. The objective of the study was to determine the current prevalence of term SGA births in a Nigerian Tertiary Hospital and the current pattern of Ponderal Indices among term SGA in a population of Nigerian babies.

METHODS

Subjects comprised of consecutive term singleton mother-baby pairs in the first 24 hours of life. It was a cross sectional study. The anthropometric parameters of each baby were recorded and the PI was also determined.

RESULTS

Out of 1,052 live births during the study period (September to December, 2009), 825 were term, singleton babies. Five hundred and eight-one babies (70.4%) fall into the upper socio-economic classes 1 and II, 193 (23.4%) in the middle class and 51 (6.2%) were of the lower classes IV and V. None of the mothers indicated ingestion of alcohol or smoking of cigarette. Fifty-nine babies (7.2%) were small-for gestational age (SGA). Of the 59 SGA subjects, 26 (44.1%) were symmetrical SGA while 33 (55.9%) were asymmetrical SGA. There was no significant sex or socioeconomic predilection for either symmetrical or asymmetrical growth (p = 0.59, 0.73 respectively).

CONCLUSION

The findings showed that proportionality in SGA fetuses is a continuum, with the PI depending on the duration of intrauterine insult and the extent of its effects on weight and length before delivery.

Early diagnosis and treatment referral of children born small for gestational age without catch-up growth are critical for optimal growth outcomes

Approximately 10% of children born small for their gestational age (SGA) fail to show catch-up growth and may remain short-statured as adults. Despite treatment guidelines for children born SGA that recommend referral for growth hormone (GH) therapy evaluation and initiation by ages 2 to 4 years, the average age of GH treatment initiation is typically much later, at ages 7 to 9 years. Delayed referral for GH treatment is problematic as studies show younger age at GH treatment initiation in children born SGA is an independent predictor for responses such as optimal growth acceleration, normalization of prepubertal height, and most importantly, adult height (AH). This review discusses the importance and associated challenges of early diagnosis of children born SGA who fail to show catch-up growth, contrasts the recommended age of referral for these patients and the average age of GH treatment initiation, and discusses studies showing the significant positive effects of early referral and treatment with GH on AHs in short-statured children born SGA. To optimize the eventual height in short-statured SGA children who fail to manifest catch-up growth, a lowering of the average age of referral for GH therapy evaluation is needed to better align with consensus recommendations for SGA management. The importance of increasing parental and physician awareness that most children born SGA will do well developmentally and will optimally benefit from early initiation of GH treatment when short-statured is addressed, as is the need to shift the age of referral to better align with consensus recommendations.

Altered gene expression and methylation of the human chromosome 11 imprinted region in small for gestational age (SGA) placentae

Imprinted genes are known to be crucial for placental development and fetal growth in mammals, but no primary epigenetic abnormality in placenta has been documented to compromise human fetal growth. Imprinted genes demonstrate parent-of-origin-specific allelic expression that is epigenetically regulated i.e. extrinsic to the primary DNA sequence. To undertake an epigenetic analysis of poor fetal growth in placentae and cord blood tissues, we first established the tissue-specific patterns of methylation and imprinted gene expression for two imprinting clusters (KvDMR and H19 DMR) on chromosome 11p15 in placentae and neonatal blood for 20 control cases and 24 Small for Gestational Age (SGA) cases. We confirmed that, in normal human placenta, the H19 promoter is unmethylated. In contrast, most other human tissues show paternal methylation. In addition, we showed that the IGF2 DMR2, also paternally methylated in most human tissues, exhibits hypomethylation in placentae. However, in neonatal blood DNA, these two regions maintain the differential methylation status seen in most other tissues. Significantly, we have been able to demonstrate that placenta does maintain differential methylation at the imprinting control regions H19 DMR and KvDMR. Of note, in one SGA placenta, we found a methylation alteration at the H19 DMR and concomitant biallelic expression of the H19 gene, suggesting that loss of imprinting at H19 is one cause of poor fetal growth in humans. Of particular interest, we demonstrated also a decrease in IGF2 mRNA levels in all SGA placentae and showed that the decrease is, in most cases, independent of H19 regulation.

A matter of size: Part 2. Evaluating the large-for-gestational-age neonate

Large for gestational age (LGA) is another designation used to assess and monitor growth throughout the pregnancy and after delivery. Large for gestational age is an abnormal growth descriptor that assists in anticipating neonatal needs pre-and postnatally. Careful monitoring for abnormal growth trends in the fetus is imperative prenatally. The relative size of a neonate affects many aspects of prenatal and postnatal surveillance. Nursing care is guided by the maternal history and the delivery room complications that may occur. Anticipating complications in the delivery room is vital to the survival of LGA neonates. Nursing care for LGA neonates requires knowledge based on these potential complications. A thorough physical assessment with appropriate glucose monitoring and parental education is required. Size matters when it comes to the health and welfare of all sizes of neonates. Anticipatory guidance with prenatal monitoring and education can improve outcomes in the neonate at risk for LGA complications at birth.