The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants

Postneonatal mortality of severely small for gestational age extremely low birth weight infants

BACKGROUND

Infants born with weights below the 10th percentile of the expected birth weight for gestational age, defined as small for gestational age (SGA), have an increased risk of neonatal mortality and prematurity-related complications. However, the relationship between SGA and postneonatal (28 days to <1 year) mortality among extremely low birth weight infants (ELBWIs) remains uncertain. Hence, this study aimed to investigate the association between birth weight percentiles and postneonatal mortality in ELBWIs.

METHODS

A cohort of ELBWIs with a gestational age greater than 23 weeks who were admitted to Osaka Women's and Children's Hospital between 2008 and 2019 were considered eligible. Infants with major congenital anomalies, those large for their gestational age, or those who died within 28 days of birth were excluded. Baseline characteristics and outcomes of the three groups of ELBWIs-severe SGA (sSGA; birth weight, <3rd percentile), moderate SGA (mSGA; birth weight, 3rd to <10th percentile), and appropriate for gestational age (AGA; birth weight, 10th to <90th percentile)-were compared. Logistic regression analysis was used to identify perinatal factors associated with postneonatal mortality in sSGA infants.

RESULTS

sSGA ELBWIs demonstrated higher incidence of meconium obstruction (25% vs. 8.3% vs. 7.6%, P < 0.001), cholestasis (21% vs. 4.2% vs. 9.7%, P < 0.003), and postneonatal mortality (7.3% vs. 0% vs. 0.7%, P < 0.004) than mSGA and AGA ELBWIs. In the logistic regression analysis, cholestasis (odds ratio, 30.1; 95% confidence interval, 2.98-304) and sepsis (odds ratio, 13.5; 95% confidence interval, 1.06-173) were significantly related to postneonatal mortality among ELBWIs with sSGA. The leading cause of postneonatal mortality in sSGA ELBWIs was liver failure (55.5%).

CONCLUSION

sSGA ELBWIs exhibited a higher rate of postneonatal mortality compared to mSGA and AGA ELBWIs. Therefore, strategies aimed at preventing liver dysfunction in severely cholestatic ELBWIs with sSGA are necessary.

Association between maternal rheumatoid arthritis and small for gestational age neonates: a systematic review and meta-analysis

Background

According to reports, maternal rheumatoid arthritis (RA) has been suggested as a possible adverse factor for developing small for gestational age (SGA) in offspring. However, some studies have also indicated a need for a more statistically significant association between the two. Understanding the relationship between maternal RA and the risk of SGA is crucial for identifying potential adverse outcomes and implementing appropriate interventions. Therefore, this study aims to elucidate the association between maternal RA and the risk of offspring developing SGA.

Methods

This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022357590). A systematic literature search was conducted to identify eligible studies up to August 2022. Quality assessment was performed according to the Newcastle-Ottawa scale. The Q test and I2 test tested and estimated heterogeneity among studies. Odds ratios (ORs) with 95% CI were calculated using random or fixed effects models depending on the heterogeneity. Subgroup analyses, sensitivity analyses, and publication bias assessments were also performed.

Results

Seven studies, including 12,323,918 participants, were included in the analysis. The results showed a statistically significant association between maternal RA and SGA (OR = 1.70, 95% CI = 1.29-2.23, p < 0.001). Sensitivity analysis showed stable results. The funnel plot of the symmetric distribution and the results of Begg's and Egger's tests showed no publication bias.

Conclusion

Maternal RA is associated with an increased risk of SGA in offspring. However, more studies are still needed to explore the potential mechanisms underlying maternal RA and SGA association.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42022357590].

Maternal socioeconomic and lifestyle factors and life dissatisfaction associated with a small for gestational age infant. The Survey of Neonates in Pomerania (SNiP)

PURPOSE

The aim is to investigate the associations of the mother's socioeconomic and lifestyle factors and life satisfaction with the delivery of a small for gestational age (SGA) infant.

METHODS

Data from 4598 participants of the population-based birth cohort study Survey of Neonates in Pomerania (SniP) including comprehensive information on pregnancies, mothers, and their offspring in Western Pomerania, Germany were used in this study. The associations were analyzed using linear and logistic regression models.

RESULTS

After logistic regression analysis adjusted for height of the mother, women who delivered SGA infants, had lower education (p < 0.01) and smoked more frequently during pregnancy (p < 0.01) compared with mothers of adequate for gestational age (AGA) neonates. A mother with less than 10 years of education and one who continued smoking during pregnancy had an odds ratio (OR) of 2.23 [95% confidence interval (CI) = 1.44 to 3.46] and 2.68 (95% CI = 2.06-3.49) of having an SGA infant, respectively. There was no association between the employment of the mother (p = 0.28), the monthly income (p = 0.09), the family status (p = 0.80), the number of friendships outside the household that the mother would not wish to relinquish (p = 0.47), the number of people that she could rely on in case of an emergency (p = 0.75), or alcohol consumption prior to (p = 0.14) or during the pregnancy (p = 0.99) with SGA. Finally, women who delivered SGA infants were more frequently dissatisfied with their employment (p = 0.03) and financial status (p < 0.01).

CONCLUSIONS

Women who delivered SGA infants had more associated socioeconomic and lifestyle risk factors and were more frequently dissatisfied with their life conditions than mothers of AGA neonates.

Diagnostic Tests in the Prediction of Neonatal Outcome in Early Placental Fetal Growth Restriction

Background and Objectives: Monitoring pregnancies with fetal growth restriction (FGR) presents a challenge, especially concerning the time of delivery in cases of early preterm pregnancies below 32 weeks. The aim of our study was to compare different diagnostic parameters in growth-restricted preterm neonates with and without morbidity/mortality and to determine sensitivity and specificity of diagnostic parameters for monitoring preterm pregnancies with early preterm fetal growth restriction below 32 weeks. Materials and Methods: Our clinical study evaluated 120 cases of early preterm deliveries, with gestational age ≤ 32 + 0 weeks, with prenatally diagnosed placental FGR. All the patients were divided into three groups of 40 cases each based on neonatal condition,: I-Neonates with morbidity/mortality (NMM); II-Neonates without morbidity with acidosis/asphyxia (NAA); III-Neonates without neonatal morbidity/acidosis/asphyxia (NWMAA). Results: Amniotic fluid index (AFI) was lower in NMM, while NWMAA had higher biophysical profile scores (BPS). UA PI was lower in NWMAA. NWMAA had higher MCA PI and CPR and fewer cases with CPR <5th percentile. NMM had higher DV PI, and more often had ductus venosus (DV) PI > 95th‱ or absent/reversed A wave, and pulsatile blood flow in umbilical vein (UV). The incidence of pathological fetal heart rate monitoring (FHRM) was higher in NMM and NAA, although the difference was not statistically significant. ROC calculated by defining a bad outcome as NMM and a good outcome as NAA and NWMAA showed the best sensitivity in DV PIi. ROC calculated by defined bad outcome in NMM and NAA and good outcome in NWMAA showed the best sensitivity in MCA PI. Conclusions: In early fetal growth restriction normal cerebral blood flow strongly predicts good outcomes, while pathological venous blood flow is associated with bad outcomes. In fetal growth restriction before 32 weeks, individualized expectant management remains the best option for the optimal timing of delivery.

Neurodevelopment and physical measurements in infants with birthweight of 500 grams or less

BACKGROUND

In infants born weighing ≤500 g, little has been studied about the association between neurodevelopmental prognosis and growth. This study aimed to evaluate the association between neurodevelopmental impairment (NDI) and z-scores of physical measurements in infants born weighing ≤500 g.

METHODS

A single-center, retrospective cohort study in a level IV neonatal intensive care unit in Japan. Infants born weighing ≤500 g between 2010 and 2019 were eligible. Z-scores in weight, length/height, and head circumference at birth, due date (or discharge), 6 and 18 months of corrected age, and 3 years of age were compared between infants with and without NDI at 3 years of age. Three infants with severe intraventricular hemorrhage or periventricular leukomalacia were excluded from the comparison analyses. NDI was defined as having a developmental quotient of ≤70, cerebral palsy, visual impairment, or hearing impairment.

RESULTS

Of 22 eligible infants, the incidence of NDI at 3 years of age was 54.5%. The z-score was significantly smaller in the NDI group (n = 10) than that in the non-NDI group (n = 9) in head circumference at birth (median, -1.94 vs. -0.75; Z = 0.54; p = 0.020), and in height at 18 months of corrected age (median, -2.84 vs. -1.79; Z = 0.58; p = 0.013) and 3 years of age (median, -2.02 vs. -1.21; Z = 0.47; p = 0.046).

CONCLUSIONS

NDI at 3 years of age was associated with a small head circumference z-score at birth, height at 18 months of corrected age, and height at 3 years of age in infants born weighing ≤500 g.

Being Small for Gestational Age does not Change Short-Term Outcomes for Extremely Low Birth Weight Babies at Townsville University Hospital

Aim To determine whether being small for gestational age (SGA) is associated with increased mortality and short-term morbidity for extremely low birth weight (ELBW) babies at Townsville University Hospital (TUH).

Methods All babies with a birth weight of <1,000 g born at TUH between January 1, 2010 and January 1, 2021 were included. Data from the neonatal unit's NeoDATA database were used to compare mortality and short-term morbidity outcomes for babies categorized as SGA (birth weight <10th centile) or not. Statistical analyses were used to determine associations between being SGA and survival to discharge, intubation for mechanical ventilation, duration of respiratory support, chronic neonatal lung disease (CNLD), home oxygen, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), sepsis, time to full enteral feeds, and duration of admission.

Results Of 461 ELBW babies, 62 (13.4%) were SGA. The SGA babies were significantly smaller at 714 (580–850) versus 810 (700–885) g (p < 0.001) and of advanced gestational age at 28.6 (26.6–30.2) versus 25.4 (24.4–26.6) weeks (p < 0.001). No significant difference in mortality existed, with 85% of SGA babies and 84% of others surviving. On univariate analysis, being SGA was associated with significant reductions in intubation for mechanical ventilation (p < 0.001), duration of respiratory support (p < 0.001), intraventricular hemorrhage (p = 0.002), NEC (p = 0.037), and admission duration (p = 0.038). After controlling for confounding factors, no outcomes were independently associated with being SGA. Logistic regression found survival was associated with birth weight (p = 0.030), gestational age (p = 0.007), and antenatal corticosteroids (p = 0.008).

Conclusions Being SGA is not an independent predictor of mortality nor adverse short-term morbidity for ELBW babies.

Respiratory and Gastrointestinal Management of an Infant with a Birth Weight of 258 Grams

Today, more infants weighing less than or equal to 300 g are born, and they survive because of the improvements in neonatal care and treatment. However, their detailed clinical course and neonatal intensive care unit management remain unknown due to their low survival rate and dearth of reports. A male infant was born at 24 weeks and 5 days of gestation and weighed 258 g. The infant received 72 days of invasive and 92 days of noninvasive respiratory support, including high-frequency oscillatory ventilation with volume guarantee and noninvasive neurally adjusted ventilatory assist. Meconium-related ileus was safely treated using diatrizoate. Although the infant was diagnosed with severe bronchopulmonary dysplasia and retinopathy of prematurity requiring laser photocoagulation, he had no other severe complications. He was discharged 201 days postdelivery (3 months of corrected age) with a weight of 3.396 kg. Although managing infants weighing less than or equal to 300 g is difficult, our experience shows that it is possible by combining traditional and modern management methods. The management of such infants requires an understanding of the expected difficulties and adaptation of existing methods to their management. The management techniques described here should help improve their survival and long-term prognosis.

Maternal dyslipidemia and altered cholesterol metabolism in early pregnancy as a risk factor for small for gestational age neonates

We evaluated the relationship between maternal cholesterol levels and its biologically active precursors and metabolites in the first trimester and subsequent risk for small-for-gestational-age birthweight (SGA). This is a secondary analysis of a prospective cohort study which enrolled healthy singleton pregnancies (n = 1337). Maternal fasting blood was taken in the first trimester and followed up till delivery. The lipid parameters were compared between women who delivered SGA neonates (SGA-group, birthweight < 10th percentile, n = 107) and women who did not (non-SGA-group, n = 1230). In addition, metabolic signatures of cholesterol were evaluated in a subset consisting of propensity-score matched SGA (n = 56) and control group (n = 56). Among lipid parameters, maternal high-density lipoprotein cholesterol (HDL-C) levels were significantly lower in SGA-group than in non-SGA-group (p = 0.022). The risk for SGA was negatively correlated with maternal serum HDL-C quartiles (p = 0.003), and this association remained significant after adjustment for confounding variables. In metabolic signatures of cholesterol, the cholesterol/lathosterol ratio in SGA-group was significantly higher than non-SGA-group [(2.7 (1.6-3.7) vs. 2.1 (1.5-2.9), respectively; p = 0.034)], suggesting increased endogenous cholesterol biosynthesis. We demonstrated that dyslipidemia and increased cholesterol biosynthesis led to delivery of SGA neonates even in early pregnancy.

Considerable mortality and morbidity in neonates born below 500 gram

Data evaluating mortality and morbidity in infants born ≤500 g are scarce and show wide variability. To support counselling and decision‐making, we analysed neurodevelopmental outcome in all neonates ≤500 g birth weight.

Retrospective analysis including preterm infants with a birth weight ≤500 g and a gestational age >22 weeks born at a single tertiary perinatal centre between 2010 and 2017.

Of 59 live births, 88% received standard care. Birth weight ranged from 318 to 500 g and gestational age from 23 to 29 weeks. 56% of neonates were born ≤3rd percentile and 42% of treated infants survived. Neurodevelopmental outcome was available in 91% of patients and was evaluated using Bayley Scales of Infant Development at two years. 50% showed a favourable mental development (normal or mild impairment), 75% a favourable motor development and 45% a favourable outcome in both outcome subcategories. When additionally considering visual and hearing disability and, or, cerebral palsy level ≥2 according to the Gross Motor Function Classification System 35% had a good neurodevelopmental outcome.

Survival rate was 37% for all live births and 42% for infants with standard care. More than one‐third of survivors showed no significant neurodevelopmental impairment at two years.

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

Antenatal corticosteroids in preterm small-for-gestational age infants: a systematic review and meta-analysis

OBJECTIVE

This study aimed to estimate the effect of antenatal corticosteroid administration on neonatal mortality and morbidity in preterm small-for-gestational age infants through a systematic review and meta-analysis.

DATA SOURCES

A predefined, systematic search was conducted through Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trial Registry Platform, and ClinicalTrials.gov yielding 5324 articles from 1970 to 2019.

STUDY ELIGIBILITY CRITERIA

Eligible studies compared neonatal morbidity and mortality among small-for-gestational age infants delivered preterm who received antenatal corticosteroids with those who did not.

METHODS

The primary outcome was neonatal mortality. Secondary outcomes were respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and periventricular leukomalacia, bronchopulmonary dysplasia or chronic lung disease of prematurity, or neonatal sepsis. We assessed heterogeneity by means of Higgins I² statistic and Cochran's Q test and calculated pooled odds ratios with 95% confidence intervals using random effects models.

RESULTS

A total of 16 observational cohort and case-control studies published from 1995 to 2018 met the selection criteria for the systematic review and included 8989 preterm small-for-gestational age infants. Antenatal corticosteroid administration was explicitly reported among 8376 small-for-gestational age infants; 4631 (55.3%) received antenatal corticosteroids and 3741 (44.7%) did not. Of note, 13 studies including 6387 preterm small-for-gestational age infants were then included in the meta-analysis. Neonatal mortality was significantly lower among infants who received antenatal corticosteroids than those who did not (12 studies: 12.8% vs 15.1%; pooled odds ratio, 0.63; 95% confidence interval, 0.46-0.86), with significant heterogeneity between studies (I²=55.1%; P=.011). There was no significant difference in respiratory distress syndrome (12 studies: odds ratio, 0.89; 95% confidence interval, 0.69-1.15), necrotizing enterocolitis (7 studies: odds ratio, 0.93; 95% confidence interval, 0.70-1.22), intraventricular hemorrhage and periventricular leukomalacia (10 studies: odds ratio, 0.82; 95% confidence interval, 0.56-1.20), bronchopulmonary dysplasia or chronic lung disease of prematurity (8 studies: odds ratio, 1.11; 95% confidence interval, 0.88-1.41), or neonatal sepsis (6 studies: odds ratio, 1.13; 95% confidence interval, 0.86-1.49).

CONCLUSION

These data indicate that antenatal corticosteroid administration reduces neonatal mortality in small-for-gestational age infants delivered preterm, with no apparent effect on neonatal morbidity. This supports the use of antenatal corticosteroids to reduce neonatal mortality in pregnancies with small-for-gestational age infants at risk of preterm birth.

Outcomes of Extremely Preterm Infants With Birth Weight Less Than 400 g

IMPORTANCE

Birth weight (BW) is an important predictor of mortality and morbidity. At extremely early gestational ages (GAs), BW may influence decisions regarding initiation of resuscitation.

OBJECTIVE

To characterize outcomes of liveborn infants with a BW less than 400 g.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective multicenter cohort study analyzed extremely preterm infants born between January 2008 and December 2016 within the National Institute of Child Health and Human Development Neonatal Research Network. Infants with a BW less than 400 g and a GA of 22 to 26 weeks were included. Active treatment was defined as the provision of any potentially lifesaving intervention after birth. Survival was analyzed for the entire cohort; neurodevelopmental impairment (NDI) was examined for those born between January 2008 and December 2015 (birth years with outcomes available for analysis). Neurodevelopmental impairment at 18 to 26 months' corrected age (CA) was defined as a Bayley Scales of Infant and Toddler Development, Third Edition, cognitive composite score less than 85, a motor composite score less than 85, moderate or severe cerebral palsy, gross motor function classification system score of 2 or greater, bilateral blindness, and/or hearing impairment. Data were analyzed from September 2017 to October 2018.

EXPOSURES

Birth weight less than 400 g.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to discharge among infants who received active treatment. Analysis of follow-up data was limited to infants born from 2008 to 2015 to ensure children had reached assessment age. Within this cohort, neurodevelopmental outcomes were assessed for infants who survived to 18 to 26 months' CA and returned for a comprehensive visit.

RESULTS

Of the 205 included infants, 121 (59.0%) were female, 133 (64.9%) were singletons, and 178 (86.8%) were small for gestational age. Almost half (101 of 205 [49.3%]) received active treatment at birth. A total of 26 of 205 infants (12.7%; 95% CI, 8.5-18.9) overall survived to discharge, and 26 of 101 actively treated infants (25.7%; 95% CI, 17.6-35.4) survived to discharge. Within the subset of infants with a BW less than 400 g and a GA of 22 to 23 weeks, 6 of 36 actively treated infants (17%; 95% CI, 6-33) survived to discharge. Among infants born between 2008 and 2015, 23 of 90 actively treated infants (26%; 95% CI, 17-36) survived to discharge. Two infants died after discharge, and 2 were lost to follow-up. Thus, 19 of 90 actively treated infants (21%; 95% CI, 13-31) were evaluated at 18 to 26 months' CA. Moderate or severe NDI occurred in 14 of 19 infants (74%).

CONCLUSIONS AND RELEVANCE

Infants born with a BW less than 400 g are at high risk of mortality and significant morbidity. Although 21% of infants survived to 18 to 26 months' CA with active treatment, NDI was common among survivors.

Variation in Use by NICU Types in the United States

: media-1vid110.1542/5828370139001PEDS-VA_2018-0457Video Abstract BACKGROUND: Increased admissions of higher birth weight and less acutely ill infants to NICUs suggests that intensive care may be used inappropriately in these populations. We describe variation in use of NICU services by gestational age and NICU type.

METHODS

Using the Vermont Oxford Network database of all NICU admissions, we assessed variation within predefined gestational age categories in the following proportions: admissions, initial NICU hospitalization days, high-acuity cases ≥34 weeks' gestation, and short-stay cases ≥34 weeks' gestation. High acuity was defined as follows: death, intubated assisted ventilation for ≥4 hours, early bacterial sepsis, major surgery requiring anesthesia, acute transport to another center, hypoxic-ischemic encephalopathy or a 5-minute Apgar score ≤3, or therapeutic hypothermia. Short stay was defined as an inborn infant staying 1 to 3 days with discharge from the hospital.

RESULTS

From 2014 to 2016, 486 741 infants were hospitalized 9 657 508 days at 381 NICUs in the United States. The median proportions of admissions, initial hospitalized days, high-acuity cases, and short stays varied significantly by NICU types in almost all gestational age categories. Fifteen percent of the infants ≥34 weeks were high acuity, and 10% had short stays.

CONCLUSIONS

There is substantial variation in use among NICUs. A campaign to focus neonatal care teams on using the NICU wisely that addresses the appropriate use of intensive care for newborn infants and accounts for local context and the needs of families is needed.

Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands

BACKGROUND

It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands.

METHODS

We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed.

RESULTS

The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses.

CONCLUSIONS

In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.

An Integrative Review of the Sleep Experiences of Mothers of Hospitalized Preterm Infants

OBJECTIVE

To determine what is known about the sleep experiences of mothers of hospitalized preterm infants.

DATA SOURCES

A literature search of PubMed and CINAHL was performed in February 2018. Additional articles were identified from reference lists.

STUDY SELECTION

Whittemore's integrative review methodology was used to synthesize existing literature; 17 articles met eligibility criteria.

DATA EXTRACTION

Data were reported in tabular format, including subjects, purpose, setting, interventions, sleep measurements, psychometric instruments, analyses, and results.

DATA SYNTHESIS

Overall, sleep is disrupted and of poor quality, and many mothers report insomnia with less total sleep time. Potential beneficial interventions include bright light therapy, relaxation guided imagery, and progressive muscle relaxation.

CONCLUSION

Although some interventions show promise, there are significant limitations. Future research should consider maternal/infant separation and milk expression.

Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives

Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.

Patterns of Oxygenation, Mortality, and Growth Status in the Surfactant Positive Pressure and Oxygen Trial Cohort

OBJECTIVE

To characterize actual achieved patterns of oxygenation in infants born appropriate vs small for gestational age (SGA) randomized to a lower (85-89%) vs higher (91%-95%) oxygen saturation target in the Surfactant Positive Pressure and Oxygen Trial. To determine the association between achieved oxygen saturation levels and survival in infants born appropriate vs SGA enrolled in the Surfactant Positive Pressure and Oxygen Trial.

STUDY DESIGN

Median oxygen saturation and intermittent hypoxemia events (<80%, 20 seconds-5  minutes) were documented in 1054 infants of 24^0/7-27^6/7 weeks of gestation while receiving supplemental oxygen during the first 3 days of life.

RESULTS

Lower target infants who were small for gestational age had the lowest oxygen saturation and highest incidence of intermittent hypoxemia during the first 3 days of life. The lowest quartile of oxygen saturation (≤92%) during the first 3 days of life was associated with lower 90-day survival for both infants born appropriate and SGA. An increased incidence of intermittent hypoxemia events during the first 3 days of life was associated with lower 90-day survival only in infants born SGA.

CONCLUSION

Lower achieved oxygen saturation during the first 3 days of life was associated with lower 90-day survival in extremely preterm infants. Infants born SGA had enhanced vulnerability to lower oxygen saturation targets as evidenced by lower achieved oxygen saturation and an association between increased intermittent hypoxemia events and lower survival.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00233324.

Maternal Interleukin Genotypes Are Associated With NICU Outcomes Among Low-Birth-Weight Infants

BACKGROUND

Maternal interleukin (IL) single nucleotide polymorphisms (SNPs) are associated with obstetrical outcomes. Conversely, infant SNPs are associated with subsequent neonatal intensive care unit (NICU) outcomes. Little is known about relationships between maternal SNPs and neonatal outcomes.

PURPOSE

To examine the relationships between maternal IL genotypes and neonatal outcomes.

METHODS

An ancillary study was conducted among mothers ( N = 63) who delivered very low-birth-weight infants ( N = 74). Maternal DNA was extracted from breast milk and genotyped. Outcomes included fecal calprotectin, length of stay, scores for neonatal acute physiology with perinatal extension (SNAPPE-II), weight gain, oxygen needs, necrotizing enterocolitis, intraventricular hemorrhage, sepsis, retinopathy of prematurity, blood transfusions, and feeding intolerance. Multivariate analyses examined the relationships between maternal IL SNPs and outcomes, controlling for gestational age and the ratio of maternal milk to total milk.

RESULTS

Absence of a minor allele in 2 IL6 SNPs was associated with fecal calprotectin ( p = .0222, p = .0429), length of stay ( p = .0158), SNAPPE-II ( p = .0497), weight gain ( p = .0272), and days on oxygen ( p = .0316). IL6 genotype GG (rs1800795) was associated with length of stay ( p = .0034) and calprotectin ( p = .0213). Minor-allele absence in 2 IL10 SNPs was associated with days on oxygen ( p = .0320). There were associations between IL10 genotype TT (rs1800871) and calprotectin ( p = .0270) and between IL10 genotypes AA (rs1800872 and rs1800896) and calprotectin ( p = .0158, p = .0045).

CONCLUSION

Maternal IL SNPs are associated with NICU outcomes. A potential clinical application includes an antenatal risk profile to identify neonatal needs.

Population-based risks of mortality and preterm morbidity by gestational age and birth weight

OBJECTIVE

The objective of this study is to examine the effect of small or large for gestational age (SGA/LGA) status on mortality and morbidity by gestational age.

STUDY DESIGN

Logistic binomial regression was used to calculate relative risks (RRs) and 95% confidence intervals for infant mortality and preterm morbidities for SGA or LGA compared with appropriately grown (AGA) deliveries stratified by gestational age group.

RESULTS

Compared with AGA infants of similar gestational age, SGA infants were at increased risk for infant mortality. Mortality risk was decreased for LGA infants born between 25 and 27 weeks (RR: 0.6) but increased for LGA infants born between 28 and 31 weeks (RR: 1.9). Risk of preterm morbidity was increased for SGA infants born between 28 and 38 weeks, but decreased for LGA infants born before 37 weeks.

CONCLUSION

This study demonstrates the importance of considering birth weight for gestational age when evaluating morbidity and mortality risks.