Intracranial hemorrhage in the preterm infant: understanding it, preventing it

Hemodynamic Risk Factors for Cerebellar Hemorrhage Presence and Volume in Infants Born Very Preterm

OBJECTIVE

To examine among infants born very preterm the role of hemodynamic disturbances in the occurrence of cerebellar hemorrhage (CbH) and whether cardiovascular instability is associated with larger CbH volume.

STUDY DESIGN

Prospective, longitudinal, multisite cohort study. Early-life and/or term-equivalent age brain magnetic resonance imaging were performed in 309 very preterm infants admitted to 3 tertiary-level neonatal intensive care units. A cut-off of 4 mm was used to distinguish punctate vs large CbH. CbH volumes were obtained by manual segmentation. As a measure of hemodynamic stability, Score for Neonatal Acute Physiology, patent ductus arteriosus requiring treatment, and hypotension treated with inotropes were recorded.

RESULTS

Sixty patients (18.3%) were diagnosed with CbH, classified as punctate in 43 infants (71.3%). Hypotension requiring treatment with inotropes was an independent risk factor for CbH (OR 3.07, 95% CI 1.15-8.21, P = .02) and was associated with larger CbH volume (0.36 log mm3, 95% CI 0.17-0.54, P < .001).

CONCLUSIONS

Hypotension treated with inotropes is shown to be an independent risk factor for the presence of CbH as well as for larger CbH volume. These results reinforce the importance of hemodynamics stability, especially an appropriate management of hypotension to prevent CbH and therefore improve neurodevelopmental outcomes among infants born very preterm.

Neurodevelopmental Outcomes in Preterm Infants at 18 Months of Corrected Age Following Coronavirus Disease 2019 (COVID-19) Pandemic-Related Neonatal Intensive Care Unit (NICU) Care Changes

BACKGROUND

 The coronavirus disease 2019 (COVID-19) pandemic led to significant changes in neonatal intensive care unit (NICU) protocols, including restrictions on parental visitation and suspension of kangaroo mother care. These modifications likely impacted preterm infants' neurodevelopmental outcomes. While previous studies have examined the short-term developmental effects of the pandemic, the long-term neurodevelopmental consequences remain unclear. This study aimed to assess the impact of pandemic-related NICU care changes on the neurodevelopmental outcomes of preterm infants at 18 months corrected age in Japan.

METHODOLOGY

 This retrospective, single-center study was conducted at a Japanese university hospital and included preterm infants born before and during the COVID-19 pandemic. Eligible infants were those with a gestational age of less than 32 weeks or a birth weight under 1,500 g, who subsequently underwent neurodevelopmental assessment at 18 months of corrected age using the Kyoto Scale of Psychological Development 2001 (KSPD). Infants were categorized into a prepandemic group (born before March 1, 2020) and a pandemic group (born on or after March 1, 2020). To compare demographic and clinical characteristics between the groups, the Mann-Whitney U test was employed for continuous variables and the chi-square test for categorical variables. All statistical analyses were performed using a predefined significance level of p < 0.05.

RESULTS

 A total of 44 preterm infants were included (22 per group). While there were no significant differences in birth weight or neonatal morbidities between the groups, the pandemic group had a significantly older gestational age (30 vs. 28 weeks, p = 0.04). KSPD assessments revealed that the pandemic group had significantly lower cognitive-adaptive (80 vs. 92, p = 0.01) and language-social (73 vs. 89, p = 0.04) developmental quotients (DQ) compared with the prepandemic group. Postural-motor DQ was lower in the pandemic group but did not reach statistical significance (82 vs. 98, p = 0.14). To account for potential confounders, an analysis of covariance was conducted, adjusting for gestational age, birth weight, and sex. The adjusted analysis remained consistent with the unadjusted findings, confirming significantly lower cognitive-adaptive DQ (F = 4.83, p = 0.03) and language-social DQ (F = 3.94, p = 0.04) in the pandemic group. Gestational age, birth weight, and sex were not significantly associated with any DQ scores.

CONCLUSIONS

 Preterm infants born during the COVID-19 pandemic exhibited significantly lower cognitive-adaptive and language-social DQs at 18 months corrected age than prepandemic infants. These findings suggest that pandemic-related restrictions on parental involvement in the NICU may have potentially influenced neurodevelopment. Further research is needed to explore long-term developmental trajectories and interventions to support optimal outcomes in this vulnerable population.

Pooled prevalence and predictors of intraventricular hemorrhage (IVH) in preterm neonates (28-34 weeks) in Africa: a systematic review and meta-analysis

OBJECTIVE

To assess the pooled prevalence and predictors of intraventricular hemorrhage (IVH) among preterm neonates born between 28 and 34 weeks of gestational age in Africa.

METHOD

A weighted inverse-variance random-effects model estimated the pooled prevalence and predictors of germinal matrix hemorrhage. Heterogeneity was assessed using forest plots and I² statistics, focusing on studies conducted in African settings. Cross-sectional studies published in English between 2004 and 2022 were identified through online and manual searches conducted from September 18 to October 27, 2024.

OUTCOME MEASURE

Intraventricular hemorrhage/Germinal matrix hemorrhage (Grades I-IV), defined as bleeding in a developing brain region that typically resolves by term gestational age.

RESULT

Ten primary studies involving 2,622 preterm neonates born at 28-34 weeks of gestation were included. The pooled prevalence of IVH was nearly three in ten cases, with substantial heterogeneity across studies (I² = 99%, P < 0.001). Extremely premature neonates had almost twice the risk of IVH compared to those born after 28 weeks (AOR = 1.98; 95% CI: 1.31-3.64). Antenatal corticosteroid (ANC) administration reduced IVH risk by 35% (AOR = 0.65; 95% CI: 0.08-0.78), while intubation status showed no significant effect (AOR = 1.04; 95% CI: -0.19-2.28).

CONCLUSION

The pooled prevalence of IVH in very preterm and very low birth weight (VLBW) neonates in Africa was considerable, affecting nearly three out of ten cases. Extremely premature neonates were almost twice as likely to develop IVH compared to those born after 28 weeks of gestation, while antenatal corticosteroid (ANC) administration significantly reduced the risk. Intubation status had no significant impact on IVH risk. These findings highlight the urgent need for healthcare professionals and policymakers to prioritize preterm care standards in Africa to improve neonatal outcomes.

PROSPERO ID

CRD42024499505.

Platelet transfusion in neonatal intensive care units of 22 European countries: a prospective observational study

Background

Platelet transfusions are given to preterm infants with severe thrombocytopenia aiming to prevent haemorrhage. The PlaNeT2/MATISSE trial revealed higher rates of mortality and/or major bleeding in preterm infants receiving prophylactic platelet transfusions at a platelet count threshold of 50 × 109/L compared to 25 × 109/L. The extent to which this evidence has been incorporated into clinical practice is unknown, thus we aimed to describe current neonatal platelet transfusion practices in Europe.

Methods

We performed a prospective observational study in 64 neonatal intensive care units across 22 European countries between September 2022 and August 2023. Outcome measures included observed transfusion prevalence rates (per country and overall, pooled using a random effects Poisson model), expected rates based on patient-mix (per country, estimated using logistic regression), cumulative incidence of receiving a transfusion by day 28 (with death and discharge considered as competing events), transfusion indications, volumes and infusion rates, platelet count triggers and increment, and adverse effects.

Findings

We included 1143 preterm infants, of whom 71 (6.2%, [71/1143]) collectively received 217 transfusions. Overall observed prevalence rate was 0.3 platelet transfusion days per 100 admission days. By day 28, 8.3% (95% CI: 5.5-11.1) of infants received a transfusion. Most transfusions were indicated for threshold (74.2%, [161/217]). Pre-transfusion platelet counts were above 25 × 109/L in 33.1% [53/160] of these transfusions. There was significant variability in volume and duration.

Interpretation

The restrictive threshold of 25 × 109/L is being integrated into clinical practice. Research is needed to explore existing variation and generate evidence for various aspects including optimal volumes and infusion rates.

Funding

Sanquin, EBA, and ESPR.

Prevalence and associated risk factors of intraventricular hemorrhage in preterm newborns in Southwestern Iran

PURPOSE

The purpose of this study was to investigate the prevalence of IVH and its associated risk factors in premature newborn admitted to NICU in Southwestern Iran.

METHODS AND MATERIALS

This cross-sectional study involved all premature newborn admitted to Namazee NICU, Southwestern Iran, during the year 2022. The diagnosis of IVH was confirmed using brain ultrasonography, following Papille's criteria. Demographic data and potential risk factors were collected and analyzed for two groups: neonate diagnosed with IVH and those without the condition.

RESULTS

Among the 275 preterm neonates studied (125 girls, 150 boys), the mean gestational age was 29.22 ± 1.44 weeks. The prevalence of IVH was found to be 20.4% within the first 7th day after birth. The recognized risk factors of IVH in our study were gestational age, pneumothorax, hypoxia, antenatal steroids, and transfusion of packed red blood cell. Duration of intubation and CPAP therapy were found to be other risk factors, too. The logistic regression model showed preterm newborns born between gestational age of 28+1 and 30+6 weeks had a twofold increased risk of developing IVH.

CONCLUSION

The prevalence of IVH in NICU hospitalized newborns with a gestational age of ≤ 32 weeks was around 20%, which is consistent with other studies conducted in Iran. The findings emphasize the importance of enhanced antenatal care for early intervention for neonates born at early gestational age to reduce or prevent the risk of IVH.

Regional variations in morbidity and mortality among neonates with intraventricular hemorrhage: a national database analysis

BACKGROUND

Intraventricular hemorrhage (IVH) often affects newborns of low gestational age and low birth weight, requires critical care for neonates, and is linked to long-term neurodevelopmental outcomes. Assessing regional differences in the U.S. in care for neonatal IVH and subsequent outcomes can shed light on ways to mitigate socioeconomic disparities.

METHODS

Using the 2016-2019 National Inpatient Sample (NIS), patients with a primary diagnosis of IVH were identified using ICD-10-CM codes. A retrospective cohort study was conducted with patients stratified by hospital region. Demographics, comorbidities, presentation, intraoperative variables, and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of insurance status on extended LOS (defined as > 75th percentile of LOS), exorbitant cost (defined as > 75th percentile of cost), and mortality.

RESULTS

Included in this study were 1630 newborns with IVH. A larger portion of patients in the South and Midwest were Black, compared to the Northeast and West (Northeast: 12.2% vs Midwest: 30.2% vs South: 22.8% vs West: 5.8%, p < 0.001), while a greater percentage of patients in the West and South were Hispanic (Northeast: 7.3% vs Midwest: 9.5% vs South: 22.8% vs West: 36.2%, p < 0.001). LOS was similar among all regions. Factors associated with prolonged LOS included hydrocephalus and CSF diversions. Median total cost of admission was highest in the West, while the South was associated with decreased odds of exorbitant cost. LOS was associated with exorbitant cost, and large bed-volume hospital, VLBW, and permanent CSF shunt were associated with mortality.

CONCLUSIONS

Demographic variables, but not presenting or intraoperative variables, differed among regions, pointing to possible geographic health disparities. The West had the highest total cost of admission, while the South was associated with reduced odds of exorbitant admission costs.

Case Report: resolution of refractory seizures after neurosurgical intervention in newborns with cerebral extra-axial hemorrhages

Introduction

Intracranial hemorrhage is a significant cause of neurological damage in newborns. Extra-axial hemorrhages with intraparenchymal extension can precipitate acute clinical deterioration. Seizures are one of the presenting symptoms, which can be refractory to treatment. These hemorrhages can result in considerable long-term morbidity and mortality.

Aim

The objective of this report was to present three cases of extra-axial hemorrhages in neonates, all exhibiting refractory seizures that resolved after neurosurgical intervention. In addition, a review of literature is provided.

Methods

Data collected included clinical history, laboratory findings, neuroimaging studies, type of neurosurgical intervention, and patient outcome. All infants presented with extra-axial hemorrhages along with clinical and radiological signs of increased intracranial pressure within the first 6 days of life. These manifestations included a decreased level of consciousness, hypertension, bradycardia, and cerebral midline shift on imaging. Refractory seizures were present in all cases. Urgent magnetic resonance imaging was performed followed by neurosurgical intervention (two needle aspirations, one cranial trepanation), leading to amelioration of clinical symptoms and complete resolution of seizures. Follow-up outcomes included normal psychomotor development in one infant, mild cerebral paresis in another, and delayed motor development in the third. None of the infants developed epilepsy.

Conclusion

This study underscores the critical importance of monitoring seizure activity, conducting urgent and appropriate imaging, and implementing targeted neurosurgical intervention, preferably through minimally invasive methods such as percutaneous needle aspiration. Clinicians should be aware of this clinical picture and respond promptly to mitigate neurological damage.

Role of the brain-sparing effect on retinopathy of prematurity in newborns with fetal growth restriction

INTRODUCTION

This study aimed to investigate the role of the brain-sparing effect (BSE) on retinopathy of prematurity (ROP) in fetal growth restriction (FGR).

METHODS

In this retrospective study, 127 pregnant women were divided into two groups considering the cerebroplacental ratio (CPR): FGR with abnormal CPR group (n = 74) and the appropriate for gestational age with normal Doppler group (n = 53). CPR was computed using the pulsatility index (PI) and resistance index (RI) to quantitate the waveforms [middle cerebral artery (MCA) PI/umbilical artery (UA) PI and MCA RI/UA RI: a result <1 was taken into account as abnormal]. ROP screening results of newborns were recorded from electronic files.

RESULTS

After adjusting for co-variants, BSE was not related to ROP (adjusted odds ratio [aOR], 1.06; 95% confidence interval [CI], 0.23-4.95). Gestational age at delivery <30 weeks (aOR, 2.55; 95% CI, 1.04-6.93) and birth weight <1500 g (aOR, 5.15; 95% CI, 1.15-25.2) were independently associated with ROP. Preeclampsia, emergency cesarean section birth, or 48 h completion after the first steroid administration were not associated with ROP.

CONCLUSIONS

Gestational age at delivery <30 weeks and birth weight <1500 g are independent risk factors for ROP in FGR whereas the BSE is not a risk factor.

Assessment of brain structure and volume reveals neurodevelopmental abnormalities in preterm infants with low-grade intraventricular hemorrhage

There is increasing evidence of abnormal neurodevelopmental outcomes in preterm infants with low-grade intraventricular hemorrhage (IVH). The purpose of the study was to explore whether brain microstructure and volume are associated with neuro-behavioral outcomes at 40 weeks corrected gestational age in preterm infants with low-grade IVH. MR imaging at term-equivalent age (TEA) was performed in 25 preterm infants with mild IVH (Papile grading I/II) and 40 control subjects without IVH. These subjects all had neonatal behavioral neurological assessment (NBNA) at 40 weeks' corrected age. Microstructure and volume evaluation of the brain were performed by using diffusion kurtosis imaging (DKI) and Synthetic MRI. Correlations among microstructure parameters, volume, and developmental outcomes were explored by using Spearman's correlation. In preterm infants with low-grade IVH, the volume of brain parenchymal fraction (BPF) was reduced. In addition, mean kurtosis (MK), fractional anisotropy (FA), radial kurtosis (RK), axial kurtosis (AK) in several major brain regions were reduced, while mean diffusivity (MD) was increased (P < 0.05). BPF, RK in the cerebellum, MK in the genu of the corpus callosum, and MK in the thalamus of preterm infants with low-grade IVH were associated with lower NBNA scores (r = 0.831, 0.836, 0.728, 0.772, P < 0.05). DKI and Synthetic MRI can quantitatively evaluate the microstructure alterations and brain volumes in preterm infants with low-grade IVH, which provides clinicians with a more comprehensive and accurate neurobehavioral assessment of preterm infants with low-grade IVH.

Natal factors affecting developmental defects of enamel in preterm infants: a prospective cohort study

This study investigated natal factors influencing developmental defects of enamel (DDE) in premature infants using a newly refined preterm developmental defects of enamel (PDDE) index. Dental examinations were conducted on a cohort of 118 preterm infants (average age 3.5 ± 1.4 years) to record PDDE scores, while reviewing their medical records to examine natal factors. According to the logistic regression analysis, factors related to DDE prevalence were advanced maternal age, gestational age < 28 weeks, birth weight < 1000 g, 1 min APGAR score < 7, and hospitalization period > 2 months, which were significantly higher by 2.91, 5.53, 7.63, 10.02, and 4.0 times, respectively. According to regression analysis with generalized linear models, the PDDE scores were approximately 7.65, 4.96, and 15.0 points higher in premature children diagnosed with bronchopulmonary dysplasia, intraventricular hemorrhage, and necrotizing enterocolitis, respectively. When endotracheal intubation was performed, the PDDE score was 5.06 points higher. The prevalence of PDDE was primarily observed bilaterally in the maxillary anterior teeth. Extremely preterm infants showed significantly delayed tooth eruption, suggesting that the influence of gestational age on dental development rates. Identifying the factors related to DDE in premature children can inform early dental interventions to support the oral health of high-risk children.

Changes in inflammatory proteins following platelet transfusion in a neonatal population

BACKGROUND

Studies have demonstrated increased morbidity and mortality with platelet transfusions in the neonatal period. Platelets are as important for host immunity and inflammation as for hemostasis. Increased inflammation may explain the dose-associated increase in mortality, bleeding, and lung disease.

OBJECTIVE

This study aims to assess if there are any changes in inflammatory cytokines post-platelet transfusion in babies in NICU.

METHODS

This prospective observational study recruited babies due to receive a non-emergency platelet transfusion. Dried whole blood samples were collected prior to and 2 h post-transfusion. Samples were processed using multiplex immunoassay to enable analysis of tiny blood volumes. Statistical analysis was performed using R.

RESULTS

Seventeen babies underwent 26 platelet transfusions across two centers. Median birthweight was 1545 g (535-3960 g) and median birth gestation was 31 weeks and 1 day (23 + 1 to 40 + 5). Median pre-transfusion platelet count was 19.5 × 109/l. There was a significant increase in levels of CXCL5 (p < 0.001), CD40 (p = 0.001), and TGF-β (p = 0.001) in neonatal blood samples post-platelet transfusion in the study group.

CONCLUSION

The increase in the cytokines CXCL5, CD40 and TGF-β after platelet transfusion in babies in NICU could potentiate existing inflammation, NEC, lung, or white matter injury. This could potentially explain long-term harm from platelet transfusion in babies.

IMPACT

There is a change in levels of immunomodulatory proteins CXCL5, CD40, and TGF-β after platelet transfusion in babies in NICU. Murine neonatal models have demonstrated an increase in cytokine levels after platelet transfusions. This is the first time that this has been demonstrated in human neonates. The increase in proinflammatory cytokines could potentially explain the long-term harm from platelet transfusion in babies, as they could potentiate existing inflammation, NEC, lung injury, or white matter injury.

The Impact of Intraventricular Hemorrhage and Periventricular Leukomalacia on Mortality and Neurodevelopmental Outcome in Very Preterm and Very Low Birthweight Infants: A Prospective Population-based Cohort Study

OBJECTIVE

To survey the incidence of intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) by gestational age and to report the impact on mortality and neurodevelopmental outcome in very preterm/very low birthweight infants.

STUDY DESIGN

This was a population-based cohort study of 1927 very preterm/very low birthweight infants born in 2014-2016 and admitted to Flemish neonatal intensive care units. Infants underwent standard follow-up assessment until 2 years corrected age with the Bayley Scales of Infant and Toddler Development and neurological assessments.

RESULTS

No brain lesion was present in 31% of infants born at <26 weeks of gestation and 75.8% in infants born at 29-32 weeks of gestation. The prevalence of low-grade IVH/PVL (grades I and II) was 16.8% and 12.7%, respectively. Low-grade IVH/PVL was not related significantly to an increased likelihood of mortality, motor delay, or cognitive delay, except for PVL grade II, which was associated with a 4-fold increase in developing cerebral palsy (OR, 4.1; 95% CI, 1.2-14.6). High-grade lesions (III-IV) were present in 22.0% of the infants born at <26 weeks of gestational and 3.1% at 29-32 weeks of gestation, and the odds of death were ≥14.0 (IVH: OR, 14.0; 95% CI, 9.0-21.9; PVL: OR, 14.1; 95% CI, 6.6-29.9). PVL grades III-IV showed an increased odds of 17.2 for motor delay and 12.3 for cerebral palsy, but were not found to be associated significantly with cognitive delay (OR, 2.9; 95% CI, 0.5-17.5; P = .24).

CONCLUSIONS

Both the prevalence and severity of IVH/PVL decreased significantly with advancing gestational age. More than 75% of all infants with low grades of IVH/PVL showed normal motor and cognitive outcome at 2 years corrected age. High-grade PVL/IVH has become less common and is associated with adverse outcomes.

Design and Superior Performance of a New Endotracheal Tube to Avoid the Asphyxiation of Premature Infants

Background Neonatal endotracheal intubation attempts often fail, with failures typically attributable to unintended esophageal intubation, with asphyxia, brief or prolonged, as the consequence. Standard-of-care neonatal endotracheal tubes have changed little over recent decades, even as the gestational age of neonates thought eligible for resuscitation and intensive care has decreased. Methods A new neonatal endotracheal tube was patterned after the soft steering mechanism of a two-string fishing line trocar. The new tube remains patent throughout the intubation for air movement and CO2 detection and allows for a finger on the intubator's hand to stiffen, curve, and elevate the tip of the tube over the epiglottis and into the trachea without occluding the vision through a laryngoscope. This tube's engineering principles were studied prospectively in a controlled open-label pilot study in premature infants. Infants were observed during 12 intubations in a one-to-one comparison with standard practice.  Results The new design in comparison to a conventional neonatal endotracheal tube (CNETT) was found to be superior. The average intubation time (mean 36.6 sec, median 30 sec) was shorter (mean 44.6 sec, median 45 sec) in the new design. Intubation attempts were fewer (0 vs. 3), and unintended esophageal intubations were also fewer (0 vs. 4). Conclusion Tracheal intubation of premature infants with the new soft-steering mechanism endotracheal tube was associated with less asphyxia, fewer intubation attempts, and fewer esophageal intubations.

Hemostasis in the Pregnant Woman, the Placenta, the Fetus, and the Newborn Infant

The hemostasis system is composed of procoagulant, anticoagulant, and fibrinolytic proteins that interact with endothelial and blood cells and with each other in a complex system of checks and balances to maintain blood flow while preventing both hemorrhage and thrombosis. Pregnancy is a unique physiological state in which biological alterations predispose both mother and fetus to both bleeding and clotting. The placenta is a vascular interface for maternal and fetal blood exchange which predisposes the mother to hemorrhage. Maternal hemostasis presents a compensatory hypercoagulability including elevated factor VIII, von Willebrand factor, fibrinogen and thrombin generation, decreased thrombin regulation with resistance to activated protein C and decreased free protein S, and decreased fibrinolysis with increased plasminogen activator inhibitors. The placental vascular surface is of fetal trophoblastic origin that derives many characteristics of endothelium but differs in that tissue factor is constitutively expressed. Ontogeny of fetal hemostasis is characteristic. Platelets, von Willebrand factor, factor VIII, and fibrinogen are expressed and mature early in gestation, while vitamin K-dependent and contact factors exhibit delayed development. The fetal hemostatic system has a decreased capacity to generate or regulate thrombin, resulting in a fragile balance with little capacity to compensate under stress conditions, particularly in the infant born prematurely. Dysfunction of the maternal/placental/fetal unit gives rise to gestational disorders including preeclampsia, fetal growth restriction, placental abruption, and premature delivery. Knowledge of normal hemostasis levels and function are critical to evaluate bleeding or clotting syndromes in the pregnant woman and her fetus or newborn infant.

Impact of low-grade intraventricular hemorrhage on neurodevelopmental outcome in very preterm infants at two years of age

BACKGROUND

High-grade intraventricular hemorrhage (IVH) in very preterm infants is a known risk factor for adverse neurodevelopmental outcome. Prognosis is less clear for low-grade (grades I/II) IVH however, with conflicting study results in recent years.

OBJECTIVE

To evaluate the impact of low-grade IVH on neurodevelopmental outcome at 2 years corrected age in preterm infants born below 32 weeks gestation at the University hospital of Zurich between 2009 and 2014.

METHODS

Among 843 live-born preterm infants born during the observation period, 509 were included in our study. Exclusion criteria were death, high-grade IVH, cystic periventricular leukomalacia and congenital malformations. Infants were grouped into those with or without low-grade IVH according to cranial ultrasound. Neurodevelopmental impairment (NDI) was defined as cognitive or motor developmental score > 2 standard deviations below the mean and/or CP grades 2-5 and/or moderate/severe vision loss and/or hearing problem corrected with hearing aids. Multivariate linear regression was used to assess effect of low-grade IVH on endpoints while adjusting for other risk factors.

RESULTS

87 preterm infants had low-grade IVH (42 grade I, 45 grade II) on cranial ultrasound. These were compared to 422 preterm infants without IVH. Follow-up rate was 82.4 %. Preterm infants with low-grade IVH had higher rates of NDI (21.8 vs 13.3 %, p = 0.047). Infants with IVH grade II had significantly higher rates for CP (8.9 % vs 3.6 %, p = 0.003), visual impairment (20.5 % vs 8.3 %, p = 0.009) and NDI (33.3 % vs 13.3 %, p < 0.001).

CONCLUSION

In our study, low-grade IVH - and especially IVH grade II - is associated with adverse neurodevelopmental outcome at 2 years of corrected age.

Risk factor analyses for intraventricular hemorrhage in preterm infants: A retrospective cohort study

BACKGROUND

Very-low-birthweight (VLBW) infants can experience severe intraventricular hemorrhage (IVH) that can lead to life-long disability by impairing neurodevelopment. The aim of this study was to identify the risk and protective factors for severe IVH in VLBW infants.

METHODS

A retrospective, cross-sectional review of VLBW infants born at 22-28 weeks' gestation between January 2003 and December 2012 and listed in the Database of Neonatal Research Network in Japan was performed using a statistical model incorporating an odds ratio (OR) and medical center variation as a center variance ratio (CVR). A two-dimensional analysis using a combination of OR and the CVR described evolving measures of a clinical trial (for OR > 1) and standardization (for CVR > 1) concerning a factor of interest.

RESULTS

The noteworthy significant protective factors were antenatal steroids (ANS) with and without premature rupture of membrane (OR: 0.43, CVR: 1.08, and OR: 0.68, CVR: 1.14, respectively) and the number of neonatal beds (OR: 0.94, CVR: 0.99) and staff nurses per neonatal bed (OR: 0.89, CVR: 0.99).

CONCLUSIONS

Active promotion of ANS administration and consolidation of perinatal medical centers can mitigate the development of severe IVH in VLBW infants.

The Regulated Cell Death and Potential Interventions in Preterm Infants after Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) in preterm infants is one of the major co-morbidities of preterm birth and is associated with long-term neurodevelopmental deficits. There are currently no widely accepted treatments to prevent ICH or therapies for the neurological sequelae. With studies broadening the scope of cell death, the newly defined concept of regulated cell death has enriched our understanding of the underlying mechanisms of secondary brain injury after ICH and has suggested potential interventions in preterm infants. In this review, we will summarize the current evidence for regulated cell death pathways in preterm infants after ICH, including apoptosis, necroptosis, pyroptosis, ferroptosis, autophagy, and PANoptosis as well as several potential intervention strategies that may protect the immature brain from secondary injury after ICH through regulating regulated cell death.

Association of red blood cell transfusion volume with postoperative complications and mortality in neonatal surgery

INTRODUCTION

Red blood cell transfusion (RBCT) is commonly administered in neonatal surgical care in the absence of clear clinical indications such as active bleeding or anemia. We hypothesized that higher RBCT volumes are associated with worse postoperative outcomes.

METHODS

Neonates within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2016) were stratified by weight-based RBCT volume: <20cc/kg, 20-40cc/kg, and >40cc/kg. Postoperative complications were categorized as wound, systemic infection, central nervous system (CNS), renal, pulmonary, and cardiovascular. Multivariable logistic regression and cubic spline analysis were used to evaluate the association between RBCT volume, postoperative complications, and 30-day mortality. Sensitivity analysis was conducted by performing propensity score matching.

RESULTS

Among 9,877 neonates, 1,024 (10%) received RBCTs. Of those who received RBCT, 53% received <20cc/kg, 27% received 20-40cc/kg, and 20% received >40cc/kg. Relative to neonates who were not transfused, RBCT volume was associated with a dose-dependent increase in renal complications, CNS complications, cardiovascular complications, and 30-day mortality. With cubic spline analysis, a lone inflection point for 30-day mortality was identified at a RBCT volume of 30 - 35 cc/kg. After propensity score matching, the dose-dependent relationship was still present for 30-day mortality.

CONCLUSION

Total RBCT volume is associated with worse postoperative outcomes in neonates with a significant increase in 30-day mortality at a RBCT volume of 30 - 35 cc/kg. Future prospective studies are needed to better understand the association between large RBCT volumes and poor outcomes after neonatal surgery.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants: a retrospective single-center cohort study

OBJECTIVE

We examined the association between the number of tracheal intubation (TI) attempts and clinical outcomes in extremely preterm infants.

METHOD

This is a single-center retrospective cohort study examining infants born at ≤28 weeks gestation intubated within the first four postnatal days. We analyzed infant, provider, and practice characteristics and clinical outcomes by exposure groups (1 vs. 2 vs. ≥3 TI attempts). Primary outcomes were death prior to NICU discharge or severe intraventricular hemorrhage (IVH).

RESULT

Ninety-nine infants were included. 46.5% required one TI attempt, 29.3% required two, and 24.2% required three or more. Increasing attempts was significantly associated with death (p = 0.004), adverse tracheal intubation-associated events (TIAEs; p = 0.004), and the training level of the first attempt provider (p = 0.002). No association was found with severe IVH or complications of prematurity.

CONCLUSIONS

Increasing attempts was associated with death and adverse TIAEs. Careful selection of providers could decrease adverse TIAEs and improve outcomes.

A Role of Complement in the Pathogenic Sequelae of Mouse Neonatal Germinal Matrix Hemorrhage

Germinal matrix hemorrhage (GMH) is a devastating disease of infancy that results in intraventricular hemorrhage, post-hemorrhagic hydrocephalus (PHH), periventricular leukomalacia, and neurocognitive deficits. There are no curative treatments and limited surgical options. We developed and characterized a mouse model of GMH based on the injection of collagenase into the subventricular zone of post-natal pups and utilized the model to investigate the role of complement in PHH development. The site-targeted complement inhibitor CR2Crry, which binds deposited C3 complement activation products, localized specifically in the brain following its systemic administration after GMH. Compared to vehicle, CR2Crry treatment reduced PHH and lesion size, which was accompanied by decreased perilesional complement deposition, decreased astrocytosis and microgliosis, and the preservation of dendritic and neuronal density. Complement inhibition also improved survival and weight gain, and it improved motor performance and cognitive outcomes measured in adolescence. The progression to PHH, neuronal loss, and associated behavioral deficits was linked to the microglial phagocytosis of complement opsonized neurons, which was reversed with CR2Crry treatment. Thus, complement plays an important role in the pathological sequelae of GMH, and complement inhibition represents a novel therapeutic approach to reduce the disease progression of a condition for which there is currently no treatment outside of surgical intervention.

Perinatal risk factors associated with central retinal changes in former preterm children on optical coherence tomography angiography

PURPOSE

To assess the association between perinatal risk factors for retinopathy of prematurity (ROP) and central retinal structures of former preterm children seen on optical coherence tomography angiography (OCTA).

METHODS

This prospective cohort study included 40 children with a history of preterm birth and 33 healthy full-term children. We documented their birth weight, gestational age, other significant risk factors for ROP development and presence of ROP. Imaging was performed using swept-source OCTA, and quantitative evaluation was performed. Analytic parameters included the area of foveal avascular zone (FAZ), foveal depth (FD), central subfoveal retinal thickness (CSFT) and capillary density index (CDI) of the deep and superficial capillary plexus.

RESULTS

Preterm children had significantly smaller FAZ, lower FD and higher CSFT compared to controls (all p < 0.001). Both groups exhibited no differences in total CDI at the superficial (p = 0.969) and deep capillary plexus (p = 0.370). The duration of mechanical ventilation correlated negatively with FAZ and FD but positively with CSFT. The duration of supplemental oxygen treatment correlated negatively with FD. The presence of intraventricular haemorrhage correlated negatively with FAZ and FD but positively with CSFT. Regression analysis found that the duration of mechanical ventilation and the presence of bronchopulmonary dysplasia were associated with lower FD (p = 0.002 and 0.01, respectively) and higher CSFT (p = 0.002 and 0.028, respectively).

CONCLUSION

Central retinal anomalies were identified in former preterm children using OCTA. Macular changes were associated with several risk factors for ROP development.

The role of the brain-sparing effect of growth-restricted fetuses in newborn germinal matrix/intraventricular hemorrhage

OBJECTIVES

The aim of the study was to evaluate the effect of the brain-sparing effect (BSE) of fetal growth restriction (FGR) in newborn germinal matrix/intraventricular hemorrhage (GM/IVH).

METHODS

A total of 320 patients who delivered prior to the 34th gestational week were analyzed from data records. 201 patients were divided into two groups according to cerebro-placental ratio (CPR): early fetal growth restriction (FGR) with abnormal CPR group (n=104) and appropriate for gestational age with normal Doppler group (control) (n=97). Using the normal middle cerebral artery (MCA) Doppler as a reference, multivariate logistic regression analysis was used to assess the association between the BSE and the primary outcome.

RESULTS

The rate of Grade I-II germinal matrix/intraventricular hemorrhage (GM/IVH) was 31(29.8%) in the group possessing early FGR with abnormal CPR and 7(7.2%) in the control group, showing a statistically significant difference. The rate of grade III-IV GM/IVH was 7(6.7%) in the group possessing early FGR with abnormal CPR and 2 (2.1%) in the control group, showing no statistically significant difference. We found that gestational age at delivery <32 weeks was an independent risk factor for GM/IVH. In addition, we found that other variables such as the presence of preeclampsia, fetal weight percentile <10, emergency CS delivery, 48-h completion after the first steroid administration and 24-h completion rate after MgSO₄ administration were not independently associated with the primary outcome.

CONCLUSIONS

Our results indicate that the rate of GM-IVH was increased in the group possessing early FGR with abnormal CPR; however, multivariate logistic regression analysis showed that BSE was not an independent risk factor for GM/IVH.

Assessing cerebral blood flow, oxygenation and cytochrome c oxidase stability in preterm infants during the first 3 days after birth

A major concern with preterm birth is the risk of neurodevelopmental disability. Poor cerebral circulation leading to periods of hypoxia is believed to play a significant role in the etiology of preterm brain injury, with the first three days of life considered the period when the brain is most vulnerable. This study focused on monitoring cerebral perfusion and metabolism during the first 72 h after birth in preterm infants weighing less than 1500 g. Brain monitoring was performed by combining hyperspectral near-infrared spectroscopy to assess oxygen saturation and the oxidation state of cytochrome c oxidase (oxCCO), with diffuse correlation spectroscopy to monitor cerebral blood flow (CBF). In seven of eight patients, oxCCO remained independent of CBF, indicating adequate oxygen delivery despite any fluctuations in cerebral hemodynamics. In the remaining infant, a significant correlation between CBF and oxCCO was found during the monitoring periods on days 1 and 3. This infant also had the lowest baseline CBF, suggesting the impact of CBF instabilities on metabolism depends on the level of blood supply to the brain. In summary, this study demonstrated for the first time how continuous perfusion and metabolic monitoring can be achieved, opening the possibility to investigate if CBF/oxCCO monitoring could help identify preterm infants at risk of brain injury.

The impact of initial hematocrit values after birth on peri-/intraventricular hemorrhage in extremely low birth weight neonates

AIM

Peri-/intaventricular hemorrhage (P/IVH) is a common condition in preterm neonates and is responsible for substantial adverse neurological outcome especially in extremely low birth weight infants. As hematocrit after birth is a surrogate marker for blood volume, this study aimed to evaluate the effect of initial hematocrit values after birth on P/IVH development in extreme low birth weight (ELBW) neonates.

PATIENTS AND METHODS

A prospective cohort analysis of 92 eligible ELBW neonates was performed. The relationship between initial hematocrit values in ELBW neonates after birth and subsequent development of P/IVH was examined.

RESULTS

Twenty-nine of 92 infants developed P/IVH. There were significant differences in initial Hct and maximum carbon dioxide (max PCO₂) in the first 3 days levels in the P/IVH group compared with no P/IVH group. Initial Hct level at birth in the P/IVH group were significantly lower than the no P/IVH group while max PCO₂ in the first 3 days were found to be significantly high in the P/IVH group. There were no significant differences in other baseline demographic, perinatal, and neonatal characteristics while in univariate analysis, higher gestational age and initial Hct were associated with decreased likelihood of P/IVH. In multiple regression analysis after adjustment, only initial Hct remained significantly associated with P/IVH. There was no difference between the population by subgroups of IVH (IVH I-II and IVH III-IV) according to hematocrit and the severity of IVH.

CONCLUSION

Higher initial Hct at birth is associated with decreased P/IVH in ELBW infants. We hypothesized the argument that ELBW infants who have lower initial Hct at birth have less suboptimal volume status that predisposing lower cerebral blood flow and the resultant decrease in cerebral blood flow precede the development of P/IVH.

Novel oxytocin receptor antagonists for tocolysis: a systematic review and meta-analysis of the available data on the efficacy, safety, and tolerability of retosiban

OBJECTIVE

To assess the efficacy, safety, and tolerability of retosiban-a novel tocolytic unavailable in the US-in the management of preterm labor.

METHODS

We searched ClinicalTrials.Gov, MEDLINE, PubMed, SCOPUS, Web of Science, and the Cochrane Library for relevant clinical trials using the terms "retosiban" and "preterm labor" through 09/2020. We included all published randomized clinical trials (three) that compared retosiban to placebo for preterm labor, excluding conferences, books, reviews, posters, case reports, and animal studies. We analyzed homogeneous data under the fixed-effects model and heterogeneous data under the random-effects model.

RESULTS

We included all randomized clinical trials addressing this topic, which ultimately resulted in three trials with a total of 116 patients. There were no significant differences between retosiban and placebo in births at term (RR = 0.41, p = .02), births ≤7 days from the first study treatment (RR = 0.59, p = .23), or administration of rescue tocolytic (RR = 0.36, p = .07); the maternal adverse events of headache, anemia, constipation, or urinary tract infection (p > .05); or neonatal outcomes of Apgar score at 1 min (p = .88) or 5 min (p = .69), weight (p = .23), head circumference (p = .55), malnutrition (p = .27), hyperbilirubinemia (RR = 0.56, p = .21), jaundice (RR = 1.21, p = .84), respiratory distress (RR = 0.53, p = .49), or tachypnea (RR = 0.40, p = .42).

CONCLUSION

With the limited high quality evidence available, retosiban demonstrates no clear benefit over placebo in the management of preterm labor. Nevertheless, its favorable safety profile, oral bioavailability, and novel mechanism of action and the limited number of studies available for review warrant further analysis.

Neonatal Platelet Transfusions: Starting Again

Preterm neonates with severe thrombocytopenia are frequently prescribed prophylactic platelet transfusions despite no evidence of benefit. Neonatal platelet transfusion practice varies, both nationally and internationally. Volumes and rates of transfusion in neonatology are based on historic precedent and lack an evidence base. The etiology of harm from platelet transfusions is poorly understood. Neonates are expected to be the longest surviving recipients of blood produce transfusions, and so avoiding transfusion associated harm is critical in this cohort. This article reviews the evidence for and against platelet transfusion in the neonate and identifies areas of future potential neonatal platelet transfusion research.

Comparison of Neonatal Outcomes With and Without Prophylaxis With Indomethacin in Premature Neonates

OBJECTIVE

Historically, prophylactic indomethacin (pINDO) has been used in some institutions for patent ductus arteriosus (PDA) in extremely low birthweight neonates while other institutions have used it as prophylaxis for intraventricular hemorrhage (IVH). The objective of this study was to evaluate the incidence of IVH and PDA with or without pINDO in premature neonates.

METHODS

This was a retrospective, single-center study comparing neonatal outcomes in neonates weighing 1250 grams or less who received pINDO (pINDO group) to those who did not (No pINDO group) after our institution discontinued its routine use.

RESULTS

A total of 399 infants were included for analysis (pINDO, n = 141; No pINDO, n = 258). No difference was found between pINDO and No pINDO groups in incidence of any IVH (18% vs 14%, respectively) or severe IVH (7% vs 3%, respectively) when adjusting for gestational age and antenatal corticosteroids. Although the incidence of moderate-to-large PDA was lower in the pINDO group (13% vs 23%, respectively, adjusted p = 0.002), there was no significant difference for PDA requiring surgery (4% vs 3%, respectively). Results demonstrated a higher incidence of bronchopulmonary dysplasia (BPD) in the pINDO group (55% vs 41%, respectively, adjusted p = 0.014).

CONCLUSION

No difference in the incidence of IVH, severe IVH, or PDA requiring surgery was observed between groups, whereas an increase in BPD was seen with use of pINDO. These data support our institutional practice change to discontinue routine use of pINDO in premature neonates. Further research is needed to guide clinical practice.

Neuroimaging at Term Equivalent Age: Is There Value for the Preterm Infant? A Narrative Summary

Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes.

Genes causing congenital hydrocephalus: Their chromosomal characteristics of telomere proximity and DNA compositions

Congenital hydrocephalus (CH) is caused by genetic mutations, but whether factors impacting human genetic mutations are disease-specific remains elusive. Given two factors associated with high mutation rates, we reviewed how many disease-susceptible genes match with (i) proximity to telomeres or (ii) high adenine and thymine (A + T) content in human CH as compared to other disorders of the central nervous system (CNS). We extracted genomic information using a genome data viewer. Importantly, 98 of 108 genes causing CH satisfied (i) or (ii), resulting in >90% matching rate. However, such a high accordance no longer sustained as we checked two factors in Alzheimer's disease (AD) and/or familial Parkinson's disease (fPD), resulting in 84% and 59% matching, respectively. A disease-specific matching of telomere proximity or high A + T content predicts causative genes of CH much better than neurodegenerative diseases and other CNS conditions, likely due to sufficient number of known causative genes (n = 108) and precise determination and classification of the genotype and phenotype. Our analysis suggests a need for identifying genetic basis of both factors before human clinical studies, to prioritize putative genes found in preclinical models into the likely (meeting at least one) and more likely candidate (meeting both), which predisposes human genes to mutations.

Transfusion in Neonatal Patients: Review of Evidence-Based Guidelines

Transfusion of red blood cells, platelets, and fresh frozen plasma in neonatal patients has not been well characterized in the literature, with guidelines varying greatly between institutions. However, anemia and thrombocytopenia are highly prevalent, especially in preterm neonates. When transfusing a neonatal patient, clinicians must take into consideration physiologic differences, gestational and postnatal age, congenital disorders, and maternal factors while weighing the risks and benefits of transfusion. This review of existing literature summarizes current evidence-based neonatal transfusion guidelines and highlights areas of current ongoing research and those in need of future studies.

Intraventricular hemorrhage in preterm babies

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a major complication of prematurity and inversely associated with gestational age and birth weight. The hemorrhage originates from the germinal matrix with an immature capillary bed where vascularization is intense and active cell proliferation is high. It occurs in around 20% of very low-birth-weight preterm neonates. Germinal matrix-intraventricular hemorrhage is less common in females, the black race, and with antenatal steroid use, but is more common in the presence of mechanical ventilation, respiratory distress, pulmonary bleeding, pneumothorax, chorioamnionitis, asphyxia, and sepsis. Ultrasonography is the diagnostic tool of choice for intraventricular hemorrhage and its complications. Approximately 25-50% of the germinal matrix-intraventricular hemorrhage cases are asymptomatic and diagnosed during routine screening. These cases are usually patients with low-grade hemorrhage. Neurologic findings are prominent in severe intraventricular hemorrhage cases. The major complications of the germinal matrix-intraventricular hemorrhage in preterm babies are periventricular hemorrhagic infarction, posthemorrhagic ventricular dilatation, periventricular leukomalacia, and cerebellar hemorrhage. It is an important cause of mortality and morbidity. The management of hemodynamics and ventilation of patients, appropriate follow-up, and early diagnosis and treatment can minimize morbidity. Prognosis in intraventricular hemorrhage is related to the severity of bleeding, parenchymal damage, and the presence of seizures and shunt surgery. The main determinant of prognosis is periventricular hemorrhagic infarction and its severity. Moderate-severe intraventricular hemorrhage can cause posthemorrhagic hydrocephalus, cerebral palsy, and mental retardation. Even mild germinal matrix-intraventricular hemorrhage can result in developmental disorders. Long-term problems such as neurodevelopmental disorders and cerebral palsy are as important as short-term problems. Improving the quality of life of these babies should be aimed through appropriate treatment and follow-up. In this review, intraventricular hemorrhage and complications are discussed.

Lawrence K. Perfusion and Metabolic Neuromonitoring during Ventricular Taps in Infants with Post-Hemorrhagic Ventricular Dilatation

Post-hemorrhagic ventricular dilatation (PHVD) is characterized by a build-up of cerebral spinal fluid (CSF) in the ventricles, which increases intracranial pressure and compresses brain tissue. Clinical interventions (i.e., ventricular taps, VT) work to mitigate these complications through CSF drainage; however, the timing of these procedures remains imprecise. This study presents Neonatal NeuroMonitor (NNeMo), a portable optical device that combines broadband near-infrared spectroscopy (B-NIRS) and diffuse correlation spectroscopy (DCS) to provide simultaneous assessments of cerebral blood flow (CBF), tissue saturation (StO2), and the oxidation state of cytochrome c oxidase (oxCCO). In this study, NNeMo was used to monitor cerebral hemodynamics and metabolism in PHVD patients selected for a VT. Across multiple VTs in four patients, no significant changes were found in any of the three parameters: CBF increased by 14.6 ± 37.6% (p = 0.09), StO2 by 1.9 ± 4.9% (p = 0.2), and oxCCO by 0.4 ± 0.6 µM (p = 0.09). However, removing outliers resulted in significant, but small, increases in CBF (6.0 ± 7.7%) and oxCCO (0.1 ± 0.1 µM). The results of this study demonstrate NNeMo's ability to provide safe, non-invasive measurements of cerebral perfusion and metabolism for neuromonitoring applications in the neonatal intensive care unit.

Planned delivery route and outcomes of cephalic singletons born spontaneously at 24-31 weeks' gestation: The EPIPAGE-2 cohort study

INTRODUCTION

The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation.

MATERIAL AND METHODS

Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31 weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association.

RESULTS

The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16).

CONCLUSIONS

Planned cesarean delivery for cephalic presentation at 24-31 weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

Placental Pathology, Cerebral Blood Flow, and Intraventricular Hemorrhage in Preterm Infants: Is There a Link?

BACKGROUND

There is growing evidence to support an association between placental inflammation and neurological sequelae of preterm infants. The goal of this study is to evaluate the relationship between placental pathology, post-natal Doppler cerebral resistive indices (RI's), and intraventricular hemorrhage (IVH) in premature infants.

METHODS

In a retrospective cohort study, preterm infants born between 23 0/7 and 32 6/7 weeks' gestation at Parkland Hospital were examined with placental pathology and serial ultrasound Doppler to evaluate for the primary outcome of IVH and death.

RESULTS

A total of 255 infants were included, and 166 (65%) had at least one significant placental pathology, most commonly chorioamnionitis. Infants with placental pathologies were significantly more likely to have mothers with clinical chorioamnionitis and to have lower gestational ages. There was no observed association between placental pathology and IVH or death. Secondary analysis demonstrated that resistive indices obtained from the first and second head ultrasounds were not different in infants with IVH.

CONCLUSION

In this study, we observed a high rate of placental pathologies but no alterations in cerebral indices on ultrasound, or differences in rates of IVH or death. Additional studies are necessary to delineate the relationship between placental pathology, white matter brain injury, and outcomes.

Do transport factors increase the risk of severe brain injury in outborn infants <33 weeks gestational age?

OBJECTIVE

We evaluated transport factors and postnatal practices to identify modifiable risk factors for SBI.

STUDY DESIGN

Retrospective review of Canadian Neonatal Transport Network data linked to Canadian Neonatal Network data for outborns <33 weeks gestational age (GA), during January 2014 to December 2015. SBI was defined as grade 3 or 4 intraventricular hemorrhage or parenchymal echogenicity, including hemorrhagic and/or ischemic lesions.

RESULT

Among 781 infants, 115 (14.7%) had SBI with range 5.6-40% among transport teams. In multivariable analysis, SBI was associated with GA [0.77 (0.71, 0.85)] per week, receipt of chest compressions and/or epinephrine at delivery [1.81 (1.08, 3.05)] and receipt of fluid boluses [1.61 (1.00, 2.58)].

CONCLUSIONS

Risk factors for SBI were related to the condition at birth and immediate postnatal management and not related to transport factors. These results highlight the importance of maternal transfer to perinatal centers to allow optimization of perinatal management.

The developing brain by trimester

Transient anatomical entities play a role in the maturation of brain regions and early functional fetal networks. At the postmenstrual age of 7 weeks, major subdivisions of the brain are visible. At the end of the embryonic period, the cortical plate covers the neopallium. The choroid plexus develops in concert with it, and the dorsal thalamus covers about half the diencephalic third ventricle surface. In addition to the fourth ventricle neuroepithelium the rhombic lips are an active neuroepithelial production site. Early reciprocal connections between the thalamus and cortex are present. The corticospinal tract has reached the pyramidal decussation, and the arteries forming the mature circle of Willis are seen. Moreover, the superior sagittal sinus has formed, and at the rostral neuropore the massa commissuralis is growing. At the viable preterm age of around 24 weeks PMA, white matter tracts are in full development. Asymmetric progenitor division permits production of neurons, subventricular zone precursors, and glial cells. Myelin is present in the ventral spinal quadrant, cuneate fascicle, and spinal motor fibers. The neopallial mantle has been separated into transient layers (stratified transitional fields) between the neuroepithelium and the cortical plate. The subplate plays an important role in organizing the structuring of the cortical plate. Commissural tracts have shaped the corpus callosum, early primary gyri are present, and opercularization has started caudally, forming the lateral fissure. Thalamic and striatal nuclei have formed, although GABAergic neurons continue to migrate into the thalamus from the corpus gangliothalamicum. Near-term PMA cerebral sublobulation is active. Between 24 and 32 weeks, primary sulci develop. Myelin is present in the superior cerebellar peduncle, rubrospinal tract, and inferior olive. Germinal matrix disappears from the telencephalon, except for the GABAergic frontal cortical subventricular neuroepithelium.

A randomized controlled trial on the use of pessary plus progesterone to prevent preterm birth in women with short cervical length (P5 trial)

BACKGROUND

Preterm birth is the leading cause of mortality and disability in newborn and infants. Having a short cervix increases the risk of preterm birth, which can be accessed by a transvaginal ultrasound scan during the second trimester. In women with a short cervix, vaginal progesterone and pessary can both reduce this risk, which progesterone more established than cervical pessary. The aim of this study is to compare the use of vaginal progesterone alone versus the association of progesterone plus pessary to prevent preterm birth in women with a short cervix.

METHODS

This is a pragmatic open-label randomized controlled trial that will take place in 17 health facilities in Brazil. Pregnant women will be screened for a short cervix with a transvaginal ultrasound between 18 0/7 until 22 6/7 weeks of gestational age. Women with a cervical length below or equal to 30 mm will be randomized to the combination of progesterone (200 mg) and pessary or progesterone (200 mg) alone until 36 + 0 weeks. The primary outcome will be a composite of neonatal adverse events, to be collected at 10 weeks after birth. The analysis will be by intention to treat. The sample size is 936 women, and a prespecified subgroup analysis is planned for cervical length (= < or > 25 mm). Categorical variables will be expressed as a percentage and continuous variables as mean with standard deviation. Time to delivery will be assessed with Kaplan-Meier analysis and Cox proportional hazard analysis.

DISCUSSION

In clinical practice, the combination of progesterone and pessary is common however, few studies have studied this association. The combination of treatment might act in both the biochemical and mechanical routes related to the onset of preterm birth.

TRIAL REGISTRATION

Brazilian Clinical Trial Registry (ReBec) RBR-3t8prz, UTN: U1111-1164-2636, 2014/11/18.

Hemostatic profile of infants with spontaneous prematurity: can we predict intraventricular hemorrhage development?

Background

Defining hemostatic profile for preterm infants is a challenge when severe bleedings are frequent.

Methods

The aim was to define the hemostatic profile at birth of infants with spontaneous prematurity and to evaluate whether characteristic profiles can predict the development of intraventricular hemorrhage (IVH) in prematures.

Results

We included 122 newborns with a median age of 31^5/7 gestational age (GA) [29^2/7;34^0/7] and median weight of 1145 g [785;1490]. Levels of fibrinogen, factor II (FII) and factor V (FV) rose with GA (p = 0.017,p = 0.009, p = 0.001). In the group of 23^0/7 – 28^6/7 GA, the 5th percentile was defined as 0.6 g/L for fibrinogen, 15 IU/dL for FII and 16 IU/dL for factor V (n = 30). In the group of 29^0/7–32^6/7 GA, the 5th percentile was defined as 1.0 g/L for fibrinogen, 24 IU/dL for FII and 41 IU/dL for factor V (n = 46). In the group of 33^0/7–36^6/7 GA, the 5th percentile was defined as 1.0 g/L for fibrinogen, 24 IU/dL for FII and 30 IU/dL for factor V (n = 46). Level of fibrinogen was higher in case of vaginal delivery and lower in case of IUGR. Only lower level of FV at birth was significantly associated with IVH (63.5 [46.0; 76.5] vs 74.0 [58.0; 89.0], p = 0.026) with an unadjusted OR per SD increase in FV of 0.57 (95%CI, 0.34 to 0.96). After adjustment for age, the association between FV level and IVH was slightly attenuated (adjusted OR, 0.70; 95%CI, 0.40 to 1.23) but remained not significant (p = 0.22).There was no correlation with FII and fibrinogen.

Conclusions

We can define hemostastic profile of prematures and corroborate references ranges for studied parameters. Further large studies are still called for, to correlate the grade of hemorrhage and the factor V level at birth.

Risk factor analysis for the development and progression of retinopathy of prematurity

Purpose

To classify the risk factors that contribute to the development versus progression of retinopathy of prematurity (ROP).

Methods

The medical records of premature infants born with a birth weight (BW) less than 1501 g or a gestational age (GA) of 32 weeks or less were retrospectively reviewed. Twenty potential risk factors that may influence the development or progression of ROP were analyzed by univariate and multivariate logistic regression analyses. The progression of ROP was defined as type 1 ROP, threshold ROP, or aggressive posterior ROP for which treatment was recommended.

Results

A total of 324 eyes were included; 157 eyes (48.5%) showed ROP development, and 48 eyes exhibited ROP progression (14.8% of all eyes and 30.6% of the ROP-developed eyes). According to the univariate and multivariate logistic regression analyses, prenatal steroid use, GA, the duration of mechanical ventilation, and respiratory distress syndrome were associated with the development of ROP. However, GA, bronchopulmonary dysplasia, the number of red blood cell units transfused, intraventricular hemorrhage, and periventricular leukomalacia were significantly correlated with ROP progression.

Conclusion

The risk factors that influenced ROP development versus ROP progression were not identical. Evaluating these risk factors during screening of high-risk premature infants will help determine the appropriate timing of examinations and treatment.

Randomized Trial of Platelet-Transfusion Thresholds in Neonates

BACKGROUND

Platelet transfusions are commonly used to prevent bleeding in preterm infants with thrombocytopenia. Data are lacking to provide guidance regarding thresholds for prophylactic platelet transfusions in preterm neonates with severe thrombocytopenia.

METHODS

In this multicenter trial, we randomly assigned infants born at less than 34 weeks of gestation in whom severe thrombocytopenia developed to receive a platelet transfusion at platelet-count thresholds of 50,000 per cubic millimeter (high-threshold group) or 25,000 per cubic millimeter (low-threshold group). Bleeding was documented prospectively with the use of a validated bleeding-assessment tool. The primary outcome was death or new major bleeding within 28 days after randomization.

RESULTS

A total of 660 infants (median birth weight, 740 g; and median gestational age, 26.6 weeks) underwent randomization. In the high-threshold group, 90% of the infants (296 of 328 infants) received at least one platelet transfusion, as compared with 53% (177 of 331 infants) in the low-threshold group. A new major bleeding episode or death occurred in 26% of the infants (85 of 324) in the high-threshold group and in 19% (61 of 329) in the low-threshold group (odds ratio, 1.57; 95% confidence interval [CI], 1.06 to 2.32; P=0.02). There was no significant difference between the groups with respect to rates of serious adverse events (25% in the high-threshold group and 22% in the low-threshold group; odds ratio, 1.14; 95% CI, 0.78 to 1.67).

CONCLUSIONS

Among preterm infants with severe thrombocytopenia, those randomly assigned to receive platelet transfusions at a platelet-count threshold of 50,000 per cubic millimeter had a significantly higher rate of death or major bleeding within 28 days after randomization than those who received platelet transfusions at a platelet-count threshold of 25,000 per cubic millimeter. (Funded by the National Health Service Blood and Transplant Research and Development Committee and others; Current Controlled Trials number, ISRCTN87736839 .).

Preterm brain injury: Germinal matrix-intraventricular hemorrhage and post-hemorrhagic ventricular dilatation

Germinal matrix hemorrhage and intraventricular hemorrhages (GMH-IVH) remain a common and clinically significant problem in preterm infants, particularly extremely preterm infants. A large GMH-IVH is often complicated by posthemorrhagic ventricular dilation (PHVD) or parenchymal hemorrhagic infarction and is associated with an increased risk of adverse neurologic sequelae. The widespread use of cranial ultrasonography since the early 1980s has shown a gradual decrease in the incidence of GMH-IVH and has helped with the identification of antenatal and perinatal risk factors and timing of the lesion. The increased use of magnetic resonance imaging (MRI) has contributed to more detailed visualization of the site and extent of the GMH-IVH. In addition, MRI has contributed to the awareness of associated white matter changes as well as associated cerebellar hemorrhages. Although GMH-IVH and PHVD still cannot be prevented, cerebrospinal fluid drainage initiated in the early stage of PHVD development seems to be associated with a better neurodevelopmental outcome. Further studies are underway to improve treatment strategies for PHVD and to potentially prevent and repair GMH-IVH and PHVD and associated brain injury. This chapter discusses the pathogenesis, incidence, risk factors, and management, including preventive measures, of GHM-IVH and PHVD.

Initial hematocrit values after birth and peri/intraventricular hemorrhage in extremely low birth weight infants

OBJECTIVE

Ischemia followed by reperfusion plays a significant role in the pathogenesis of peri/intraventricular hemorrhage (P/IVH). Delayed cord clamping promotes placental transfusion to newborn and is associated with decreased P/IVH. We hypothesized that extremely low birth weight (ELBW) infants with higher initial hematocrit (Hct) after birth are less likely to develop P/IVH.

STUDY DESIGN

Pre- and postnatal data on inborn ELBW infants over 7 years were reviewed. We examined the relationship between P/IVH in the first week and initial Hct using logistic regression modeling.

RESULTS

We studied 225 infants with a median gestational age (GA) 25.7 (22.4-31.7). Forty-one percent had grade I-IV P/IVH. In univariate analysis, cesarean section (CS) and higher GA, birth weight, 5-minute Apgar, and initial Hct were associated with decreased likelihood of P/IVH while higher maximum PCO₂ in first 3 days and use of inotropes/vasopressors, postnatal steroid for hypotension, hypernatremia, transfusion, and use of insulin for hyperglycemia during the first week of life were associated with increased likelihood of P/IVH. In multiple regression analysis, only GA, CS, and initial Hct remained significantly associated with P/IVH. Adjusting for GA and CS, the odds of P/IVH was higher with Hct < 40% (OR 2.04, 95% CI [1.11, 3.76]) and Hct < 45% (2.38 [1.19, 4.76]).

CONCLUSION

Higher initial Hct is associated with decreased P/IVH. Initial Hct < 45% was associated with a 2-fold increase in P/IVH. We speculate that lower initial Hct represents a lower intravascular volume status and promotes cerebral hypoperfusion preceding P/IVH.

Predictors of mortality for preterm infants with intraventricular hemorrhage: a population-based study

PURPOSE

The goal of this longitudinal, population-level study was to examine factors affecting mortality in preterm infants with intraventricular hemorrhage (IVH).

METHODS

The study examined patients who were born at 36 weeks estimated gestational age (EGA) or less with a diagnosis of IVH between the years 2005 and 2014 using data from the New York and Nebraska State Inpatient Databases. Potential predictors for mortality were investigated with multivariable survival analysis.

RESULTS

The cohort included 7437 preterm infants with IVH. All-cause inpatient mortality occurred in 746 (10.0%). The majority of deaths were in infants born at less than 25 weeks EGA (378 or 50.7%) and with birthweight less than 750 g (459 or 61.5%). Mortality was highest for children with grade IV IVH (306/848 or 36.1%), followed by grades III (203/955 or 21.3%), II (103/1328 or 7.8%), and I (134/4306 or 3.1%). Hydrocephalus was diagnosed within 6 months in 627 (8.4%) patients, with cerebrospinal fluid shunts required in 237 (3.2%). Shunts were eventually revised in 122 (51.5% of shunts), and 43 (18.1%) had infections. Multivariable Cox survival analyses found male sex (HR 1.3 [95% CI 1.1-1.5]), Asian race (HR 1.5 [1.1-2.2]), lower EGA (HR 9.9 [6.3-15.5] for < 25 weeks), higher IVH grade (HR 6.1 [4.9-7.6] for grade IV), gastrostomy (HR 4.0 [2.0-7.7]), tracheostomy (HR 3.5 [1.7-7.1]), and shunt infection (HR 3.2 [1.0-9.9]) to be independently associated with increased mortality risk.

CONCLUSIONS

This database is the first of its kind assembled for population-based investigations of long-term neurosurgical outcomes in preterm infants with IVH.

Are thrombocytopenia and platelet transfusions associated with major bleeding in preterm neonates? A systematic review

Over 75% of severely thrombocytopenic preterm neonates receive platelet transfusions to prevent bleeding, but transfusion guidelines are based mainly on expert opinion. The aim of this review was to investigate whether platelet counts, platelet transfusions or platelet indices are associated with major bleeding in preterm neonates. We performed a systematic search of the EMBASE and MEDLINE databases until December 2017. We included randomized trials, cohort and case control studies. (Prospero: CRD42015013399). We screened 8734 abstracts and 1225 fulltexts, identifying 36 eligible studies. In 30, timing of the platelet counts or transfusions in relation to the bleeding was unclear. Of the remaining six studies, two showed that thrombocytopenia was associated with increased risk of bleeding, two showed no such assocation, and three showed lack of an association between platelet transfusions and bleeding risk. No studies assessing platelet indices were found. The study results suggest that prophylactic platelet transfusions may not reduce bleeding risk in preterm neonates.

The effect of peri-intraventricular hemorrhage on the auditory pathway of infants

OBJECTIVE

To verify the effect of peri-intraventricular hemorrhage on the auditory pathway of preterm infants.

METHOD

It is a non-concurrent cohort study. This study was conducted in a tertiary public. Preterm infants with peri-intraventricular hemorrhage comprised the study group, and preterm infants without peri-intraventricular hemorrhage were included as a comparison group, both were similar in relation to gestational age and risk indicators for hearing loss. Participants had to meet the following inclusion criteria: have been born at the study site, presence of otoacoustic emissions by transient stimulus in both ears and brainstem auditory evoked potentials with all components bilaterally identified.

RESULTS

44 infants with an average age of 3 months with peri-intraventricular hemorrhage and 2,6 months without peri-intraventricular hemorrhage met the inclusion criteria. Regarding the brainstem auditory evoked potentials results, a significant increase was observed in absolute latency values of waves I, III and V, as well as in the interpeak intervals I-III and I-V, bilaterally, in infants with peri-intraventricular hemorrhage.

CONCLUSION

This study concluded that infants with peri-intraventricular hemorrhage presented a delay in the neural conduction of sound, which justifies the monitoring of the auditory function in these infants during the period of language development.

Initial Metabolic Profiles Are Associated with 7-Day Survival among Infants Born at 22-25 Weeks of Gestation

OBJECTIVE

To evaluate the association between early metabolic profiles combined with infant characteristics and survival past 7 days of age in infants born at 22-25 weeks of gestation.

STUDY DESIGN

This nested case-control consisted of 465 singleton live births in California from 2005 to 2011 at 22-25 weeks of gestation. All infants had newborn metabolic screening data available. Data included linked birth certificate and mother and infant hospital discharge records. Mortality was derived from linked death certificates and death discharge information. Each death within 7 days was matched to 4 surviving controls by gestational age and birth weight z score category, leaving 93 cases and 372 controls. The association between explanatory variables and 7-day survival was modeled via stepwise logistic regression. Infant characteristics, 42 metabolites, and 12 metabolite ratios were considered for model inclusion. Model performance was assessed via area under the curve.

RESULTS

The final model included 1 characteristic and 11 metabolites. The model demonstrated a strong association between metabolic patterns and infant survival (area under the curve [AUC] 0.885, 95% CI 0.851-0.920). Furthermore, a model with just the selected metabolites performed better (AUC 0.879, 95% CI 0.841-0.916) than a model with multiple clinical characteristics (AUC 0.685, 95% CI 0.627-0.742).

CONCLUSIONS

Use of metabolomics significantly strengthens the association with 7-day survival in infants born extremely premature. Physicians may be able to use metabolic profiles at birth to refine mortality risks and inform postnatal counseling for infants born at <26 weeks of gestation.

Antenatal Corticosteroids: Who Should We Be Treating?

Antenatal corticosteroids remain one of the crucial interventions in those at risk for imminent preterm birth. Therapeutic benefits include reducing major complications of prematurity such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis, as well as an overall decrease in neonatal deaths. Optimal reductions in neonatal morbidity and mortality require a thoughtful review of the timing of administration. In addition, a thorough understanding is required of which patients maximally benefit from this intervention in the management and counseling of those at risk for preterm birth.

Lawrence K, Diop M. Simultaneous monitoring of cerebral perfusion and cytochrome c oxidase by combining broadband near-infrared spectroscopy and diffuse correlation spectroscopy

Preterm infants born with very low birth weights are at a high risk of brain injury, in part because the premature brain is believed to be prone to periods of low cerebral blood flow (CBF). Tissue damage is likely to occur if reduction in CBF is sufficient to impair cerebral energy metabolism for extended periods. Therefore, a neuromonitoring method that can detect reductions in CBF, large enough to affect metabolism, could alert the neonatal intensive care team before injury occurs. In this report, we present the development of an optical system that combines diffuse correlation spectroscopy (DCS) for monitoring CBF and broadband near-infrared spectroscopy (B-NIRS) for monitoring the oxidation state of cytochrome c oxidase (oxCCO) - a key biomarker of oxidative metabolism. The hybrid instrument includes a multiplexing system to enable concomitant DCS and B-NIRS measurements while avoiding crosstalk between the two subsystems. The ability of the instrument to monitor dynamic changes in CBF and oxCCO was demonstrated in a piglet model of neonatal hypoxia-ischemia (HI). Experiments conducted in eight animals, including two controls, showed that oxCCO exhibited a delayed response to ischemia while CBF and tissue oxygenation (StO2) responses were instantaneous. These findings suggest that simultaneous neuromonitoring of perfusion and metabolism could provide critical information regarding clinically significant hemodynamic events prior to the onset of brain injury.