Preterm Birth as a Risk Factor for Metabolic Syndrome and Cardiovascular Disease in Adult Life: A Systematic Review and Meta-Analysis

Preterm birth: A neuroinflammatory origin for metabolic diseases?

Preterm birth and its related complications have become more and more common as neonatal medicine advances. The concept of "developmental origins of health and disease" has raised awareness of adverse perinatal events in the development of diseases later in life. To explore this concept, we propose that encephalopathy of prematurity (EoP) as a potential pro-inflammatory early life event becomes a novel risk factor for metabolic diseases in children/adolescents and adulthood. Here, we review epidemiological evidence that links preterm birth to metabolic diseases and discuss possible synergic roles of preterm birth and neuroinflammation from EoP in the development of metabolic diseases. In addition, we explore theoretical underlying mechanisms regarding developmental programming of the energy control system and HPA axis.

Young hearts, early risks: novel cardiovascular biomarkers in former very preterm infants at kindergarten age

BACKGROUND

Preterm birth is associated with long-term cardiovascular morbidity and mortality. In adults, fibroblast growth factor-23 (FGF-23), α-Klotho, and secretoneurin have all garnered attention as cardiovascular biomarkers, but their utility in pediatric populations has not yet been ascertained. The aim of this pilot study was to evaluate these novel cardiovascular biomarkers and their association with indicators of cardiovascular impairment in the highly vulnerable population of former very preterm infants.

METHODS

Five- to seven-year-old children born at < 32 weeks' gestation were eligible for the study. Healthy same-aged children born at term served as controls. Biomarkers were quantified in fasting blood samples, and echocardiographic measurements including assessment of aortic elastic properties were obtained.

RESULTS

We included 26 former very preterm infants and 21 term-born children in the study. At kindergarten age, former very preterm infants exhibited significantly higher plasma concentrations of biologically active intact FGF-23 (iFGF-23; mean 43.2 pg/mL vs. 29.1 pg/mL, p = 0.003) and secretoneurin (median 93.8 pmol/L vs. 70.5 pmol/L, p = 0.046). iFGF-23 inversely correlated with distensibility of the descending aorta.

CONCLUSION

In preterm-born children, iFGF-23 and secretoneurin both offer prospects as valuable cardiovascular biomarkers, potentially allowing for risk stratification and timely implementation of preventive measures.

IMPACT

Former very preterm infants have increased plasma concentrations of the novel cardiovascular biomarkers intact fibroblast growth factor-23 (iFGF-23) and secretoneurin at kindergarten age. Increases in iFGF-23 concentrations are associated with decreased distensibility of the descending aorta even at this early age. Monitoring of cardiovascular risk factors is essential in individuals with a history of preterm birth. Both iFGF-23 and secretoneurin hold promise as clinically valuable biomarkers for risk stratification, enabling the implementation of early preventive measures.

Children born to subfertile couples, how are they doing? Evidence from research

More than 10 million children have been born with assisted reproductive technology (ART) as we begin to enter the third generation of individuals conceived by ART. Here we summarise key messages from an enlarging body of literature regarding their health. Earlier research had pointed towards increases in perinatal, neonatal and neurological risks, such as preterm birth, low birth weight, congenital malformations and cerebral palsy. Many of these risks have continued to persist in most recent work but have shown reduction. Newer research proposes long-term cardiometabolic and endocrine concerns. Fortunately, most reports conclude there is little or no risk of increased childhood malignancy or abnormal neurodevelopment. Moving forward, new research may benefit from changes in comparator groups and a better understanding of infertility per se in ART, and the confounding role it probably plays in many of the known risk associations, to reliably scan the horizon for health threats for individuals born after ART.

Glucose-regulatory hormones and growth in very preterm infants fed fortified human milk

BACKGROUND

Bovine colostrum (BC) contains a range of milk bioactive components, and it is unknown how human milk fortification with BC affects glucose-regulatory hormones in very preterm infants (VPIs). This study aimed to investigate the associations between hormone concentrations and fortification type, birth weight (appropriate/small for gestational age, AGA/SGA), milk intake, postnatal age, and body growth.

METHODS

225 VPIs were randomized to fortification with BC or conventional fortifier (CF). Plasma hormones were measured before, one and two weeks after start of fortification. ΔZ-scores from birth to 35 weeks postmenstrual age were calculated.

RESULTS

Compared with CF, infants fortified with BC had higher plasma GLP-1, GIP, glucagon, and leptin concentrations after start of fortification. Prior to fortification, leptin concentrations were negatively associated with growth, while IGF-1 concentrations associated positively with growth during fortification. In AGA infants, hormone concentrations generally increased after one week of fortification. Relative to AGA infants, SGA infants showed reduced IGF-1 and leptin concentrations.

CONCLUSION

Fortification with BC increased the plasma concentrations of several glucose-regulatory hormones. Concentrations of IGF-1 were positively, and leptin negatively, associated with growth. Glucose-regulatory hormone levels were affected by birth weight, milk intake and postnatal age, but not closely associated with growth in VPIs.

IMPACT

Little is known about the variation in glucose-regulatory hormones in the early life of very preterm infants (VPIs). This study shows that the levels of glucose-regulatory hormones in plasma of VPIs are highly variable and modified by birth weight (appropriate or small for gestational age, AGA or SGA), the type of fortifier, enteral nutritional intake, and advancing postnatal age. The results confirm that IGF-1 levels are positively associated with early postnatal growth in VPIs, yet the levels of both IGF-1 and other glucose-regulatory hormones appeared to explain only a small part of the overall variation in growth rates.

Body composition in adults born preterm with very low birth weight

BACKGROUND

Studies on body composition in preterm very low birth weight (VLBW < 1500 g) survivors are inconsistent and trajectories later in life unknown. We assessed body composition and its change from young to mid-adulthood in VLBW adults.

METHODS

We studied 137 VLBW adults and 158 term-born controls from two birth cohorts in Finland and Norway at mean age 36 years. Body composition was assessed by 8-polar bioelectrical impedance. We compared results with dual-energy x-ray absorptiometry measurements at 24 years.

RESULTS

In mid-adulthood, VLBW women and men were shorter than controls. Fat percentage (mean difference in women 1.1%; 95% CI, -1.5% to 3.5%, men 0.8%; -2.0% to 3.6%) and BMI were similar. VLBW women had 2.9 (0.9 to 4.8) kg and VLBW men 5.3 (2.7 to 8.1) kg lower lean body mass than controls, mostly attributable to shorter height. Between young and mid-adulthood, both groups gained fat and lean body mass (p for interaction VLBW x age>0.3).

CONCLUSION

Compared with term-born controls, VLBW adults had similar body fat percentage but lower lean body mass, largely explained by their shorter height. This could contribute to lower insulin sensitivity and muscular fitness previously found in VLBW survivors and predispose to functional limitations with increasing age.

IMPACT

In mid-adulthood, individuals born preterm with very low birth weight had similar body fat percentage but lower lean body mass than those born at term. This was largely explained by their shorter height. First study to report longitudinal assessments of body size and composition from young to mid-adulthood in very low birth weight adults. Lower lean body mass in very low birth weight adults could contribute to lower insulin sensitivity and muscular fitness and lead to earlier functional limitations with increasing age.

Associations of Early Gut Microbiome and Metabolome with Growth and Body Composition of Preterm Infants Within the First 6 Months

Objectives: This study aimed to explore the associations of growth and body composition with gut microbiome and metabolome in preterm infants. Materials and Methods: A prospective cohort study including 73 human milk-fed very preterm infants was conducted. During hospitalization, fecal samples were collected to detect microbes and metabolites using 16S rRNA gene sequencing and liquid chromatography-mass spectrometry. Growth and body composition indices were measured at term equivalent age (TEA) and 6 months of corrected age (CA). Associations of the fecal microbiome and metabolome profiles with growth and body composition indices, as well as their changes, were analyzed. Results: A higher abundance of Streptococcus was associated with a lower fat-free mass (FFM) z-score at 6 months of CA (p = 0.002) and a smaller increase in FFM z-score from TEA to 6 months of CA (p = 0.018). Higher levels of 3'-sialyllactose and 6'-sialyllactose (6'-SL) in feces were correlated with a lower z-score of percentage body fat (PBF) (p = 0.018 and 0.020, respectively) and a lower z-score of fat mass (p = 0.044 and 0.043, respectively) at 6 months of CA. A higher level of 6'-SL in feces was correlated with a greater increase in FFM z-score from TEA to 6 months of CA (p = 0.021). Conclusions: This study sheds light on the role of specific microbial-host interactions in metabolic changes in preterm infants, indicating the potential role of sialylated human milk oligosaccharides in optimizing body composition.

c-Myc Drives inflammation of the maternal-fetal interface, and neonatal lung remodeling induced by intra-amniotic inflammation

Background: Intra-amniotic inflammation (IAI) is associated with increased risk of preterm birth and bronchopulmonary dysplasia (BPD), but the mechanisms by which IAI leads to preterm birth and BPD are poorly understood, and there are no effective therapies for preterm birth and BPD. The transcription factor c-Myc regulates various biological processes like cell growth, apoptosis, and inflammation. We hypothesized that c-Myc modulates inflammation at the maternal-fetal interface, and neonatal lung remodeling. The objectives of our study were 1) to determine the kinetics of c-Myc in the placenta, fetal membranes and neonatal lungs exposed to IAI, and 2) to determine the role of c-Myc in modulating inflammation at the maternal-fetal interface, and neonatal lung remodeling induced by IAI. Methods: Pregnant Sprague-Dawley rats were randomized into three groups: 1) Intra-amniotic saline injections only (control), 2) Intra-amniotic lipopolysaccharide (LPS) injections only, and 3) Intra-amniotic LPS injections with c-Myc inhibitor 10058-F4. c-Myc expression, markers of inflammation, angiogenesis, immunohistochemistry, and transcriptomic analyses were performed on placenta and fetal membranes, and neonatal lungs to determine kinetics of c-Myc expression in response to IAI, and effects of prenatal systemic c-Myc inhibition on lung remodeling at postnatal day 14. Results: c-Myc was upregulated in the placenta, fetal membranes, and neonatal lungs exposed to IAI. IAI caused neutrophil infiltration and neutrophil extracellular trap (NET) formation in the placenta and fetal membranes, and neonatal lung remodeling with pulmonary hypertension consistent with a BPD phenotype. Prenatal inhibition of c-Myc with 10058-F4 in IAI decreased neutrophil infiltration and NET formation, and improved neonatal lung remodeling induced by LPS, with improved alveolarization, increased angiogenesis, and decreased pulmonary vascular remodeling. Discussion: In a rat model of IAI, c-Myc regulates neutrophil recruitment and NET formation in the placenta and fetal membranes. c-Myc also participates in neonatal lung remodeling induced by IAI. Further studies are needed to investigate c-Myc as a potential therapeutic target for IAI and IAI-associated BPD.

Growth patterns of preterm and small for gestational age children during the first 10 years of life

Background

Preterm and small for gestational age (SGA) remain significant public health concerns worldwide. Yet limited evidence exists on their growth patterns during childhood from low-or middle-income countries.

Objectives

We investigated the postnatal growth patterns of preterm and SGA compared to term appropriate for gestational age (AGA) children from birth to 10-11y, and examined the impact of birth status on child nutritional status during the school age years.

Methods

Children born to women who participated in a double-blinded randomized controlled trial of preconception micronutrient supplementation in Vietnam were classified into three groups: preterm AGA (n = 130), full-term SGA (n = 165) and full-term AGA (n = 1,072). Anthropometric data (weight and height) were collected prospectively at birth, 3, 6, 12, 18, 24 months and at 6-7 and 10-11y. We used ANOVA and multiple regression models to examine the differences in growth patterns from birth to 10-11y as well as child undernutrition and overnutrition by birth status.

Results

Children who were born preterm exhibited rapid postnatal growth, but still had lower HAZ at 1y and 2y and showed catch up to the AGA group at 6y. Compared to those born AGA, SGA infants had higher risk of thinness (BMIZ < -2) at 2y and 6y (adjusted Odds Ratio, AOR [95% CI] 2.5 [1.0, 6.1] and 2.6 [1.4, 4.6], respectively); this risk reduced at 10-11y (1.6 [0.9, 2.8]). The risk of stunting (HAZ < -2) was also 2.4 [1.5, 3.8] and 2.3 times [1.2, 4.1] higher in SGA than AGA group at ages 2y and 6-7y, respectively, with no differences at 10y. Although preterm children had higher rates of thinness and stunting at 2y compared to AGA children, these differences were not statistically significant. No associations were found between preterm or SGA and overweight /obesity at age 10-11y.

Conclusion

Children who were born term-SGA continued to demonstrate deficits in weight and height during childhood whereas those born preterm showed catch-up growth by age 6-7y. Additional efforts to reduce the burden of these conditions are needed, particularly during school-age and early adolescents when children are exposed to challenging environments and have higher demands for nutrition.

Risk of Obesity and Unhealthy Central Adiposity in Adolescents Born Preterm With Very Low Birthweight Compared to Term-Born Peers

Background: Early-life factors such as preterm birth or very low birthweight (VLBW) are associated with increased cardiovascular disease risk. However, it remains unknown whether this is due to an increased risk of obesity (unhealthy central adiposity) because studies have predominantly defined obesity based on BMI, an imprecise adiposity measure. Objective: Investigate if adolescents born preterm with VLBW have a higher risk of unhealthy central adiposity compared to term-born peers. Study Design: Cross-sectional analysis of data from a prospective cohort study of 177 individuals born preterm with VLBW (<1500 g) and 51 term-born peers (birthweight ≥2500 g). Individuals with congenital anomalies, genetic syndromes, or major health conditions were excluded. Height, weight, waist circumference, skin fold thickness, and dual energy X-ray absorptiometry body composition were measured at age 14 years. We calculated BMI percentiles and defined overweight/obesity as BMI ≥85th percentile for age and sex. We estimated the preterm-term differences in overweight/obesity prevalence and adiposity distribution with multivariable generalized linear models. Results: There was no difference in small for gestational age status or overweight/obesity prevalence. Compared to term, youth born preterm with VLBW had lower BMI z-score [β -0.38, 95% confidence limits (CL) -0.75 to -0.02] but no differences in adiposity apart from subscapular-to-triceps ratio (STR; β 0.18, 95% CL 0.08 to 0.28). Conclusions: Adolescents born preterm with VLBW had smaller body size than their term-born peers and had no differences in central adiposity except greater STR.

Prenatal Exposure to Severe Stress and the Risk of Heart Failure Up to Middle-Age

BACKGROUND

Prenatal stress is a potential risk factor for cardiovascular disease, but its association with heart failure (HF) is unknown.

OBJECTIVES

The purpose of this study was to investigate whether prenatal stress, defined as maternal bereavement, was associated with HF risk up to middle-age.

METHODS

This cohort study included 6,758,560 live singleton births from the Danish (1973-2016) and the Swedish (1973-2014) Medical Birth Registers. The authors retrieved information on death of the mothers' close family members (partner, older children, parents, and siblings) and offspring's HF (up to 2016 in Denmark and 2020 in Sweden) from nationwide registers. They estimated HRs and 95% CIs for HF in the offspring according to maternal bereavement.

RESULTS

During up to 48 years of follow-up, 4,812 offspring (0.07%) had a diagnosis of HF. Maternal loss of any close family member was not associated with HF in the offspring (adjusted HR: 1.04; 95% CI: 0.88-1.23). However, the most severe forms of bereavement, ie, death of a partner or an older child (adjusted HR: 1.47; 95% CI: 1.06-2.04) and unnatural death of a relative (adjusted HR: 2.77; 95% CI: 1.49-5.17), were associated with increased risks of HF. Congenital heart disease and preterm birth contributed substantially to the association of maternal loss of a partner or older child with HF risk in the offspring.

CONCLUSIONS

Maternal loss of a partner or older child and loss of a close relative caused by unnatural causes the year before or during pregnancy were associated with increased risk of HF in offspring.

Insulin resistance prior to term age in very low birthweight infants: a prospective study

OBJECTIVE

To explore the glucose-related hormone profile of very low birthweight (VLBW) infants and assess the association between neonatal hyperglycaemia and insulin resistance during the admission period.

DESIGN

A prospective observational study-the Very Low Birth Weight Infants, Glucose and Hormonal Profiles over Time study.

SETTING

A tertiary neonatal intensive care unit and four neonatal units in county hospitals in Sweden.

PATIENTS

48 infants born <1500 g (VLBW) during 2016-2019.

OUTCOME MEASURES

Plasma concentrations of glucose-related hormones and proteins (C-peptide, insulin, ghrelin, glucagon-like peptide 1 (GLP-1), glucagon, leptin, resistin and proinsulin), insulin:C-peptide and proinsulin:insulin ratios, Homoeostatic Model Assessment 2 (HOMA2) and Quantitative Insulin Sensitivity Check (QUICKI) indices, measured on day of life (DOL) 7 and at postmenstrual age 36 weeks.

RESULTS

Lower gestational age was significantly associated with higher glucose, C-peptide, insulin, proinsulin, leptin, ghrelin, resistin and GLP-1 concentrations, increased HOMA2 index, and decreased QUICKI index and proinsulin:insulin ratio. Hyperglycaemic infants had significantly higher glucose, C-peptide, insulin, leptin and proinsulin concentrations, and lower QUICKI index, than normoglycaemic infants. Higher glucose and proinsulin concentrations and insulin:C-peptide ratio, and lower QUICKI index on DOL 7 were significantly associated with longer duration of hyperglycaemia during the admission period.

CONCLUSIONS

VLBW infants seem to have a hormone profile consistent with insulin resistance. Lower gestational age and hyperglycaemia are associated with higher concentrations of insulin resistance markers.

Pulsatile Leucine Administration during Continuous Enteral Feeding Enhances Skeletal Muscle Mechanistic Target of Rapamycin Complex 1 Signaling and Protein Synthesis in a Preterm Piglet Model

BACKGROUND

Continuous feeding does not elicit an optimal anabolic response in skeletal muscle but is required for some preterm infants. We reported previously that intermittent intravenous pulses of leucine (Leu; 800 μmol Leu·kg-1·h-1 every 4 h) to continuously fed pigs born at term promoted mechanistic target of rapamycin complex 1 (mTORC1) activation and protein synthesis in skeletal muscle.

OBJECTIVES

The aim was to determine the extent to which intravenous Leu pulses activate mTORC1 and enhance protein synthesis in the skeletal muscle of continuously fed pigs born preterm.

METHODS

Pigs delivered 10 d preterm was advanced to full oral feeding >4 d and then assigned to 1 of the following 4 treatments for 28 h: 1) ALA (continuous feeding; pulsed with 800 μmol alanine·kg-1·h-1 every 4 h; n = 8); 2) L1× (continuous feeding; pulsed with 800 μmol Leu·kg-1·h-1 every 4 h; n = 7); 3) L2× (continuous feeding; pulsed with 1600 μmol Leu·kg-1·h-1 every 4 h; n = 8); and 4) INT (intermittent feeding every 4 h; supplied with 800 μmol alanine·kg-1 per feeding; n = 7). Muscle protein synthesis rates were determined with L-[2H5-ring]Phenylalanine. The activation of insulin, amino acid, and translation initiation signaling pathways were assessed by Western blot.

RESULTS

Peak plasma Leu concentrations were 134% and 420% greater in the L2× compared to the L1× and ALA groups, respectively (P < 0.01). Protein synthesis was greater in the L2× than in the ALA and L1× groups in both the longissimus dorsi and gastrocnemius muscles (P < 0.05) but not different from the INT group (P > 0.10). Amino acid signaling upstream and translation initiation signaling downstream of mTORC1 largely corresponded to the differences in protein synthesis.

CONCLUSIONS

Intravenous Leu pulses potentiate mTORC1 activity and protein synthesis in the skeletal muscles of continuously fed preterm pigs, but the amount required is greater than in pigs born at term.

High Amino Acid Intake in Early Life Is Associated With Systolic but Not Diastolic Arterial Hypertension at 5 Years of Age in Children Born Very Preterm

BACKGROUND

The life course of individuals born very premature is a topic of increasing concern. The association between high early amino acid intake and later high blood pressure (HBP) in preterm neonates is debated.

METHODS AND RESULTS

In a national, prospective, population-based birth cohort, EPIPAGE-2 (Etude Epidémiologique sur Petits Ages Gestationnels), we assessed blood pressure at 5 years. Eligible infants were those born between 24 and 29 weeks of gestation. Infants were distributed in 2 groups of 717 infants matched on propensity score on whether or not they were exposed to high amino acid intake (>3.5 g/kg per day at day 7); 455 control term infants were also enrolled. A value ≥95th percentile of reference values for age and height defined systolic or diastolic HBP. Blood pressure at 5 years of age was assessed for 389 and 385 children in the exposed and nonexposed groups, respectively. Rates (in percent) of systolic and diastolic HBP were 18.0% (95% CI, 14.5%-22.2%), 13.3% (95% CI, 10.3%-17.0%), 8.5% (95% CI, 6.5%-11.1%), and 9.0% (95% CI, 6.6%-12.3%), 10.2% (95% CI, 7.5%-13.6%), and 5.4% (95% CI, 3.8%-7.6%) in exposed, nonexposed, and term-born groups, respectively. Exposure to high early amino acid intake and maximal serum creatinine (by 50 μmol/L) between day 3 and day 7 were 2 independent risk factors for systolic HBP (adjusted odds ratio [aOR], 1.60 [95% CI, 1.05-2.43] and aOR, 1.59 [95% CI, 1.12-2.26], respectively) but not for diastolic HBP (aOR, 0.84 [95% CI, 0.50-1.39] and aOR, 1.09 [95% CI, 0.71-1.67], respectively). After adjustment for 5-year weight Z score, the aOR between high early amino acid intake and systolic HBP was 1.50 [95% CI, 0.98-2.30].

CONCLUSIONS

These results suggest that mechanisms of childhood systolic HBP involve neonatal renal challenge by high amino acid intake or dysfunction.

Maternal Nativity and Preterm Birth

Importance

Preterm birth is a major contributor to neonatal morbidity and mortality, and considerable differences exist in rates of preterm birth among maternal racial and ethnic groups. Emerging evidence suggests pregnant individuals born outside the US have fewer obstetric complications than those born in the US, but the intersection of maternal nativity with race and ethnicity for preterm birth is not well studied.

Objective

To determine if there is an association between maternal nativity and preterm birth rates among nulliparous individuals, and whether that association differs by self-reported race and ethnicity of the pregnant individual.

Design, Setting, and Participants

This was a nationwide, cross-sectional study conducted using National Center for Health Statistics birth registration records for 8 590 988 nulliparous individuals aged 15 to 44 years with singleton live births in the US from 2014 to 2019. Data were analyzed from March to May 2022.

Exposures

Maternal nativity (non-US-born compared with US-born individuals as the reference, wherein US-born was defined as born within 1 of the 50 US states or Washington, DC) in the overall sample and stratified by self-reported ethnicity and race, including non-Hispanic Asian and disaggregated Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Pacific Islander, Vietnamese, and other Asian), non-Hispanic Black, Hispanic and disaggregated Hispanic subgroups (Cuban, Mexican, Puerto Rican, and other Hispanic), and non-Hispanic White.

Main Outcomes and Measures

The primary outcome was preterm birth (<37 weeks of gestation) and the secondary outcome was very preterm birth (<32 weeks of gestation).

Results

Of 8 590 988 pregnant individuals included (mean [SD] age at delivery, 28.3 [5.8] years in non-US-born individuals and 26.2 [5.7] years in US-born individuals; 159 497 [2.3%] US-born and 552 938 [31.2%] non-US-born individuals self-identified as Asian or Pacific Islander, 1 050 367 [15.4%] US-born and 178 898 [10.1%] non-US-born individuals were non-Hispanic Black, 1 100 337 [16.1%] US-born and 711 699 [40.2%] non-US-born individuals were of Hispanic origin, and 4 512 294 [66.1%] US-born and 328 205 [18.5%] non-US-born individuals were non-Hispanic White), age-standardized rates of preterm birth were lower among non-US-born individuals compared with US-born individuals (10.2%; 95% CI, 10.2-10.3 vs 10.9%; 95% CI, 10.9-11.0) with an adjusted odds ratio (aOR) of 0.90 (95% CI, 0.89-0.90). The greatest relative difference was observed among Japanese individuals (aOR, 0.69; 95% CI, 0.60-0.79) and non-Hispanic Black individuals (aOR, 0.74; 0.73-0.76) individuals. Non-US-born Pacific Islander individuals experienced higher preterm birth rates compared with US-born Pacific Islander individuals (aOR, 1.15; 95% CI, 1.04-1.27). Puerto Rican individuals born in Puerto Rico compared with those born in US states or Washington, DC, also had higher preterm birth rates (aOR, 1.07; 95% CI, 1.03-1.12).

Conclusions and Relevance

Overall preterm birth rates were lower among non-US-born individuals compared with US-born individuals. However, there was substantial heterogeneity in preterm birth rates across maternal racial and ethnic groups, particularly among disaggregated Asian and Hispanic subgroups.

Cardiometabolic health in adults born with very low birth weight-a sibling study

BACKGROUND

Preterm survivors have increased risk for impaired cardiometabolic health. We assessed glucose regulation and cardiometabolic biomarkers in adult very low birth weight (VLBW, <1500 g) survivors, using siblings as controls.

METHODS

VLBW-participants were matched with term-born, same-sex siblings. At mean age 29.2 years (SD 3.9), 74 VLBW-adults and 70 siblings underwent a 2-h 75 g oral glucose tolerance test and blood tests for assessment of cardiometabolic biomarkers.

RESULTS

Of participants, 23 (31%) VLBW and 11 (16%) sibling-controls met World Health Organization criteria for impaired glucose regulation (OR adjusted for age and sex 2.5, 95% CI: 1.1 to 5.8). Adjusting for age and sex, VLBW-participants showed 9.2% higher 2-h glucose (95% CI: 0.4% to 18.8%) than their siblings. Also, fasting (13.4%, -0.3% to 29.0%) and 2-h free fatty acids (15.6%, -2.4% to 36.9%) were higher in VLBW-participants. These differences were statistically significant only after further adjusting for confounders. No statistically significant differences were found regarding other measured biomarkers, including insulin resistance, atherogenic lipid profiles or liver tests.

CONCLUSIONS

VLBW-adults showed more impaired fatty acid metabolism and glucose regulation. Differences in cardiometabolic biomarkers were smaller than in previous non-sibling studies. This may partly be explained by shared familial, genetic, or environmental factors.

IMPACT

At young adult age, odds for impaired glucose regulation were 3.4-fold in those born at very low birth weight, compared to same-sex term-born siblings. Taking into consideration possible unmeasured, shared familial confounders, we compared cardiometabolic markers in adults born preterm at very low birth weight with term-born siblings. Prematurity increased risk for impaired glucose regulation, unrelated to current participant characteristics, including body mass index. In contrast to previous studies, differences in insulin resistance were not apparent, suggesting that insulin resistance may partially be explained by factors shared between siblings. Also, common cardiometabolic biomarkers were similar within sibling pairs.

Young adult outcomes following premature birth: A Western Australian experience

BACKGROUND

Childhood outcomes following preterm birth are widely published, however long-term adult outcomes are less well described. We aimed to determine the quality of life and burden of co-morbidities experienced by preterm-born young adults in Western Australia.

METHODS

A retrospective observational study was conducted. Participants born at 23-33 weeks gestation cared for at King Edward Memorial Hospital during 1990 and 1991 were recruited from a historical birth cohort. Participants completed general, medical and reproductive health questionnaires. Results were compared with contemporaneous cohort data and/or population statistics.

RESULTS

Questionnaires were received from 73 young adults aged 28 to 30 years. The majority of respondents completed high school (94.5 %), were employed fulltime (74.0 %) and had close friends and family relationships. Almost all the participants considered their health to be good (94.0 %) and participated in light exercise (90.0 %). Increased hypertension, hypercholesterolaemia, asthma, neuropsychiatric conditions and visual impairment were reported. Depression Anxiety and Stress Scale (DASS-21) scoring identified increased mild anxiety. Increased consultation with healthcare workers and use of prescription medications were reported.

CONCLUSION

The group of preterm-born adults surveyed reported a good quality of life, supportive interpersonal relationships and they provided significant contributions to society. They did report increased medical and psychological conditions than the general population.

Baroreflex sensitivity is blunted in hypoxia independently of changes in inspired carbon dioxide pressure in prematurely born male adults

Premature birth may result in specific cardiovascular responses to hypoxia and hypercapnia, that might hamper high-altitude acclimatization. This study investigated the consequences of premature birth on baroreflex sensitivity (BRS) under hypoxic, hypobaric and hypercapnic conditions. Seventeen preterm born males (gestational age, 29 ± 1 weeks), and 17 age-matched term born adults (40 ± 0 weeks) underwent consecutive 6-min stages breathing different oxygen and carbon dioxide concentrations at both sea-level and high-altitude (3375 m). Continuous blood pressure and ventilatory parameters were recorded in normobaric normoxia (NNx), normobaric normoxic hypercapnia (NNx + CO2 ), hypobaric hypoxia (HHx), hypobaric normoxia (HNx), hypobaric normoxia hypercapnia (HNx + CO2 ), and hypobaric hypoxia with end-tidal CO2 clamped at NNx value (HHx + clamp). BRS was assessed using the sequence method. Across all conditions, BRS was lower in term born compared to preterm (13.0 ± 7.5 vs. 21.2 ± 8.8 ms⋅mmHg-1 , main group effect: p < 0.01) participants. BRS was lower in HHx compared to NNx in term born (10.5 ± 4.9 vs. 16.0 ± 6.0 ms⋅mmHg-1 , p = 0.05), but not in preterm (27.3 ± 15.7 vs. 17.6 ± 8.3 ms⋅mmHg-1 , p = 0.43) participants, leading to a lower BRS in HHx in term born compared to preterm (p < 0.01). In conclusion, this study reports a blunted response of BRS during acute high-altitude exposure without any influence of changes in inspired CO2 in healthy prematurely born adults.

Effect of preterm birth on growth and blood pressure in adulthood in the Pelotas 1993 cohort

BACKGROUND

Preterm birth has been associated with increased risk of hypertension and cardiovascular disease later in adulthood, attributed to cardiovascular and metabolic alterations in early life. However, there is paucity of evidence from low- and middle-income countries (LMICs).

METHODS

We investigated the differences between preterm (<37 weeks gestational age) and term-born individuals in birth length and weight as well as adult (18 and 20 years) height, weight and blood pressure in the Brazilian 1993 Pelotas birth cohort using linear regressions. Analyses were adjusted for the maternal weight at the beginning of pregnancy and maternal education and family income at childbirth. Additional models were adjusted for body mass index (BMI) and birthweight. Separate analyses were run for males and females. The complete sample was analysed with an interaction term for sex.

RESULTS

Of the 3585 babies included at birth, 3010 were followed up in adulthood at 22 years. Preterm participants had lower length and weight at birth. This difference remained for male participants in adulthood, but female participants were no shorter than their term counterparts by 18 years of age. At 22 years, females born preterm had lower blood pressures (systolic blood pressure -1.00 mmHg, 95%CI -2.7, 0.7 mmHg; diastolic blood pressure -1.1 mmHg, 95%CI -2.4, 0.3 mmHg) than females born at term. These differences were not found in male participants.

CONCLUSIONS

In this Brazilian cohort we found contrasting results regarding the association of preterm birth with blood pressure in young adulthood, which may be unique to an LMIC.

Early and exclusive enteral nutrition in infants born very preterm

OBJECTIVE

To characterise the effects of early and exclusive enteral nutrition with either maternal or donor milk in infants born very preterm (280/7-326/7 weeks of gestation).

DESIGN

Parallel-group, unmasked randomised controlled trial.

SETTING

Regional, tertiary neonatal intensive care unit.

PARTICIPANTS

102 infants born very preterm between 2021 and 2022 (51 in each group).

INTERVENTION

Infants randomised to the intervention group received 60-80 mL/kg/day within the first 36 hours after birth. Infants randomised to the control group received 20-30 mL/kg/day (standard trophic feeding volumes).

MAIN OUTCOME MEASURES

The primary outcome was the number of full enteral feeding days (>150 mL/kg/day) in the first 28 days after birth. Secondary outcomes included growth and body composition at the end of the first two postnatal weeks, and length of hospitalisation.

RESULTS

The mean birth weight was 1477 g (SD: 334). Half of the infants were male, and 44% were black. Early and exclusive enteral nutrition increased the number of full enteral feeding days (+2; 0-2 days; p=0.004), the fat-free mass-for-age z-scores at postnatal day 14 (+0.5; 0.1-1.0; p=0.02) and the length-for-age z-scores at the time of hospital discharge (+0.6; 0.2-1.0; p=0.002). Hospitalisation costs differed between groups (mean difference favouring the intervention group: -$28 754; -$647 to -$56 861; p=0.04).

CONCLUSIONS

In infants born very preterm, early and exclusive enteral nutrition increases the number of full enteral feeding days. This feeding practice may also improve fat-free mass accretion, increase length and reduce hospitalisation costs.

TRIAL REGISTRATION NUMBER

NCT04337710.

Preterm Birth: Screening and Prediction

Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.

Heart Rate and Heart Rate Variability in Healthy Preterm-Born Young Adults and Association with Vitamin D: A Wearable Device Assessment

Prematurity has been associated with impaired parasympathetic cardiac regulation later in life. Changes in heart rate (HR) and heart rate variability (HRV) may indicate a risk for future cardiac dysfunction. The putative role of Vitamin D on cardiac autonomic function in individuals born preterm (PT) remains unknown. This study involves monitoring autonomic cardiac regulation and Vitamin D concentrations in 30 PT and 16 full-term (FT) young adults in a free-living context. The PT subjects were born between 1994 and 1997 at Oulu University Hospital. The inclusion criteria were (1) being born ≤ 32 gestation weeks or (2) being born < 34 gestation weeks with a birth weight under 1500 g. Participants wore an Oura ring sleep tracer, a smart ring device, for 2 weeks to monitor cardiac autonomic function. Parameters related to autonomic cardiac regulation, lowest nighttime resting HR, and the root mean square of successive differences (RMSSD) to describe HRV were collected. PT males exhibited a tendency toward lower RMSSD (71.8 ± 22.6) compared to FT males (95.63 ± 29.0; p = 0.10). Female participants had a similar mean RMSSD in the FT and PT groups at 72.04 ± 33.2 and 74.0 ± 35.0, respectively. Serum 25-hydroxyvitamin D concentration did not correlate with cardiac autonomic function parameters. When assessing the lowest resting nighttime HRs and HRVs in a long-term, real-world context, healthy female PT young adults performed similarly to their FT peers. In contrast, the present study's results suggest that male PT young adults exhibit impaired autonomic cardiac function, potentially putting them at risk for cardiovascular disease later in adulthood.

A synthesis of pathways linking diet, metabolic risk and cardiovascular disease: a framework to guide further research and approaches to evidence-based practice

Cardiovascular disease (CVD) is the most common non-communicable disease occurring globally. Although previous literature has provided useful insights into the important role that diet plays in CVD prevention and treatment, understanding the causal role of diets is a difficult task considering inherent and introduced weaknesses of observational (e.g. not properly addressing confounders and mediators) and experimental research designs (e.g. not appropriate or well designed). In this narrative review, we organised current evidence linking diet, as well as conventional and emerging physiological risk factors, with CVD risk, incidence and mortality in a series of diagrams. The diagrams presented can aid causal inference studies as they provide a visual representation of the types of studies underlying the associations between potential risk markers/factors for CVD. This may facilitate the selection of variables to be considered and the creation of analytical models. Evidence depicted in the diagrams was systematically collected from studies included in the British Nutrition Task Force report on diet and CVD and database searches, including Medline and Embase. Although several markers and disorders linked to conventional and emerging risk factors for CVD were identified, the causal link between many remains unknown. There is a need to address the multifactorial nature of CVD and the complex interplay between conventional and emerging risk factors with natural and built environments, while bringing the life course into the spotlight.

Hofbauer cell function in the term placenta associates with adult cardiovascular and depressive outcomes

Pathological placental inflammation increases the risk for several adult disorders, but these mediators are also expressed under homeostatic conditions, where their contribution to adult health outcomes is unknown. Here we define an inflammation-related expression signature, primarily expressed in Hofbauer cells of the term placenta and use expression quantitative trait loci to create a polygenic score (PGS) predictive of its expression. Using this PGS in the UK Biobank we conduct a phenome-wide association study, followed by Mendelian randomization and identify protective, sex-dependent effects of the placental module on cardiovascular and depressive outcomes. Genes differentially regulated by intra-amniotic infection and preterm birth are over-represented within the module. We also identify aspirin as a putative modulator of this inflammation-related signature. Our data support a model where disruption of placental Hofbauer cell function, due to preterm birth or prenatal infection, contributes to the increased risk of depression and cardiovascular disease observed in these individuals.

Effect of preterm birth on blood pressure in later life: A systematic review and meta-analysis

Introduction

Preterm birth is linked to various complications in both infancy and adulthood. We assessed the association between preterm birth and hypertension in adulthood.

Materials and Methods

PubMed, EMBASE, and Cochrane CENTRAL Register were searched for randomized controlled trials (RCT) comparing systolic and diastolic blood pressures in individuals born preterm and those born full-term, from inception till April 11th, 2022. Data were extracted, pooled, and analyzed. Forest plots were created for a visual demonstration.

Results

Twenty-eight studies were included in our meta-analysis. SBP and DBP across all categories (Mean, Ambulatory, Daytime, and Nighttime) were higher in the preterm group compared to the term group. Mean SBP, mean ambulatory SBP, mean daytime SBP and mean nighttime SBP were 4.26 mmHg [95% CI: 3.09-5.43; P < 0.00001], 4.53 mmHg [95% CI: 1.82-7.24; P = 0.001], 4.51 mmHg [95% CI: 2.56-6.74; P < 0.00001], and 3.06 mmHg [95% CI: 1.32-4.80; P = 0.0006] higher in the preterm group, respectively. Mean DBP, mean ambulatory DBP, mean daytime DBP, and mean nighttime DBP were 2.32 mmHg [95% CI: 1.35-3.29; P < 0.00001], 1.54 mmHg [95% CI 0.68-2.39; P = 0.0004], 1.74 mmHg [95% CI: 0.92-2.56; P < 0.0001], and 1.58 mmHg [95% CI: 0.34-2.81; P = 0.01] higher in the preterm group, respectively.

Conclusion

Our observations suggest that individuals who were born preterm may have higher blood pressures as compared to those who were born full-term.

Risk Factors of Preterm Delivery in the Lao PDR: Hospital-Based Matched Case-Control Study

OBJECTIVE

To describe the risk factors among mothers in four central hospitals and two provincial hospitals in the Lao PDR, a lower-middle-income country in Southeast Asia.

METHOD

The study used a hospital-based matched case-control design study. Purposive sampling was used to select 320 mothers (80 cases and 240 controls) from the six hospitals. Cases were mothers who had delivered a live newborn between 28 and 36 weeks and 6 days, while controls were mothers who had delivered a live newborn within 37 and 40 weeks. Data were collected through a review of medical records and face-to-face interviews using a structured questionnaire. Data were entered into EPI info (Version 3.1) then exported to the STATA programme (Version 14) for univariate and conditional multiple logistic regressions to identify risk factors for PTD at p ≤ 0.05.

RESULTS

The mean maternal age of cases and controls was 25.2 (SD = 5.33) and 25.8 (SD = 4.37), respectively. In the multivariate analysis, factors with statistically significant relationships with PTD were the mother's religion (AOR: 3.01; 95% CI 1.24-7.26), the number of antenatal care visits (AOR: 3.39; 95% CI 1.6-7.18), having a pre-pregnancy maternal weight of less than 45 kg (AOR: 3.05; 95% CI 1.66-10.5), having had a premature preterm rupture of the membrane (AOR: 7.13; 95% CI 2.44-20.8) and vaginal bleeding during pregnancy (AOR: 6.89; 95% CI 3.02-15.73).

CONCLUSIONS FOR PRACTICE

Improving capacity of the Laotian health system to provide quality ANC and increasing the number of ANC contacts is critical. This requires context specific strategies that also address the socio-economic factors, such as access to a nutritious diet, that contribute to PTD.

Sociodemographic determinants and mortality of premature newborns in a medium and low-income population in Colombia, 2017-2019

Introduction

The birth of premature babies is a public health problem with a high impact on infant morbidity and mortality. About 40% of mortality in children under five years occurs in the first month of life.

Objective

To identify the association between maternal sociodemographic factors, premature birth, and mortality in newborns under 37 weeks in Santiago de Cali, 2017-2019.

Materials and methods

We conducted a descriptive, cross-sectional study. We evaluated the records of Cali's Municipal Public Health Office. We calculated the crude and adjusted odd ratios and confidence intervals (95%) using the logistic regression model, data processing in Stata 16, and georeferencing the cases in the QGIS software.

Results

From 2017 to 2019, premature babies in Cali corresponded to 11% of births. Poor prenatal care increased 3.13 times the risk of being born before 32 weeks (adjusted OR = 3.13; 95% CI = 2.75 - 3.56) and 1.27 times among mothers from outside the city (adjusted OR = 1.27; 95% CI = 1.15-1.41). Mortality was 4.29 per 1,000 live births. The mortality risk in newborns weighing less than 1,000 g increased 3.42 times (OR = 3.42; 95% CI = 2.85-4.12), delivery by cesarean section in 1.46 (OR = 1.46; CI 95% = 1.14-1.87) and an Apgar score - five minutes after birth- lower than seven in 1.55 times (OR = 1.55; CI 95% = 1.23-1.96).

Conclusions

We found that less than three prenatal controls, mothers living outside Cali, afro-ethnicity, and cesarean birth were associated with prematurity of less than 32 weeks. We obtained higher mortality in newborns weighing less than 1,000 g.

Prematurity and Low Birth Weight and Their Impact on Childhood Growth Patterns and the Risk of Long-Term Cardiovascular Sequelae

Preterm birth (before 37 completed weeks of gestation) is a global health problem, remaining the main reason for neonatal mortality and morbidity. Improvements in perinatal and neonatal care in recent decades have been associated with a higher survival rate of extremely preterm infants, leading to a higher risk of long-term sequelae in this population throughout life. Numerous surveillance programs for formerly premature infants continue to focus on neurodevelopmental disorders, while long-term assessment of the impact of preterm birth and low birth weight on child growth and the associated risk of cardiovascular disease in young adults is equally necessary. This review will discuss the influence of prematurity and low birth weight on childhood growth and cardiovascular risk in children, adolescents and young adults. The risk of cardiovascular and metabolic disorders is increased in adult preterm survivors. In early childhood, preterm infants may show elevated blood pressure, weakened vascular growth, augmented peripheral vascular resistance and cardiomyocyte remodeling. Increased weight gain during the early postnatal period may influence later body composition, promote obesity and impair cardiovascular results. These adverse metabolic alterations contribute to an increased risk of cardiovascular incidents, adult hypertension and diabetes. Preterm-born children and those with fetal growth restriction (FGR) who demonstrate rapid changes in their weight percentile should remain under surveillance with blood pressure monitoring. A better understanding of lifelong health outcomes of preterm-born individuals is crucial for developing strategies to prevent cardiovascular sequelae and may be the basis for future research to provide effective interventions.

Hormonal Determinants of Growth and Weight Gain in the Human Fetus and Preterm Infant

The factors controlling linear growth and weight gain in the human fetus and newborn infant are poorly understood. We review here the changes in linear growth, weight gain, lean body mass, and fat mass during mid- and late gestation and the early postnatal period in the context of changes in the secretion and action of maternal, placental, fetal, and neonatal hormones, growth factors, and adipocytokines. We assess the effects of hormonal determinants on placental nutrient delivery and the impact of preterm delivery on hormone expression and postnatal growth and metabolic function. We then discuss the effects of various maternal disorders and nutritional and pharmacologic interventions on fetal and perinatal hormone and growth factor production, growth, and fat deposition and consider important unresolved questions in the field.

Severity of preterm birth and the risk of pulmonary hypertension in childhood: A population-based cohort study in Sweden

BACKGROUND

Preterm birth (<37 completed gestational weeks) has been linked to pulmonary hypertension (PH), but the relationship to severity of preterm birth has not been studied.

OBJECTIVES

We investigated associations between extremely (<28 weeks), very (28-31 weeks), moderately (32-36 weeks) preterm birth, early-term birth (37-38 weeks) and later PH. Additionally, we explored associations between birthweight for gestational age and PH.

METHODS

This registry-based cohort study followed 3.1 million individuals born in Sweden (1987-2016) from 1 up to a maximum of 30 years of age. The outcome was diagnosis or death from PH in national health registers. Adjusted hazard ratios (HR) were estimated using Cox regression analysis. Unadjusted and confounder-adjusted incidence rate differences were also calculated.

RESULTS

Of 3,142,812 individuals, there were 543 cases of PH (1.2 per 100,000 person-years), 153 of which in individuals without malformations. Compared with individuals born at 39 weeks, adjusted HRs with 95% confidence interval (CI) for PH for extremely, moderately, and very preterm birth were 68.78 (95% CI 49.49, 95.57), 13.86 (95% CI 9.27, 20.72) and 3.42 (95% CI 2.46, 4.74), respectively, and for early-term birth 1.74 (1.31, 2.32). HRs were higher in subjects without malformations. There were 90 additional cases of PH per 100,000 person-years in the extremely preterm group (50 after excluding malformations). Very small for gestational age (below 2 SD from estimated birthweight for gestational age and sex) was also associated with increased risk of PH (adjusted HR 2.02, 95% CI 1.14, 3.57).

CONCLUSIONS

We found an inverse association between gestational age and later PH, but the incidence and absolute risks are low. The severity of preterm birth adds clinically relevant information to the assessment of cardiovascular risks in childhood.

Association of preterm birth with poor metabolic outcomes in schoolchildren

OBJECTIVE

To investigate, at school age, the metabolic profile of children born preterm.

METHODS

A cross-sectional study of children 5 to 8 years old, born with gestational age (GA) < 34 weeks and/or weight ≤ 1,500 grams. Clinical and anthropometric data were assessed by a single trained pediatrician. Biochemical measurements were done at the organization's Central Laboratory using standard methods. Data on health conditions, eating, and daily life habits were retrieved from medical charts and through validated questionnaires. Binary logistic and linear regression models were built to identify the association between variables, weight excess, and GA.

RESULTS

Out of 60 children (53.3% female), 6.8 ± 0.7 years old, 16.6% presented excess weight, 13.3% showed increased insulin resistance markers and 36.7% had abnormal blood pressure values. Those presenting excess weight had higher waist circumferences and higher HOMA-IR than normal-weight children (OR = 1.64; CI = 1.035-2.949). Eating and daily life habits were not different among overweight and normal-weight children. The small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA, 83.3%) birth weight children did not differ regarding clinical (body weight, blood pressure) or biochemical variables (serum lipids, blood glucose, HOMA-IR).

CONCLUSION

Schoolchildren born preterm, regardless of being AGA or SGA, were overweight, and presented increased abdominal adiposity, reduced insulin sensitivity, and altered lipid profile, justifying longitudinal follow-up regarding adverse metabolic outcomes in the future.

Small for gestational age preterm infants and later adiposity and height: A systematic review and meta-analysis

BACKGROUND

Overweight and obesity and their consequent morbidities are important worldwide health problems. Some research suggests excess adiposity origins may begin in fetal life, but unknown is whether this applies to infants born preterm.

OBJECTIVE

The objective of the study was to assess the association between small for gestational age (SGA) birth and later adiposity and height among those born preterm.

DATA SOURCES

MEDLINE, EMBASE and CINAHL until October 2022.

STUDY SELECTION AND DATA EXTRACTION

Studies were included if they reported anthropometric (adiposity measures and height) outcomes for participants born preterm with SGA versus non-SGA. Screening, data extraction and risks of bias assessments were conducted in duplicate by two reviewers.

SYNTHESIS

We meta-analysed across studies using random-effects models and explored potential heterogeneity sources.

RESULTS

Thirty-nine studies met the inclusion criteria. In later life, preterm SGA infants had a lower body mass index (-0.66 kg/m2 , 95% CI -0.79, -0.53; 32 studies, I2  = 16.7, n = 30,346), waist circumference (-1.20 cm, 95% CI -2.17, -0.23; 13 studies, I2  = 19.4, n = 2061), lean mass (-2.62 kg, 95% CI -3.45, 1.80; 7 studies, I2  = 0, n = 205) and height (-3.85 cm, 95% CI -4.73, -2.96; 26 studies, I2  = 52.6, n = 4174) compared with those preterm infants born non-SGA. There were no differences between preterm SGA and preterm non-SGA groups in waist/hip ratio, body fat, body fat per cent, truncal fat per cent, fat mass index or lean mass index, although power was limited for some analyses. Studies were rated at high risk of bias due to potential residual confounding and low risk of bias in other domains.

CONCLUSIONS

Compared to their preterm non-SGA peers, preterm infants born SGA have lower BMI, waist circumference, lean body mass and height in later life. No differences in adiposity were observed between SGA preterm infants and non-SGA preterm infants.

Handling misclassified stratification variables in the analysis of randomised trials with continuous outcomes

Many trials use stratified randomisation, where participants are randomised within strata defined by one or more baseline covariates. While it is important to adjust for stratification variables in the analysis, the appropriate method of adjustment is unclear when stratification variables are affected by misclassification and hence some participants are randomised in the incorrect stratum. We conducted a simulation study to compare methods of adjusting for stratification variables affected by misclassification in the analysis of continuous outcomes when all or only some stratification errors are discovered, and when the treatment effect or treatment-by-covariate interaction effect is of interest. The data were analysed using linear regression with no adjustment, adjustment for the strata used to perform the randomisation (randomisation strata), adjustment for the strata if all errors are corrected (true strata), and adjustment for the strata after some errors are discovered and corrected (updated strata). The unadjusted model performed poorly in all settings. Adjusting for the true strata was optimal, while the relative performance of adjusting for the randomisation strata or the updated strata varied depending on the setting. As the true strata are unlikely to be known with certainty in practice, we recommend using the updated strata for adjustment and performing subgroup analyses, provided the discovery of errors is unlikely to depend on treatment group, as expected in blinded trials. Greater transparency is needed in the reporting of stratification errors and how they were addressed in the analysis.

Cardiovascular health profiles in adolescents being born term or preterm-results from the EVA-Tyrol study

BACKGROUND AND AIMS

Preterm birth has been linked with an increased risk of cardiovascular (CV) disease from childhood into adolescence and early adulthood. In this study, we aimed to investigate differences in CV health profiles between former term- and preterm-born infants in a cohort of Tyrolean adolescents.

METHODS

The Early Vascular Aging (EVA)-Tyrol study is a population-based non-randomized controlled trial, which prospectively enrolled 14- to 19-year-old adolescents in North Tyrol, Austria and South Tyrol, Italy between 2015 and 2018. Metrics of CV health (body mass index (BMI), systolic (SBP) and diastolic blood pressure (DBP), smoking, physical activity, dietary patterns, total cholesterol and fasting blood glucose) were assessed and compared between former term- and preterm-born girls and boys.

RESULTS

In total, 1,491 study participants (59.5% female, mean age 16.5 years) were included in the present analysis. SBP and DBP were significantly higher in former preterm-born adolescents (mean gestational age 34.6 ± 2.4 weeks) compared to term-born controls (p < 0.01). In the multivariate regression analysis these findings remained significant after adjustment for potential confounders in all models. No differences were found in all other CV health metrics. The number of participants meeting criteria for all seven health metrics to be in an ideal range was generally very low with 1.5% in former term born vs. 0.9% in former preterm born adolescents (p = 0.583).

CONCLUSIONS

Preterm birth is associated with elevated SBP and DBP in adolescence, which was even confirmed for former late preterm-born adolescents in our cohort. Our findings underscore the importance of promoting healthy lifestyles in former term- as well as preterm-born adolescents. In addition, we advise early screening for hypertension and long-term follow-up in the group of preterm-born individuals.

Review: Nutritional regulation of muscle growth in neonatal swine

Despite advances in the nutritional support of low birth weight and early-weaned piglets, most experience reduced extrauterine growth performance. To further optimize nutritional support and develop targeted intervention strategies, the mechanisms that regulate the anabolic response to nutrition must be fully understood. Knowledge gained in these studies represents a valuable intersection of agriculture and biomedical research, as low birth weight and early-weaned piglets face many of the same morbidities as preterm and low birth weight infants, including extrauterine growth faltering and reduced lean growth. While the reasons for poor growth performance are multifaceted, recent studies have increased our understanding of the role of nutrition in the regulation of skeletal muscle growth in the piglet. The purpose of this review is to summarize the published literature surrounding advances in the current understanding of the anabolic signaling that occurs after a meal and how this response is developmentally regulated in the neonatal pig. It will focus on the regulation of protein synthesis, and especially the upstream and downstream effectors surrounding the master protein kinase, mechanistic target of rapamycin complex 1 (mTORC1) that controls translation initiation. It also will examine the regulatory pathways associated with the postprandial anabolic agents, insulin and specific amino acids, that are upstream of mTORC1 and lead to its activation. Lastly, the integration of upstream signaling cascades by mTORC1 leading to the activation of translation initiation factors that regulate protein synthesis will be discussed. This review concludes that anabolic signaling cascades are stimulated by both insulin and amino acids, especially leucine, through separate pathways upstream of mTORC1, and that these stimulatory pathways result in mTORC1 activation and subsequent activation of downstream effectors that regulate translation initiation Additionally, it is concluded that this anabolic response is unique to the skeletal muscle of the neonate, resulting from increased sensitivity to the rise in both insulin and amino acid after a meal. However, this response is dampened in skeletal muscle of the low birth weight pig, indicative of anabolic resistance. Elucidation of the pathways and regulatory mechanisms surrounding protein synthesis and lean growth allow for the development of potential targeted therapeutics and intervention strategies both in livestock production and neonatal care.

Paraben exposure through drugs in the neonatal intensive care unit: a regional cohort study

Background and objectives: Environmental factors influence the development of very preterm infants (VPIs, born at less than 32 weeks of gestation). It is important to identify all potential sources of paraben exposure in these vulnerable infants. We aimed to quantify paraben exposure via drug administration in a cohort of VPI cared for in neonatal intensive care units (NICUs). Methods: A prospective, observational study was carried out over a five-year period in a regional setting (two NICUs using the same computerized order-entry system). The main outcome was exposure to paraben-containing drugs. The secondary outcomes were: time of the first exposure, daily intake, number of infants exceeding paraben acceptable daily intake (ADI: 0-10 mg/kg/d), duration of exposure, and cumulative dose. Results: The cohort consisted of 1,315 VPIs [BW 1129.9 (±360.4) g]. Among them, 85.5% were exposed to paraben-containing drugs. In 40.4% of infants, the first exposure occurred during the second week of life. Mean paraben intake and duration of exposure were, respectively, 2.2 (±1.4) mg/kg/d and 33.1 (±22.3) days. The cumulative paraben intake was 80.3 (±84.6) mg/kg. The ADI was exceeded in 3.5% of exposed infants. Lower GA was associated with higher intake and longer exposure (p < 0.0001). The main molecules involved in paraben exposure were: sodium iron feredetate, paracetamol, furosemide, and sodium bicarbonate + sodium alginate. Conclusion: Commonly used drugs are potential source of parabens, and ADI can be easily exceeded in VPIs cared for in NICUs. Efforts are needed to identify paraben-free alternative formulations for these vulnerable infants.

Birth size, growth trajectory and later cardio-metabolic risk

There is increasing evidence of a strong association between intrauterine growth and subsequent development of chronic disease in adult life. Birth size and growth trajectory have been demonstrated to have an impact on cardio-metabolic health, both in childhood and adult life. Hence, careful observation of the children's growth pattern, starting from the intrauterine period and the first years of life, should be emphasized to detect the possible onset of cardio-metabolic sequelae. This allows to intervene on them as soon as they are detected, first of all through lifestyle interventions, whose efficacy seems to be higher when they are started early. Recent papers suggest that prematurity may constitute an independent risk factor for the development of cardiovascular disease and metabolic syndrome, regardless of birth weight. The purpose of the present review is to examine and summarize the available knowledge about the dynamic association between intrauterine and postnatal growth and cardio-metabolic risk, from childhood to adulthood.

Cardioprotective Effects of Dexmedetomidine in an Oxidative-Stress In Vitro Model of Neonatal Rat Cardiomyocytes

Preterm birth is a risk factor for cardiometabolic disease. The preterm heart before terminal differentiation is in a phase that is crucial for the number and structure of cardiomyocytes in further development, with adverse effects of hypoxic and hyperoxic events. Pharmacological intervention could attenuate the negative effects of oxygen. Dexmedetomidine (DEX) is an α2-adrenoceptor agonist and has been mentioned in connection with cardio-protective benefits. In this study, H9c2 myocytes and primary fetal rat cardiomyocytes (NRCM) were cultured for 24 h under hypoxic condition (5% O₂), corresponding to fetal physioxia (pO₂ 32-45 mmHg), ambient oxygen (21% O₂, pO₂ ~150 mmHg), or hyperoxic conditions (80% O₂, pO₂ ~300 mmHg). Subsequently, the effects of DEX preconditioning (0.1 µM, 1 µM, 10 µM) were analyzed. Modulated oxygen tension reduced both proliferating cardiomyocytes and transcripts (CycD2). High-oxygen tension induced hypertrophy in H9c2 cells. Cell-death-associated transcripts for caspase-dependent apoptosis (Casp3/8) increased, whereas caspase-independent transcripts (AIF) increased in H9c2 cells and decreased in NRCMs. Autophagy-related mediators (Atg5/12) were induced in H9c2 under both oxygen conditions, whereas they were downregulated in NRCMs. DEX preconditioning protected H9c2 and NRCMs from oxidative stress through inhibition of transcription of the oxidative stress marker GCLC, and inhibited the transcription of both the redox-sensitive transcription factors Nrf2 under hyperoxia and Hif1α under hypoxia. In addition, DEX normalized the gene expression of Hippo-pathway mediators (YAP1, Tead1, Lats2, Cul7) that exhibited abnormalities due to differential oxygen tensions compared with normoxia, suggesting that DEX modulates the activation of the Hippo pathway. This, in the context of the protective impact of redox-sensitive factors, may provide a possible rationale for the cardio-protective effects of DEX in oxygen-modulated requirements on survival-promoting transcripts of immortalized and fetal cardiomyocytes.

Small vulnerable newborns-big potential for impact

Despite major achievements in child survival, the burden of neonatal mortality has remained high and even increased in some countries since 1990. Currently, most neonatal deaths are attributable to being born preterm, small for gestational age (SGA), or with low birthweight (LBW). Besides neonatal mortality, these conditions are associated with stillbirth and multiple morbidities, with short-term and long-term adverse consequences for the newborn, their families, and society, resulting in a major loss of human capital. Prevention of preterm birth, SGA, and LBW is thus critical for global child health and broader societal development. Progress has, however, been slow, largely because of the global community's failure to agree on the definition and magnitude of newborn vulnerability and best ways to address it, to frame the problem attractively, and to build a broad coalition of actors and a suitable governance structure to implement a change. We propose a new definition and a conceptual framework, bringing preterm birth, SGA, and LBW together under a broader umbrella term of the small vulnerable newborn (SVN). Adoption of the framework and the unified definition can facilitate improved problem definition and improved programming for SVN prevention. Interventions aiming at SVN prevention would result in a healthier start for live-born infants, while also reducing the number of stillbirths, improving maternal health, and contributing to a positive economic and social development in the society.

Myocardial function including estimates of myocardial work in young adults born very preterm or with extremely low birthweight - a cohort study

BACKGROUND

Preterm birth and low birthweight have been associated with increased risk of heart failure and cardiovascular disease in young adulthood. However, results from clinical studies of myocardial function are not consistent. Echocardiographic strain analyses allow detection of early stages of cardiac dysfunction, and non-invasive estimates of myocardial work can provide additional information on cardiac function. We aimed to evaluate left ventricular (LV) myocardial function including measures of myocardial work in young adults born very preterm (gestational age < 29 weeks) or with extremely low birthweight (< 1000 g) (PB/ELBW), compared with term-born age- and sex matched controls.

METHODS

63 PB/ELBW and 64 controls born in Norway in the periods 1982-1985, 1991-1992, and 1999-2000 were examined with echocardiography. LV ejection fraction (EF) and LV global longitudinal strain (GLS) were measured. Myocardial work was estimated from LV pressure-strain loops after determination of GLS and construction of a LV pressure curve. Diastolic function was evaluated by determination of the presence or absence of elevated LV filling pressure, including measures of left atrial longitudinal strain.

RESULTS

The PB/ELBW with mean birthweight 945 (standard deviation (SD) 217) grams, mean gestational age 27 (SD 2) weeks, and mean age 27 (SD 6) years had LV systolic function mainly within normal range. Only 6% had EF < 50% or impaired GLS >-16%, but 22% had borderline impaired GLS between - 16% and - 18%. Mean GLS in PB/ELBW (-19.4% (95% confidence interval (CI) -20.0, -18.9)) was impaired compared to controls (-20.6% (95% CI -21.1, -20.1)), p = 0.003. Lower birthweight was associated to more impaired GLS (Pearson correlation coefficient - 0.2). Means of EF, measures of diastolic function including left atrial reservoir strain, global constructive and wasted work, global work index and global work efficiency was similar in PB/ELBW and controls.

CONCLUSION

The young adults born very preterm or with extremely low birthweight had impaired LV-GLS compared to controls, although systolic function mainly within normal range. Lower birthweight was associated with more impaired LV-GLS. These findings could indicate an elevated lifetime risk of developing heart failure in preterm born individuals. Measures of diastolic function and myocardial work were similar compared to controls.

Microvascular and oxidative stress responses to acute high-altitude exposure in prematurely born adults

Premature birth is associated with endothelial and mitochondrial dysfunction, and chronic oxidative stress, which might impair the physiological responses to acute altitude exposure. We assessed peripheral and oxidative stress responses to acute high-altitude exposure in preterm adults compared to term born controls. Post-occlusive skeletal muscle microvascular reactivity and oxidative capacity from the muscle oxygen consumption recovery rate constant (k) were determined by Near-Infrared Spectroscopy in the vastus lateralis of seventeen preterm and seventeen term born adults. Measurements were performed at sea-level and within 1 h of arrival at high-altitude (3375 m). Plasma markers of pro/antioxidant balance were assessed in both conditions. Upon acute altitude exposure, compared to sea-level, preterm participants exhibited a lower reperfusion rate (7 ± 31% vs. 30 ± 30%, p = 0.046) at microvascular level, but higher k (6 ± 32% vs. -15 ± 21%, p = 0.039), than their term born peers. The altitude-induced increases in plasma advanced oxidation protein products and catalase were higher (35 ± 61% vs. -13 ± 48% and 67 ± 64% vs. 15 ± 61%, p = 0.034 and p = 0.010, respectively) and in xanthine oxidase were lower (29 ± 82% vs. 159 ± 162%, p = 0.030) in preterm compared to term born adults. In conclusion, the blunted microvascular responsiveness, larger increases in oxidative stress and skeletal muscle oxidative capacity may compromise altitude acclimatization in healthy adults born preterm.

Physical fitness trajectories from childhood to adolescence in extremely preterm children: A longitudinal cohort study

OBJECTIVE

Cohort studies on physical fitness (PF) in former extremely preterm children are scarce and yield conflicting results. Therefore, this study aimed to assess the effect of extremely preterm birth on PF in school-age with a focus on bronchopulmonary dysplasia (BPD).

METHODS

Eighty school-aged children were enrolled in the longitudinal cohort study. Fifty were born extremely preterm (<completed 28 weeks of gestation): 19 had BPD, and 31 did not; 30 term-born healthy children were included as controls. They were monitored annually throughout primary school (ages 7-14 years) with eight annual fitness testings within the Slovenian national surveillance system of children's somatic and motor development (SLOfit). The physical fitness index (PFI), calculated as the mean of percentiles of eight fitness tests, was used as an indicator of overall PF. Generalised estimating equations were used to compare changes in PFI between ages 7 and 14 in the three cohort groups: preterm children with BPD, preterm children without BPD and term controls.

RESULTS

Preterm children with BPD had significantly and persistently lower PFI than preterm children without BPD and term-born children throughout primary school age. Their PFI was less than half that of national median values (15.1st-19.7th percentile). Preterm children without BPD experienced progressive improvement in PFI during their school age (from 32.6th to 44.7th percentile of national median PFI values), while the ones with BPD did not.

CONCLUSION

Extreme prematurity per se is not a risk factor for lower PF at school age. However, if complicated by BPD, PF is significantly and sustainably reduced.

Early growth and body composition assessed by air displacement plethysmography in infants born with simple gastroschisis

BACKGROUND

Gastroschisis is an abdominal wall malformation usually associated with impaired growth.

OBJECTIVE

To evaluate the growth and body composition of infants born with simple gastroschisis in a referral center.

METHODS

This was a single-center, prospective case series of infants with simple gastroschisis who were measured at birth, at discharge, and at 3 months. Body composition was assessed via air-displacement plethysmography at discharge and at 3 months. The results were compared with those reported for healthy infants at an equivalent gestational age.

RESULTS

Simple gastroschisis infants were lighter and smaller at birth and remained similar at 3 months. All anthropometric z scores decreased from birth to discharge, followed by an increase but not a full recovery toward 3 months. Overall, gastroschisis infants had a similar FM percentage, FM% (11.1 ± 4.7), but a lower FFM, FFM (2481 ± 478 g), at discharge. FM% (18.5 ± 5.3) decreased at 3 months, and FFM remained lower (3788 ± 722 g) but improved between the two exams. Boys had significantly more FFM than girls at both evaluations. The multiple regression analysis showed that male sex, prematurity, total parenteral nutrition duration, and exclusive breast milk diets were associated with differences in body composition.

CONCLUSIONS

Infants with simple gastroschisis cared for in a referral center experienced growth failure at discharge and showed a similar FM% but lower FFM than healthy infants. At 3 months, they exhibited smaller FM% and FFM, but FFM improved after the first exam, representing a better protein accretion.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

IV.

Impaired pulmonary function mediates the impact of preterm birth on later-life stroke: a 2-step, multivariable Mendelian randomization study

OBJECTIVES

Observational studies have suggested an association between preterm birth and stroke in late adulthood, but it remains unclear whether the association is causal. The purpose of this study was to evaluate the causal effects of gestational age on stroke and to determine the pathophysiological mechanisms underlying the causal associations.

METHODS

Two-sample Mendelian randomization (MR) was performed to assess the causal effects of fetal gestational duration, early preterm birth (EPB), preterm birth, or postterm birth on stroke and its subtypes. Two-step Mendelian randomization (TSMR) and multivariable Mendelian randomization (MVMR) were additionally used to determine the role of common stroke risk factors, including cardiovascular diseases, hypertension, pulmonary impairment, inflammation, and metabolic diseases, in mediating the causal associations between gestational age and stroke and its subtypes.

RESULTS

Genetically predicted EPB increased the risk of cardioembolic stroke (CES; odds ratio [OR], 1.115; 95% confidence interval [CI], 1.036 to 1.200; p=0.004) and large artery stroke (LAS; OR, 1.131; 95% CI, 1.031 to 1.241; p=0.009). The TSMR results showed that EPB was associated with a lower forced expiratory volume in the first second and forced vital capacity ratio (FEV1/FVC) (β=-0.020; 95% CI, -0.035 to -0.005; p=0.009), which increased the risk of CES and LAS. Further MVMR analysis showed that the associations between EPB and stroke disappeared after adjustment for FEV1/FVC.

CONCLUSIONS

Our data demonstrate that EPB is causally associated with an elevated risk of CES and LAS, and that pulmonary dysfunction mediates the causal impact of EPB on CES and LAS.

Growth trajectory during the first 1000 days and later overweight in very preterm infants

OBJECTIVE

To identify the characteristics of early life growth associated with later overweight or obesity (OWO) in very preterm population.

DESIGN

Length, weight and body mass index (BMI) were prospectively recorded from three prospective, population-based cohorts with 5 years (Loire Infant Follow-up Team (LIFT), EPIPAGE2 (Etude EPIdémiologique sur les Petits Ages GEstationnels 2)) and 15 years (EPIPAGEADO, Etude EPIdémiologique sur les Petits Ages GEstationnels-Adolescents) of follow-up. Missing data were imputed.

SETTING

Regional (LIFT), national (EPIPAGE2) and multiregional (EPIPAGEADO) cohorts in France.

PATIENTS

Eligible infants born before 33 weeks of gestation in 1997 (EPIPAGEADO), between 2003 and 2014 (LIFT), and in 2011 (EPIPAGE2).

MAIN OUTCOME MEASURES

OWO was determined as BMI Z-score >85th percentile of the WHO reference curves at 5 years (LIFT, EPIPAGE2) and 15 years (EPIPAGEADO).

RESULTS

In EPIPAGEADO, LIFT and EPIPAGE2, BMI Z-scores were known for 302 adolescents, 1016 children and 2022 children, respectively. In EPIPAGEADO, OWO was observed in 42 (13.9%, 95% CI 10.5 to 18.3) adolescents. In multivariable models, birthweight Z-score, increase in weight Z-score during neonatal hospital stay and increase in BMI between discharge and at 2 years of corrected age were positively associated with OWO at 15 years (adjusted OR (aOR)=3.65, 95% CI 1.36 to 9.76; aOR=3.82, 95% CI 1.42 to 10.3; and aOR=2.55, 95% CI 1.72 to 3.78, respectively, by Z-score), but change in length Z-score during neonatal hospital stay was negatively associated (aOR=0.41, 95% CI 0.21 to 0.78, p=0.007). These four associations with OWO assessed at 5 years were confirmed in the LIFT and EPIPAGE2 cohorts.

CONCLUSIONS

Change in length Z-score during hospitalisation, a putative proxy of quality of neonatal growth, was negatively associated with risk of later OWO when change in BMI between discharge and at 2 years was included in the multivariable model.

Effect of covering perinatal health-care costs on neonatal outcomes in Switzerland: a quasi-experimental population-based study

BACKGROUND

Low birthweight and preterm birth are associated with an increased risk of neonatal death and chronic conditions across the life course. Reducing these adverse birth outcomes is a global public health priority and requires strategies to improve health care during pregnancy. We aimed to assess the effect of a Swiss health policy expansion fully covering illness-related costs during pregnancy on health outcomes in newborn babies.

METHODS

We implemented a quasi-experimental difference in regression discontinuity design to assess the effect of expansion of Swiss health insurance (on March 1, 2014), to fully cover health-care costs during pregnancy and 8 weeks postpartum, on neonatal outcomes. Before this reform, only costs specific to the standard monitoring of a normal pregnancy were covered. Babies born before March 1, 2014, and their mothers were assigned to the unexposed group, and babies born on or after March 1, 2014, and their mothers were assigned to the exposed group. We included nearly all children born 2011-19 in Switzerland within a period of 9 months around the date March 1, 2014, and control years 2012, 2016, and 2018. Outcomes were birthweight, low birthweight, very low birthweight, gestational age, preterm or extremely preterm birth, and neonatal death. We estimated the intention-to-treat effect of the policy using parametric regression models.

FINDINGS

61 910 children were born 9 months before and 63 991 were born 9 months after March 1, 2014. 382 861 children were born in the same time period around the three control dates. In the period before policy implementation, mean birthweight was 3289 g, gestational age was 275 days, and 6·5% of children had low birthweight, 1·0% very low birthweight, 7·1% were preterm, 0·4% were extremely preterm, and 0·3% died within the first 28 days of life. After initiation of the policy (vs before) mean birthweight increased by 23 g (95% CI 5 to 40) and the predicted proportion of low birthweight births decreased by 0·81% (0·14 to 1·48) and of very low birthweight births decreased by 0·41% (0·17 to 0·65). The effect on very low birthweight was not robust in sensitivity analyses. The policy had a negligible effect on gestational age (mean difference 1 day, 95% CI 0 to 1) and no clear effects on the other examined outcomes. The change in predicted proportion for preterm births was -0·39% (95% CI -1·2 to 0·38), for extremely preterm births was -0·09% (-0·27 to 0·08), and for neonatal death was -0·07% (-0·2 to 0·07).

INTERPRETATION

Free access to prenatal care in Switzerland reduced the risk of some adverse health outcomes in newborn babies. Expanding health-care coverage is a relevant health system intervention to reduce the risk of adverse health outcomes in the newborn baby and, potentially, across the life course.

FUNDING

Swiss National Science Foundation.

Prematurity and BPD: what general pediatricians should know

More and more very low birth weight (VLBW) infants around the world survive nowadays, with consequently larger numbers of children developing prematurity-related morbidities, especially bronchopulmonary dysplasia (BPD). BPD is a multifactorial disease and its rising incidence in recent years means that general pediatricians are much more likely to encounter a child born extremely preterm, possibly with BPD, in their clinical practice. Short- and long-term sequelae in VLBW patients may affect not only pulmonary function (principally characterized by an obstructive pattern), but also other aspect including the neurological (neurodevelopmental and neuropsychiatric disorders), the sensorial (earing and visual impairment), the cardiological (systemic and pulmonary hypertension, reduced exercise tolerance and ischemic heart disease in adult age), nutritional (feeding difficulties and nutritional deficits), and auxological (extrauterine growth restriction). For the most premature infants at least, a multidisciplinary follow-up is warranted after discharge from the neonatal intensive care unit in order to optimize their respiratory and neurocognitive potential, and prevent respiratory infections, nutritional deficiencies or cardiovascular impairments.  Conclusion: The aim of this review is to summarize the main characteristics of preterm and BPD infants, providing the general pediatrician with practical information regarding these patients' multidisciplinary complex follow-up. We explore the current evidence on respiratory outcomes and their management that actually does not have a definitive available option. We also discuss the available investigations, treatments, and strategies for prevention and prophylaxis to improve the non-respiratory outcomes and the quality of life for these children and their families, a critical aspect not always considered. This comprehensive approach, added to the increased needs of a VLBW subjects, is obviously related to very high health-related costs that should be beared in mind. What is Known: • Every day, a general pediatrician is more likely to encounter a former very low birth weight infant. • Very low birth weight and prematurity are frequently related not only with worse respiratory outcomes, but also with neurological, sensorial, cardiovascular, renal, and nutritional issues. What is New: • This review provides to the general pediatrician a comprehensive approach for the follow-up of former premature very low birth weight children, with information to improve the quality of life of this special population.