Incidence of metabolic bone disease in preterm infants of birth weight <1250 g and in those suffering from bronchopulmonary dysplasia

Respiratory and chest wall mechanics in very preterm infants

Data on static compliance of the chest wall (Ccw) in preterm infants are scarce. We characterized the static compliance of the lung (CL) and Ccw to determine their relative contribution to static compliance of the respiratory system (Crs) in very preterm infants at 36 wk postmenstrual age (PMA). We also aimed to investigate how these compliances were influenced by the presence of bronchopulmonary dysplasia (BPD) and impacted breathing variables. Airway opening pressure, esophageal pressure, and tidal volume (VT) were measured simultaneously during a short apnea evoked by the Hering-Breuer reflex. We computed tidal breathing variables, airway resistance (R), and dynamic lung compliance (CL,dyn), inspiratory capacity (IC), and Crs, CL, and Ccw. Functional residual capacity was assessed by the multiple breath washout technique (FRCmbw). Breathing variables, compliances, and lung volumes were adjusted for body weight. Twenty-three preterm infants born at 27.2 ± 2.0 wk gestational age (GA) were studied at 36.6 ± 0.6 wk PMA. Median and interquartile range (IQR) Crs/kg is 0.69 (0.6), CL/kg 0.95 (1.0), and Ccw/kg 3.0 (2.4). Infants with BPD (n = 11) had lower Crs/kg (P = 0.013), CL/kg (P = 0.019), and Ccw/kg (P = 0.027) compared with infants without BPD. Ccw/CL ratio was equal between groups. FRCmbw/kg (P = 0.044) and IC/kg (P = 0.005) were decreased in infants with BPD. Infants with BPD have reduced static compliance of the respiratory system, the lungs, and chest wall. Decreased Crs, CL, and Ccw in infants with BPD explain the lower FRC and IC seen in these infants.NEW & NOTEWORTHY Data on chest wall compliance in very preterm infants in the postsurfactant era are scarce. To our knowledge, we are the first group to report data on static respiratory system compliance (Crs), lung compliance (CL), and chest wall compliance (Ccw) in preterm infants with and without bronchopulmonary dysplasia (BPD) in the postsurfactant era.

Nutritional Needs of the Infant with Bronchopulmonary Dysplasia

Growth failure is a common problem in infants with established bronchopulmonary dysplasia (BPD). Suboptimal growth for infants with BPD is associated with unfavorable respiratory and neurodevelopmental outcomes; however, high-quality evidence to support best nutritional practices are limited for this vulnerable patient population. Consequently, there exists a wide variation in the provision of nutritional care and monitoring of growth for infants with BPD. Other neonatal populations at risk for growth failure, such as infants with congenital heart disease, have demonstrated improved growth outcomes with the creation and compliance of clinical protocols to guide nutritional management. Developing clinical protocols to guide nutritional management for infants with BPD may similarly improve long-term outcomes. Given the absence of high-quality trials to guide nutritional practice in infants with BPD, the best available evidence of systematic reviews and clinical recommendations can be applied to optimize growth and decrease variation in the care of these infants.

Bone Status and Early Nutrition in Preterm Newborns with and without Intrauterine Growth Restriction

Intrauterine growth restriction (IUGR) together with preterm birth could be harmful to bone health. The aim of the study was to examine bone status in IUGR versus non-IUGR preterms and to analyze the nutritional management best correlated with its improvement. Newborns < 34 weeks of gestational age (wGA), 75 IUGR and 75 non-IUGR, admitted to the Neonatal Intensive Care Unit of the University Hospital of Padova were enrolled and monitored from birth until 36 wGA through anthropometry (weight, length, head circumference, lower limb length (LLL)), biochemistry, bone quantitative ultrasound assessment of bone status (metacarpus bone transmission time, mc-BTT, us) and nutritional intakes monitoring during parenteral nutrition. IUGR compared to non-IUGR showed lower mean mc-BTT (0.45 vs. 0.51, p = 0.0005) and plasmatic phosphate (1.45 vs. 1.79, p < 0.001) at birth. Mc-BTT at 36 wGA, though equal between groups, correlated in IUGR newborns with basal phosphate, mean total energy of the first week and month (positively) and days to reach full enteral feeding (negatively). Lower i.v. vitamin D intake, LLL and prolonged total parenteral nutrition predicted worse mc-BTT at 36 wGA in the enrolled infants. These results suggest that preterms and in particular IUGR newborns need special nutritional care to promote bone development.

Association of Preterm Birth and Low Birthweight with Bone Fractures during Childhood

Preterm birth and low birthweight have been associated with increased fracture risk in children. Our aim was to analyze bone fractures during childhood in preterm, and low-birthweight newborns compared to full-term and normal-birthweight newborns. We conducted a nationwide register-based cohort study in Finland from 1998 to 2017 and utilized the Medical Birth Register and Care Register for Health Care. All newborns alive 28 days after birth were included, and data on all fracture visits in specialized healthcare units were gathered. Incidences per 100,000 person-years with 95% confidence intervals (CI) were calculated, and comparisons were made by incidence rate ratios (IRRs). Kaplan-Meier analysis was used to analyze the timing of fractures during childhood (0-20 years). We included a total of 997,468 newborns and 95,869 fractures; the mean follow-up was 10.0 years, and the overall incidence of fractures was 963 per 100,000 person-years. Very preterm (<32 gestational weeks) newborns had 23% lower fracture incidence than term newborns (IRR 0.77; CI: 0.70-0.85). Preterm newborns (32 to 36 gestational weeks) had a fracture rate (IRR 0.98; CI: 0.95-1.01) similar to that of term newborns. Birthweight showed a linear increase in the fracture rates as newborns with birthweight less than 1000 g had the lowest fracture incidence of 773 per 100,000 person-years and the highest incidence (966 per 100,000 person-years) was among newborns with birthweight 2500 g or more. Children born very preterm or with extremely low birthweight have in general a lower fracture incidence during childhood compared to children born full term and with normal birthweight. These findings possibly reflect, in addition to improvements of neonatal intensive care and early nutrition, the fact that childhood fracture incidences are more dependent on issues other than early life events. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Establishment of a nomogram model for predicting metabolic bone disease in preterm infants: A case‒control study

OBJECTIVE

To investigate risk factors for metabolic bone disease (MBD) in preterm infants and establish a nomogram model for predicting MBD risk.

METHODS

A total of 1104 preterm infants were enrolled, among whom 809 were included in the modelling set and 295 were included in the validation set. The modelling set was divided into MBD (n = 185) and non-MBD (n = 624) groups. A multivariate logistic regression analysis was used to investigate the independent risk factors for MBD. R software was used to plot the nomogram model, which was then validated by the data of the validation set. Receiver operating characteristic (ROC) and calibration curves were used to evaluate the nomogram model's performance, and the clinical decision curve was used to assess the clinical practicability of the model.

RESULTS

Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants (P < 0.05). The ROC curve of the modelling set had an area under the curve (AUC) of 0.801; the risk prediction value of 0.196 corresponding to the maximum Youden index was the best value, and the prediction critical value was 125 points. The ROC curve of the validation set had an AUC of 0.854. The calibration curve analysis showed good accuracy and consistency between the model's predicted and actual values.

CONCLUSIONS

The nomogram model provides an efficient tool for the early assessment of MBD risk. Preterm infants with scores ≥ 125 should receive close attention and interventions in the early stage.

WHAT IS KNOWN

• The incidence and severity of MBD are inversely proportional to gestational age and birth weight. Bone loss can lead to prolonged hospital stay, ventilator dependence, pathological fractures and short stature.

WHAT IS NEW

• Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants. The nomogram model provides an efficient tool for the early assessment of MBD risk.

A review and guide to nutritional care of the infant with established bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) remains the most common long-term morbidity of premature birth, and the incidence of BPD is not declining despite medical advancements. Infants with BPD are at high risk for postnatal growth failure and are often treated with therapies that suppress growth. Additionally, these infants may display excess weight gain relative to linear growth. Optimal growth and nutrition are needed to promote lung growth and repair, improve long-term pulmonary function, and improve neurodevelopmental outcomes. Linear growth in particular has been associated with favorable outcomes yet can be difficult to achieve in these patients. While there has been a significant clinical and research focus regarding BPD prevention and early preterm nutrition, there is a lack of literature regarding nutritional care of the infant with established BPD. There is even less information regarding how nutritional needs change as BPD evolves from an acute to chronic disease. This article reviews the current literature regarding nutritional challenges, enteral nutrition management, and monitoring for patients with established BPD. Additionally, this article provides a practical framework for interdisciplinary nutritional care based on our clinical experience at the Comprehensive Center for Bronchopulmonary Dysplasia.

Don't Forget the Bones: Incidence and Risk Factors of Metabolic Bone Disease in a Cohort of Preterm Infants

Metabolic bone disease of prematurity (MBD) is a condition of reduced bone mineral content (BMC) compared to that expected for gestational age (GA). Preterm birth interrupts the physiological process of calcium (Ca) and phosphorus (P) deposition that occurs mostly in the third trimester of pregnancy, leading to an inadequate bone mineralization during intrauterine life (IUL). After birth, an insufficient intake of Ca and P carries on this alteration, resulting in overt disease. If MBD is often a self-limited condition, in some cases it could hesitate the permanent alteration of bone structures with growth faltering and failure to wean off mechanical ventilation due to excessive chest wall compliance. Despite advances in neonatal intensive care, MBD is still frequent in preterm infants, with an incidence of 16−23% in very-low-birth-weight (VLBW, birth weight <1500 g) and 40−60% in extremely low-birth-weight (ELBW, birth weight <1000 g) infants. Several risk factors are associated with MBD (e.g., malabsorption syndrome, parenteral nutrition (PN), pulmonary bronchodysplasia (BPD), necrotizing enterocolitis (NEC), and some chronic medications). The aim of this study was to evaluate the rate of MBD in a cohort of VLBWI and the role of some risk factors. We enrolled 238 VLBWIs (107 male). 52 subjects were classified as increased risk (G1) and 186 as standard risk (G2) according to serum alkaline phosphatase (ALP) and phosphorus (P) levels. G1 subjects have lower GA (p < 0.01) and BW (p < 0.001). Moreover, they need longer PN support (p < 0.05) and invasive ventilation (p < 0.01). G1 presented a higher rate of BPD (p = 0.026). At linear regression analysis, BW and PN resulted as independent predictor of increased risk (p = 0.001, p = 0.040, respectively). Preventive strategies are fundamental to prevent chronic alteration in bone structures and to reduce the risk of short stature. Screening for MBD based on serum ALP could be helpful in clinical practice to identify subjects at increased risk.

Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes

Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.

The Role of Nutrition in the Prevention and Management of Bronchopulmonary Dysplasia: A Literature Review and Clinical Approach

Bronchopulmonary dysplasia (BPD) remains the most common severe complication of preterm birth, and nutrition plays a crucial role in lung growth and repair. A practical nutritional approach for infants at risk of BPD or with established BPD is provided based on a comprehensive literature review. Ideally, infants with BPD should receive a fluid intake of not more than 135-150 mL/kg/day and an energy intake of 120-150 kcal/kg/day. Providing high energy in low volume remains a challenge and is the main cause of growth restriction in these infants. They need a nutritional strategy that encompasses early aggressive parenteral nutrition and the initiation of concentrated feedings of energy and nutrients. The order of priority is fortified mother's own milk, followed by fortified donor milk and preterm enriched formulas. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy. Specialized nutritional strategies may be necessary to overcome difficulties common in BPD infants, such as gastroesophageal reflux and poorly coordinated feeding. Planning nutrition support after discharge requires a multidisciplinary approach to deal with multiple potential problems. Regular monitoring based on anthropometry and biochemical markers is needed to guide the nutritional intervention.

Risk factors for metabolic bone disease among preterm infants less than 32 weeks gestation with Bronchopulmonary dysplasia

Background

Bronchopulmonary dysplasia (BPD) infants present an increased incidence of metabolic bone disease (MBD), but it is unknown which factors contribute to this. The aim of this study was to determine the risk factors for developing MBD in BPD infants.

Methods

A retrospective review of the medical records of BPD infants admitted to the Neonatal intensive care unit at Zhangzhou Hospital between Jun 2016 and May 2020 was performed. BPD infants with MBD were identified, two contemporaneous without MBD matched by gestational age and gender were randomly selected as controls for each case of MBD. The association between putative risk factors and MBD was estimated with ORs and 95% CIs. A P-value threshold ≤0.2 was used in univariate analysis for inclusion into a multivariate (adjusted) model with a P-value of < 0.05 as statistically significant.

Results

A total of 156 BPD infants were enrolled with 52 cases of MBD and 104 controls. Fetal growth restriction (OR 6.00, 95% CI, 1.81–19.84), extremely low birth weight (OR 3.10, 95% CI, 1.07–8.94), feeding volume < 80 mL/kg/d at the end of the 4th week after birth (OR 14.98, 95% CI, 4.04–55.58), cholestasis (OR 4.44, 95% CI, 1.59–12.40), late onset sepsis (OR 3.95, 95% CI, 1.12–13.98) and prolonged (> 2 weeks) diuretics application (OR 5.45, 95% CI, 1.25–23.84) were found to be statistically significant risk factors for MBD in BPD infants.

Conclusion

In BPD infants of homogeneous gestational age, fetal growth restriction, extremely low birth weight, feeding volume < 80 mL/kg/d at the end of the 4th week after birth, cholestasis and late onset sepsis are significant risk factors for MBD. These findings provide potential predictive factors for MBD in BPD infants and warrant prospective validation.

[Association of early nutrition deficiency with the risk of bronchopulmonary dysplasia: a Meta analysis]

OBJECTIVE

To systematically evaluate the association of early nutrition intake with the risk of bronchopulmonary dysplasia (BPD).

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, and Weipu Periodical Database were searched for the observational studies on the association between early nutrition intake and BPD. RevMan 5.3 software was used to perform a Meta analysis of eligible studies.

RESULTS

Eight observational studies were included, with 548 infants with BPD and 522 infants without BPD. The Meta analysis showed that the BPD group had a significantly lower caloric intake than the non-BPD group within the first week after birth and in the first 2 weeks after birth (P < 0.05). The BPD group had a significantly lower enteral nutrition intake than the non-BPD group (WMD=-18.27, 95%CI:-29.70 to -6.84, P < 0.05), as well as a significantly lower intake of carbohydrate, fat, and protein (P < 0.05). The BPD group had a significantly longer duration of parenteral nutrition than the non-BPD group (WMD=14.26, 95%CI:13.26-15.25, P < 0.05).

CONCLUSIONS

Early nutrition deficiency may be associated with the development of BPD, and more attention should be paid to enteral feeding of infants at a high risk of BPD to achieve total enteral feeding as soon as possible.

Is quantitative ultrasound a measure for metabolic bone disease in preterm-born infants? A prospective subcohort study

In this study, we aimed to (a) evaluate postnatal changes in bone development in relation to growth and (b) to determine factors associated with bone development, from birth to 24 months of corrected age. The metacarpal speed of sound (mcSOS) and metacarpal bone transmission time (mcBTT) were used to evaluate bone development in 98 preterm infants, during hospitalization and follow-up. The mcSOS and mcBTT values not only declined in the first 6 weeks of hospitalization but also during follow-up. The mcSOS reached its lowest point at 12 months (β=-34.64), while the mcBTT reached a plateau between 12 and 24 months (β=0.06). Univariable analysis showed that gender (p=0.28), time (p<0.001), and growth parameters (p<0.001) were significant negative associated factors with mcSOS, whereas with mcBTT, time (p=0.009), length (p=0.063), length standard deviation scores (SDS) (p=0.027), head circumference (p=0.005), and head circumference SDS (p=0.007) were significant positive. The multivariable model revealed that time (β= -3.364, p=<0.001), weight (β=-0.007, p<0.001) and length (β=1.163, p<0.001) for mcSOS and length (β=-0.021, p<0.001), and length SDS (β= 0.066, p<0.001) and head circumference (β=0.049, p<0.001) for mcBTT remained highly significant associated factors.Conclusion: The most important finding is that mcSOS decreased and the mcBTT reached a plateau to 24 months. In both mcSOS and mcBTT, the growth parameters were significant factors.Clinical Trial Registration: N/A What is known: • Metabolic bone disease is one of the possible long term adverse outcomes after preterm birth. • Metacarpal speed of sound (mcSOS) and metacarpal bone transmission time (mcBTT) decline in the early postnatal period. What is new: • During follow-up, mcSOS further decreased and reached its lowest point at 12 months, while the mcBTT reached a plateau up to 24 months. • Postnatal nutrition in relation to comorbidity does not meet the optimal mineralization rate of the developing preterm bone.

Hypophosphatemia as an Early Metabolic Bone Disease Marker in Extremely Low-Birth-Weight Infants After Prolonged Parenteral Nutrition Exposure

BACKGROUND

Early metabolic bone disease (MBD) detection is important in preterm infants to decrease long-term consequence. We aim to explore the early MBD biochemical marker in extremely low-birth-weight (ELBW) infants.

METHODS

Retrospective cohort study of 95 preterm infants born in a tertiary care-level neonatal intensive care unit between January 2015 and June 2018, with birth weight <1000 g. Thirty-five infants were "nothing by mouth" for >14 days and categorized as the high-risk group; the remaining 60 were categorized as the control group. Mineral intake in the first 14 days and the trend of serum calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP) levels were compared in both groups.

RESULTS

The Ca and P supplementation in the first 2 weeks of life were inadequate in both groups. Compared with the control group, significantly lower serum P (mg/dL) levels were noted in the high-risk group on weeks 2 (3.65 ± 1.2 vs 4.67 ± 1.45; P < .001), 4 (3.21 ± 0.95 vs 5.83 ± 1.18; P < .0001), and 6 (3.94 ± 1.1 vs 6.22 ± 0.78; P <.0001). There was no significant difference in the serum Ca level, and significantly higher ALP (U/L) levels were found up until 2 months of life in the high-risk group (458.36 ± 189.02 vs 335.7 ± 111.51; P < .014).

CONCLUSION

Hypophosphatemia developed as early as 2 weeks old in high-risk preterm infants because of inadequate supplementation. Neither the serum Ca or ALP levels were affected. Thus, the routine monitoring of serum P level should be started 2 weeks after birth for early MBD detection in extremely ELBW infants.

Diet in pregnant women that delivered prematurely and preterm newborn's bone status

OBJECTIVES

Inadequate maternal dietary pattern has been associated to negative pregnancy and fetal outcomes. With this study, we aimed to evaluate the adequacy of diet in pregnant women that delivered prematurely and its possible correlations with bone status of preterm newborns.

STUDY DESIGN

We prospectively enrolled women who delivered prematurely (≤than 34 gestational weeks) and their newborns (Neonatal Intensive Care, University Hospital of Padova) from January 2017 to May 2018. Maternal nutritional status and diet supplementations were assessed using a validated questionnaire. The preterm newborns were evaluated with anthropometric measurements and bone status by Quantitative Ultrasound of the second metacarpal bone within 72 h from birth.

RESULTS

One hundred and eighty mothers and 202 preterm newborns were evaluated. The mothers assumed more calories, proteins, total lipids and simple sugars compared to the revised National Guidelines. The intake of calcium, phosphorus and Vitamin D was inadequate despite the use of multivitamin supplements. The mothers assumption of vitamin D and zinc positively correlated with bone status and mothers with very low intake of vitamin D during gestation (<7 µg/die) had preterm newborns with a worst bone status at birth compared to those with a better intake (>7 µg/die).

CONCLUSIONS

Nutrition of pregnant women could be improved and maternal intakes of Vitamin D and zinc positively correlated with preterm newborn's bone status.

Association between vitamin D level and bronchopulmonary dysplasia: A systematic review and meta-analysis

Neonatal vitamin D deficiency is common and is associated with development of pulmonary disease in children and adults. While the role of vitamin D in normal lung development is well established, the association between vitamin D deficiency and bronchopulmonary dysplasia (BPD) remains unclear. The present meta-analysis was conducted to evaluate the relationship between vitamin D and BPD. We identified relevant studies (n = 8) using the PubMed, EMBASE, Cochrane Library, and KoreaMed databases and applied the Newcastle–Ottawa Scale to assess the methodological components of each study, and used I² statistic to evaluate heterogeneity. Comprehensive Meta-Analysis software version 3.3 was used for the statistical analysis. A total of 909 infants were included, of whom 251 (27.6%) were diagnosed with BPD. We found that both vitamin D deficiency at birth (four studies; OR 2.405; 95% CI 1.269 to 4.560; p = 0.007) and low levels of vitamin D at birth (four studies; standardized mean difference -1.463; 95% CI -2.900 to -0.027; p = 0.046) were associated with BPD. The compiled data suggest that antenatal vitamin D deficiency and low vitamin D levels are associated with neonatal BPD.

Intrauterine Growth Restriction: New Insight from the Metabolomic Approach

Recognizing intrauterine growth restriction (IUGR) is a matter of great concern because this condition can significantly affect the newborn's short- and long-term health. Ever since the first suggestion of the "thrifty phenotype hypothesis" in the last decade of the 20th century, a number of studies have confirmed the association between low birth weight and cardiometabolic syndrome later in life. During intrauterine life, the growth-restricted fetus makes a number of hemodynamic, metabolic, and hormonal adjustments to cope with the adverse uterine environment, and these changes may become permanent and irreversible. Despite advances in our knowledge of IUGR newborns, biomarkers capable of identifying this condition early on, and stratifying its severity both pre- and postnatally, are still lacking. We are also still unsure about these babies' trajectory of postnatal growth and their specific nutritional requirements with a view to preventing, or at least limiting, long-term complications. In this setting, untargeted metabolomics-a relatively new field of '-omics' research-can be a good way to investigate the metabolic perturbations typically associated with IUGR. The aim of this narrative review is to provide a general overview of the pathophysiological and clinical aspects of IUGR, focusing on evidence emerging from metabolomic studies. Though still only preliminary, the reports emerging so far suggest an "early" pattern of glucose intolerance, insulin resistance, catabolite accumulation, and altered amino acid metabolism in IUGR neonates. Further, larger studies are needed to confirm these results and judge their applicability to clinical practice.

Bronchopulmonary Dysplasia: An Update on Experimental Therapeutics

Bronchopulmonary dysplasia (BPD) is a chronic inflammatory lung disease that affects thousands of newborns and infants every year. Although it is accepted that BPD results from lung damage and inflammation triggered by mechanical ventilation and hyperoxia, the causes and molecular events leading to lung damage and arrested development remain unknown. While recent advances in neonatal care have improved the survival of very low-weight infants, the rates of BPD have not improved accordingly. This is mainly due to our limited understanding of the disease’s pathogenesis and the effective therapeutic options available. Current therapeutics for BPD involve ventilation management, steroid treatment, and administration of various agents, such as pulmonary surfactant, caffeine, vitamin A, nitric oxide, and stem cells. However, the efficacy of these agents in preventing and ameliorating BPD symptoms varies depending on the populations studied and the disease stage. As the field moves towards personalised therapeutic approaches, this review summarises clinical and experimental studies conducted in various models, aiming to increase understanding of the cellular and molecular mechanisms by which these agents can prevent or treat BPD. Due to the increasing number of extremely premature infants, it is imperative that we continue to work towards understanding the mechanisms of BPD pathogenesis and generating more effective therapeutic options.