Preterm white matter injury: ultrasound diagnosis and classification

A neuronal Slit1-dependent program rescues oligodendrocyte differentiation and myelination under chronic hypoxic conditions

Oligodendrocyte maturation arrest in hypoxia-induced white matter injury (WMI) results in long-term neurofunctional disabilities of preterm infants. Although neurons are closely linked to myelination regulation, how neurons respond to the above process remains elusive. Here, we identify a compensatory role of neuronal Slit1-dependent signaling in protecting against hypoxia-induced hypomyelination and ameliorating motor and cognitive disabilities. Conditional ablation of Slit1 in neurons exacerbates hypoxia-induced hypomyelination but is negligible for developmental myelination. Secreted Slit1 from hypoxic neurons directly targets oligodendrocyte, acting through Robo2-srGAP1-RhoA signaling. Pharmacological inhibition of RhoA restores myelination and promotes neurofunctional recovery in adolescent mice. Notably, natural selection analysis and functional validation indicate an adaptive variant with higher Slit1 gene expression in the Tibetan population, which has low oxygen availability. Collectively, these findings show a neuronal Slit1-dependent program of OL differentiation and suggest that targeting the Slit1-Robo2 signaling axis may have therapeutic potential for treatment of preterm infants with hypoxic WMI.

A Novel Model for Simultaneous Evaluation of Hyperoxia-Mediated Brain and Lung Injury in Neonatal Rats

Despite improved neonatal intensive care, the risk of premature-born infants developing bronchopulmonary dysplasia (BPD) and encephalopathy of prematurity (EoP) remains high. With hyperoxia being a major underlying factor, both preterm-birth-related complications are suggested to be closely interrelated. However, experimental models are lacking for the assessment of the potentially close interplay between both organs. To establish a model, suitable for the assessment of both affected organs, Wistar rats were exposed to 80% oxygen from postnatal day 2 (P2) for seven days. Brain and lung tissues were analysed via histomorphometry, immunohistochemistry, real-time PCR, and western blot at term P11. In the brain, hyperoxia induced significant hypomyelination accompanied by a reduction in oligodendrocytes and CD68 expression on microglia cells. These changes correlate with arrested alveolarisation and an increased number of macrophages in the lung. Interestingly, in contrast to the reduced formation of pulmonary microvessels, an increased vascular density was detected in the brain. Seven days of hyperoxia induces typical characteristics of BPD and EoP in neonatal rats, thereby linking impaired alveolarisation with disturbed myelination in the brain and providing an experimental model for understanding pathophysiological mechanisms and identifying organ-spanning novel therapeutic interventions targeting both diseases.

Predictive value of transcranial Doppler ultrasound for brain development and craniocerebral injury in premature infants

OBJECTIVE

To investigate the diagnostic value of early transcranial Doppler (TCD) ultrasound in assessing brain function development and intracranial diseases in preterm infants.

METHODS

A retrospective analysis was conducted on the data of 100 preterm infants admitted to the neonatal intensive care unit (NICU) of Affiliated Changzhou Children's Hospital of Nantong University from June 2022 to December 2023. Based on clinical diagnosis, the infants were divided into two groups: brain injury group (47 cases) and non-brain injury group (53 cases). All infants underwent bedside transcranial ultrasound examination using a color Doppler ultrasound diagnostic instrument. Ultrasound imaging and hemodynamic indices were compared between the two groups. The diagnostic value of color Doppler ultrasound for brain injury in premature infants and the correlation between cerebral hemodynamic indices and brain injury severity were analyzed.

RESULTS

The sensitivity and accuracy of TCD ultrasound for diagnosing brain injury in preterm infants were 82.98% and 85.00%, respectively. Hemodynamic findings showed that the mean velocity (Vm) in the brain injury group was higher than in the non-brain injury group within 12-24 hours after birth, while the pulsatility index (PI) and resistance index (RI) were lower (both P<0.001). In the moderate to severe brain injury group, Vm was markedly higher, while PI and RI were significantly lower than those of the mild brain injury group within 12-24 hours after birth (P<0.001). The area under the ROC curve for Vm, PI, and RI in predicting brain injury in preterm infants was 0.898, 0.940, and 0.794, respectively, with PI showing the highest diagnostic value. Vm was positively correlated with the degree of brain injury with a coefficient of 0.713; However, PI and RI were negatively correlated with the degree of brain injury (r=-0.706 and -0.645, respectively).

CONCLUSION

Bedside transcranial ultrasound can effectively reflect the brain parenchymal development of preterm infants. Its hemodynamic indicators can accurately assess intracranial blood flow, making it valuable for detecting brain hemorrhage. Additionally, this method is convenient, non-invasive, and well-accepted by patients, making it a promising tool for clinical practice.

State-of-the-art cranial ultrasound in clinical scenarios for infants born at term and near-term

Neonates admitted to the intensive care unit are at risk of brain injury. Importantly, infants with signs of neurological impairment need prompt diagnosis to guide intervention. Cranial ultrasound (CUS) is the first-line imaging tool for infants born preterm. New developments in this technology, which now incorporates high-resolution equipment, have notably improved the performance of CUS in infants born at term and near-term. On the other hand, the potential of CUS as a diagnostic tool in older infants is less established. The lack of studies focusing on this topic, local protocol variability among clinical sites, and divergent opinions on CUS patterns of disease entities are the main constraints. This review provides an overview of state-of-the-art CUS as a decision-making tool under different clinical scenarios, such as neonatal encephalopathy, seizures, and suspected central nervous system infection. The CUS features that characterize several patterns supporting a diagnosis are detailed, focusing on haemorrhage and infection.

Development of a New Animal Model for Non-Cystic Periventricular Leukomalacia

Periventricular leukomalacia (PVL) is a major cause of cerebral palsy in preterm neonates. Though many interventions are being explored as therapeutic options in PVL, all these therapies are still in preclinical phase. This emphasizes the need for the development of robust animal models for PVL. We aimed to develop a new animal (rat) model for PVL using natural pattern of perinatal insults as in humans. The animal model was developed using a combination of three insults: prenatal inflammation, prenatal near total ischemia and postnatal recurrent hypoxia. Pathological and immunohistochemical analysis of pup brains was performed on day 28. We had 33 pups in experimental (inflammation, ischemia and hypoxia, LIH) group and 34 normal pups as controls. Histopathological analysis and immunohistochemistry with anti myelin basic protein (MBP) antibody showed myelin loss in corpus callosum or periventricular white matter in all pups in LIH group. Nissl's stain showed focal to generalized cortical disorganization. On functional assessment, LIH pups had prolonged escape latency in morris water maze test suggestive of cognitive/memory impairment. To conclude, we have developed a new animal model for PVL in rat, using a similar pattern of perinatal insults as in human preterm neonates. The model resembles non-cystic PVL in both pathological and functional analysis.

Outcome prediction for late-onset sepsis after premature birth

BACKGROUND

Our aim was to develop a quantitative model for immediately estimating the risk of death and/or brain injury in late-onset sepsis (LOS) in preterm infants, based on objective and measurable data available at the time sepsis is first suspected (i.e., time of blood culture collection).

METHODS

Retrospective study on neonates ≤36 weeks' gestation with a positive blood and/or cerebrospinal fluid culture after 72 hours from birth.

RESULTS

Among 3217 preterm live births, 94 cases were included (median gestational age 26.5 weeks' IQR 25.0;28.0), of whom 26 (27.7%) had poor outcomes (17 death; 9 brain injuries). Infants with poor outcomes showed lower postnatal age (11.5 vs 12.5 days, p < 0.001), lower mean blood pressure (30.5 vs 43 mmHg, p < 0.001) and higher lactate levels (4.4 vs 1.5 mmol/l, p < 0.001). Our multivariable model showed good discrimination and calibration (c statistic=0.8618, Hosmer-Lemeshow p = 0.8532), stratifying the population into 3 groups: low-risk (sensitivity 97%, specificity 52%), middle-risk, and high-risk (sensitivity 77%, specificity 80%).

CONCLUSION

This predictive model performs well as a practical and easy-to-use tool to help clinicians early identify the sickest neonates who may benefit from timely and aggressive support (e.g., central line, haemodynamic assessment) and close monitoring (e.g., 1:1 nursing assignment, frequent reassessments).

IMPACT

We lack data to early identify the severity of neonatal late-onset sepsis in preterm infants. Delay in treatment contributes to poor prognosis. We developed a model for early prediction of poor outcomes (mortality and brain injuries). The model utilizes immediately available and measurable data at the time sepsis is first suspected. This can help clinicians in tailoring management based on individual risks.

Exploring the mechanism of Pujin oral liquid in the treatment of preterm white matter injury using network pharmacology and molecular docking

We aimed to elucidate the pharmacological mechanisms of Pujin oral liquid in treating preterm white matter injury (PWMI). The Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform was used to identify Pujin oral liquid's active ingredients and predict their targets. The known targets related to treating PWMI were identified from the GeneCards, Online Mendelian Inheritance in Man, DisGeNet, PharmGKB, and CTD databases. A drug-disease intersecting protein-protein interaction network using a STRING database was built; gene ontology function and Kyoto Encyclopedia of Genes and Genomes signaling pathway enrichment analyses were performed on common target genes using the Metascape database. Molecular docking of the active ingredients and key targets was validated using the AutoDock Vina software. In total, 470 Pujin oral liquid targets and 13,290 disease targets were screened from multiple databases, and Venn analysis identified 407 common targets. Protein-protein interaction analysis showed that Pujin oral liquid may impact SRC, MAPK3, MAPK1, TP53, STAT3, AKT1, PIK3R1, JUN, RELA, CTNNB1, and ESR1. Moreover, gene ontology functional analysis revealed processes such as the response to inorganic substances, cellular response to organic cyclic compounds, response to xenobiotic stimuli, regulation of system processes, and protein phosphorylation. The main signaling pathways were neuroactive ligand-receptor interaction and the cGMP-PKG, JAK-STAT, and cAMP signaling pathways. Molecular docking showed that the active ingredients' small molecules bond strongly to target proteins. The therapeutic effect of Pujin oral liquid on PWMI is multifaceted, involving multiple targets and pathways. Its clinical application in treating preterm white matter injuries is promising.

Posterior subependymal germinal matrix hemorrhage as a mild form of hemorrhage in extremely preterm infants: neurodevelopmental outcomes at corrected ages of 18-24 months

PURPOSE

This study aimed to explore the effects of both the presence and size of posterior subependymal germinal matrix hemorrhage (PS-GMH), considered a mild form of hemorrhage, on the neurodevelopmental outcomes of extremely preterm infants.

METHODS

A retrospective analysis was conducted on 221 extremely preterm infants, assessing their initial and term-equivalent age (TEA) cranial ultrasound (cUS) examinations from 2016 to 2021. Infants were classified based on the presence and size (small/large) of PS-GMH. Neurodevelopmental outcomes at corrected ages of 18-24 months were analyzed in 135 infants.

RESULTS

PS-GMH was identified in 86.9% (192/221) of the infants, with 13.5% (26/192) exhibiting large PS-GMH. Among the 135 infants who were followed up, those with PS-GMH were found to have younger gestational ages (P<0.001) and a higher incidence of maternal chorioamnionitis (P=0.016) than those without PS-GMH. Significant differences were observed in the incidence of grade II intraventricular hemorrhage (IVH) on initial cUS (P=0.003) and ventriculomegaly at TEA cUS (P=0.026) across the groups with no PS-GMH, small PS-GMH, and large PS-GMH. The large PS-GMH group exhibited a higher occurrence of grade II IVH than the small PS-GMH group (P=0.006). However, ventriculomegaly incidence did not significantly vary with PS-GMH status. Neurodevelopmental outcomes were also not significantly different across PS-GMH statuses. The adjusted odds ratios for any neurodevelopmental impairment, compared to the no PS-GMH group, were 1.70 (95% confidence interval [CI], 0.40 to 7.26; P=0.471) for all PS-GMH, 1.61 (95% CI, 0.37 to 6.93; P=0.526) for small PS-GMH, and 3.84 (95% CI, 0.62 to 24.00; P=0.150) for large PS-GMH.

CONCLUSION

PS-GMH was frequently observed in extremely preterm infants; however, it did not independently predict adverse neurodevelopmental outcomes.

Corpus callosum biometry in children born very preterm with and without cerebral palsy

BACKGROUND

Corpus callosum (CC) measurements are used as a biomarker of white matter volume in infants born very preterm (VPT; gestational age≤32 weeks). Although smaller CC measurements are found in both children born VPT and those with cerebral palsy (CP) compared to neurotypical children born at term, there is a lack of research specifically comparing CC measurements in VPT children with and without CP at different ages.

PARTICIPANTS AND METHODS

We compared five CC measurements (total length, and thickness of genu, body, isthmus, and splenium) calculated on the midsagittal plane of T1 magnetic resonance imaging (MRI) in a retrospective case-control study between VPT children with (case) and without CP (control) matched 1:1 by age at MRI at different ages (<12 months age; 5-11 years-old).

RESULTS

Seventy-four VPT children were included (median age 5.8 months [2.1-89.3], 34 females). Children with CP showed shorter length (45.3 mm [40.9-66.2] vs 50.9 mm [44.5-69]; p = 0.01), smaller isthmus thickness (1.8 mm [1.2-2.2] vs 2.2 mm [1.8-4.1]; p = 0.03), and smaller splenium thickness (3.5 [2.7-7.9] vs 5 mm [3.7-9.8]; p = 0.04) compared to children without CP. Comparison of the two groups by age at MRI, showed significantly smaller splenium thickness in both infants (<12 months age) and children (5-11 years-old) with CP than in controls.

CONCLUSION

Infants and children born VPT with CP had smaller CC measurements than those without CP, with the posterior region being the most affected. Splenium thickness in VPT infants could serve as a biomarker for white matter damage, potentially leading to CP.

Cerebral Ultrasound at Term-Equivalent Age: Correlations with Neuro-Motor Outcomes at 12-24 Months Corrected Age

Background/Objectives: Our research aimed to assess if correlations could be found between items evaluated at the cerebral ultrasound performed at term-equivalent age (TEA) and neuro-motor outcomes evaluated at 12 and 24 months of corrected age in a group of preterm infants. Methods: The following were assessed: the Levine Index, the diagonals of the lateral ventricles, the size of the ventricular midbody, the sinocortical distance, the width of the basal ganglia, the cortical depth at the level of the cingular sulcus and the maturation of the gyral folding. The neurologic evaluation was performed at 12 and 24 months of corrected age, according to the Amiel Tison neurologic examination, and the items from the calendar of motor acquisitions were used as outcome measures of the study-gross and fine motor subsets. The comparisons between the different groups were performed using the FANOVA test, with a statistically significant association for a p < 0.05. Results: The abnormal gross motor acquisitions at 12 months were significantly associated with an increased size of the ventricular midbody (p < 0.009) and a significantly decreased diameter of the basal ganglia (p < 0.011) on the TEA cerebral ultrasound. At 24 months, a significant association was found with increased size of the ventricular midbody (>10.33 mm) (p < 0.001), a decreased diameter of the basal ganglia (<12.9 mm) (p < 0.016), a decreased cortical depth (p < 0.021) and an immature gyral maturation pattern (p < 0.001). In the case of severely abnormal fine motor outcomes, at 12 months, there were statistically significant associations with an increased size of the ventricular midbody (p < 0.001) and an immature gyral folding pattern (p < 0.0180); at 24 months, significant associations were noted with the size of ventricular midbody (p < 0.001), a decreased diameter of the basal ganglia (p < 0.016), a decreased cortical depth (p < 0.021) and an immature gyration folding (p < 0.001). Conclusions: The abnormal gross and fine motor outcome in former premature infants at 12-24 months corrected age is significantly associated with abnormal findings in the head ultrasound examination performed at TEA reflecting both white matter (increased midbody distance) and grey matter (decreased diameter of the basal ganglia, decreased cortical depth and an immature gyration pattern) involvement.

Risk factors and nomogram for the prediction of intracranial hemorrhage in very preterm infants

AIMS

This study aims to identify important risk factors for intracranial hemorrhage (ICH) in very preterm infants at our institution and develop a predictive nomogram for early detection of ICH.

METHODS

We retrospectively analyzed neonates with a gestational age (GA) under 32 weeks, admitted to the neonatal intensive care unit from March 2022 to July 2023. Infants were categorized into two groups based on ultrasound findings and assessed for thirteen variables including gender, GA, birth weight (BW), acidosis, among others. We used multivariate logistic regression analysis to build a prediction model and identify independent risk factors for ICH. We build a prediction model by assigning 241 cases to the training set and 103 to the validation set (ratio 7:3).

RESULTS

Among 344 very preterm infants, the incidence of ICH was 36.9% (89 cases) in training set. Significant differences were observed in gestational age, birth weight, antenatal corticosteroids, mechanical ventilation days, and acidosis between cases and controls. Logistic regression analysis identified gestational age (OR = 0.674), antenatal corticosteroids (OR = 0.257), acidosis (OR = 2.556), and mechanical ventilation mechanical ventilation days(OR = 0.257) as independent risk factors for ICH. The C-index of the training and validation sets was 0.814 (95% CI: 0.762-0.869) and 0.784 (95% CI: 0.693-0.875), respectively. According to decision curve analysis, our model outperformed the "None" and "All" baseline lines over a wide range of risk thresholds (0.12-0.92).

CONCLUSION

Acidosis and mechanical ventilation are independent risk factors for ICH in very preterm neonates, while higher gestational age and antenatal corticosteroid use are protective. The nomogram developed from these four factors demonstrates strong predictive accuracy and calibration, which can aid clinicians in identifying preterm infants at high risk for ICH and facilitate early diagnosis and management.

DFC-Igloo: A dynamic functional connectome learning framework for identifying neurodevelopmental biomarkers in very preterm infants

BACKGROUND AND OBJECTIVE

Very preterm infants are susceptible to neurodevelopmental impairments, necessitating early detection of prognostic biomarkers for timely intervention. The study aims to explore possible functional biomarkers for very preterm infants at born that relate to their future cognitive and motor development using resting-state fMRI. Prior studies are limited by the sample size and suffer from efficient functional connectome (FC) construction algorithms that can handle the noisy data contained in neonatal time series, leading to equivocal findings. Therefore, we first propose an enhanced functional connectome construction algorithm as a prerequisite step. We then apply the new FC construction algorithm to our large prospective very preterm cohort to explore multi-level neurodevelopmental biomarkers.

METHODS

There exists an intrinsic relationship between the structural connectome (SC) and FC, with a notable coupling between the two. This observation implies a putative property of graph signal smoothness on the SC as well. Yet, this property has not been fully exploited for constructing intrinsic dFC. In this study, we proposed an advanced dynamic FC (dFC) learning model, dFC-Igloo, which leveraged SC information to iteratively refine dFC estimations by applying graph signal smoothness to both FC and SC. The model was evaluated on artificial small-world graphs and simulated graph signals.

RESULTS

The proposed model achieved the best and most robust recovery of the ground truth graph across different noise levels and simulated SC pairs from the simulation. The model was further applied to a cohort of very preterm infants from five Neonatal Intensive Care Units, where an enhanced dFC was obtained for each infant. Based on the improved dFC, we identified neurodevelopmental biomarkers for neonates across connectome-wide, regional, and subnetwork scales.

CONCLUSION

The identified markers correlate with cognitive and motor developmental outcomes, offering insights into early brain development and potential neurodevelopmental challenges.

The Relationship between the Improvement Level in Blood Gas Parameters in Time and Brain MRI Findings in Newborns with the Diagnosis of Hypoxic Ischemic Encephalopathy

Objective

In this study, we aimed to evaluate the relationship between the level of improvement in blood gas parameters in the first hours of age and normal and diffusion-restriction brain magnetic resonance imaging (MRI).

Materials and Methods

The study is a retrospective cohort study. Cases of the diagnosis of hypoxic-ischemic encephalopathy (HIE) who received therapeutic hypothermia in our unit between January 2022 and January 2024 were included in the study. Clinical findings, blood gas values (first, cord; second, first hours of age; third, 24th hour of age), and MRI results were recorded from the case files and compared between normal and diffusion-restricted brain MRI groups.

Results

Diffusion-restricted brain MRI was detected in 10 out of a total of 19 cases. The 5-minute Apgar score was lower (p=0.038) and mechanical ventilator support was higher (P=.003) in the diffusion-restricted MRI group than in the normal MRI group. The relationship was shown between high base excess (P=.022) in cord blood gas, low HCO₃ (p=0.025) in the 24th hour blood gas, and convulsion (P=.033) in the diffusion-restricted MRI group. Additionally, it was found that only the improvement level of the pH value in the first hour of age was significant (P=.025) in the diffusion-restricted brain MRI group than in the normal MRI group.

Conclusion

We showed that there was a relationship between diffusion-restricted brain MRI and the improvement level in the pH value in the first hours of age of patients diagnosed with HIE who received treatment for therapeutic hypothermia.

Comparative utility of MRI and EEG for early detection of cortical dysmaturation after postnatal systemic inflammation in the neonatal rat

BACKGROUND

Exposure to postnatal systemic inflammation is associated with increased risk of brain injury in preterm infants, leading to impaired maturation of the cerebral cortex and adverse neurodevelopmental outcomes. However, the optimal method for identifying cortical dysmaturation is unclear. Herein, we compared the utility of electroencephalography (EEG), diffusion tensor imaging (DTI), and neurite orientation dispersion and density imaging (NODDI) at different recovery times after systemic inflammation in newborn rats.

METHODS

Sprague Dawley rat pups of both sexes received single-daily lipopolysaccharide (LPS; 0.3 mg/kg i.p.; n = 51) or saline (n = 55) injections on postnatal days (P)1, 2, and 3. A subset of these animals were implanted with EEG electrodes. Cortical EEG was recorded for 30 min from unanesthetized, unrestrained pups at P7, P14, and P21, and in separate groups, brain tissues were collected at these ages for ex-vivo MRI analysis (9.4 T) and Golgi-Cox staining (to assess neuronal morphology) in the motor cortex.

RESULTS

Postnatal inflammation was associated with reduced cortical pyramidal neuron arborization from P7, P14, and P21. These changes were associated with dysmature EEG features (e.g., persistence of delta waveforms, higher EEG amplitude, reduced spectral edge frequency) at P7 and P14, and higher EEG power in the theta and alpha ranges at P21. By contrast, there were no changes in cortical DTI or NODDI in LPS rats at P7 or P14, while there was an increase in cortical fractional anisotropy (FA) and decrease in orientation dispersion index (ODI) at P21.

CONCLUSIONS

EEG may be useful for identifying the early evolution of impaired cortical development after early life postnatal systemic inflammation, while DTI and NODDI seem to be more suited to assessing established cortical changes.

Quantitative Evaluation of White Matter Injury by Cranial Ultrasound to Detect the Effects of Parenteral Nutrition in Preterm Babies: An Observational Study

Nutrition in early life has an impact on white matter (WM) development in preterm-born babies. Quantitative analysis of pixel brightness intensity (PBI) on cranial ultrasound (CUS) scans has shown a great potential in the evaluation of periventricular WM echogenicity in preterm newborns. We aimed to investigate the employment of this technique to objectively verify the effects of parenteral nutrition (PN) on periventricular WM damage in preterm infants. Prospective observational study including newborns with gestational age at birth ≤32 weeks and/or birth weight ≤1500 g who underwent CUS examination at term-equivalent age. The echogenicity of parieto-occipital periventricular WM relative to that of homolateral choroid plexus (RECP) was calculated on parasagittal scans by means of quantitative analysis of PBI. Its relationship with nutrient intake through enteral and parenteral routes in the first postnatal week was evaluated. The study included 42 neonates for analysis. We demonstrated that energy and protein intake administered through the parenteral route positively correlated with both right and left RECP values (parenteral energy intake vs. right RECP: r = 0.413, p = 0.007; parenteral energy intake vs. left RECP: r = 0.422, p = 0.005; parenteral amino acid intake vs. right RECP: r = 0.438, p = 0.004; parenteral amino acid intake vs. left RECP: r = 0.446, p = 0.003). Multivariate linear regression analysis confirmed these findings. Quantitative assessment of PBI could be considered a simple, risk-free, and repeatable method to investigate the effects of PN on WM development in preterm neonates.

Adjusted versus Targeted Fortification in Extremely Low Birth Weight Preterm Infants: Fortin Study-A Randomized Clinical Trial

Fortified human milk is the first choice for preterm infants. Although individualized fortification is recommended, the optimal method for this population remains uncertain. We conducted a comparative study assessing the growth effects of adjusted (AF) and targeted fortification (TF) in extremely low birth weight (ELBW) infants. This single-center, randomized, controlled clinical trial was conducted at a tertiary neonatal unit in Spain. Eligible participants were premature infants with a birthweight of <1000 g exclusively fed with human milk. A total of 38 patients were enrolled, 15 of them randomized to AF group and 23 to TF group. AF was based on blood urea nitrogen (BUN) concentration and TF on human milk analysis. The primary outcome was weight gain velocity (g/kg/day). No significant differences were found in weight gain velocity at 28 days, at 36 weeks of postmenstrual age, at discharge, nor during the intervention. Protein intake was significantly higher in the AF group (5.02 g/kg/day vs. 4.48 g/kg/day, p = 0.001). No differences were found in the lipid, carbohydrate, and energy intake; in the weight z score change between the different time points; nor in the length and head circumference growth. Both AF and TF are comparable methods of fortification and provide the appropriate growth rate in ELBW infants.

Machine Learning for the Identification of Key Predictors to Bayley Outcomes: A Preterm Cohort Study

BACKGROUND

The aim of this study was to understand how neurological development of preterm infants can be predicted at earlier stages and explore the possibility of applying personalized approaches.

METHODS

Our study included a cohort of 64 preterm infants, between 24 and 34 weeks of gestation. Linear and nonlinear models were used to evaluate feature predictability to Bayley outcomes at the corrected age of 2 years. The outcomes were classified into motor, language, cognitive, and socio-emotional categories. Pediatricians' opinions about the predictability of the same features were compared with machine learning.

RESULTS

According to our linear analysis sepsis, brain MRI findings and Apgar score at 5th minute were predictive for cognitive, Amiel-Tison neurological assessment at 12 months of corrected age for motor, while sepsis was predictive for socio-emotional outcome. None of the features were predictive for language outcome. Based on the machine learning analysis, sepsis was the key predictor for cognitive and motor outcome. For language outcome, gestational age, duration of hospitalization, and Apgar score at 5th minute were predictive, while for socio-emotional, gestational age, sepsis, and duration of hospitalization were predictive. Pediatricians' opinions were that cardiopulmonary resuscitation is the key predictor for cognitive, motor, and socio-emotional, but gestational age for language outcome.

CONCLUSIONS

The application of machine learning in predicting neurodevelopmental outcomes of preterm infants represents a significant advancement in neonatal care. The integration of machine learning models with clinical workflows requires ongoing education and collaboration between data scientists and healthcare professionals to ensure the models' practical applicability and interpretability.

Thalamic volume in very preterm infants: associations with severe brain injury and neurodevelopmental outcome at two years

Introduction

Several studies demonstrate the relationship between preterm birth and a reduced thalamus volume at term-equivalent age. In contrast, this study aims to investigate the link between the thalamic growth trajectory during the early postnatal period and neurodevelopment at two years of age.

Methods

Thalamic volume was extracted from 84 early MRI scans at postmenstrual age of 32.33 (± 2.63) weeks and 93 term-equivalent age MRI scans at postmenstrual age of 42.05 (± 3.33) weeks of 116 very preterm infants (56% male) with gestational age at birth of 29.32 (± 2.28) weeks and a birth weight of 1158.92 (± 348.59) grams. Cognitive, motor, and language outcomes at two years of age were assessed with Bayley Scales of Infant and Toddler Development Third Edition. Bivariate analysis was used to describe the clinical variables according to neurodevelopmental outcomes and multilevel linear regression models were used to examine the impact of these variables on thalamic volume and its relationship with neurodevelopmental outcomes.

Results

The results suggest an association between severe brain injury and thalamic growth trajectory (β coef = -0.611; p < 0.001). Moreover, thalamic growth trajectory during early postnatal life was associated with the three subscale scores of the neurodevelopmental assessment (cognitive: β coef = 6.297; p = 0.004; motor: β coef = 7.283; p = 0.001; language: β coeficient = 9.053; p = 0.002).

Discussion

These findings highlight (i) the impact of severe brain injury on thalamic growth trajectory during early extrauterine life after preterm birth and (ii) the relationship of thalamic growth trajectory with cognitive, motor, and language outcomes.

Cranial ultrasound in preterm infants ≤ 32 weeks gestation-novel insights from the use of very high-frequency (18-5 MHz) transducers: a case series

The quality of cranial ultrasound has improved over time, with advancing technology leading to higher resolution, faster image processing, digital display, and back-up. However, some brain lesions may remain difficult to characterize: since higher frequencies result in greater spatial resolution, the use of additional transducers may overcome some of these limitations. The very high-frequency transducers (18-5 MHz) are currently employed for small parts and lung ultrasound. Here we report the first case series comparing the very high-frequency probes (18-5 MHz) with standard micro-convex probes (8-5 MHz) for cranial ultrasound in preterm infants. In this case series, we compared cranial ultrasound images obtained with a micro-convex transducer (8-5 MHz) and those obtained with a very high-frequency (18-5 MHz) linear array transducer in 13 preterm infants ≤ 32 weeks gestation (9 with cerebral abnormalities and 4 with normal findings). Ultrasound examinations using the very high-frequency linear transducer and the standard medium-frequency micro-convex transducer were performed simultaneously. We also compared ultrasound findings with brain MRI images obtained at term corrected age. Ultrasound images obtained with the very high-frequency (18-5 MHz) transducer showed high quality and accuracy. Notably, despite their higher frequency and expected limited penetration capacity, brain size is small enough in preterm infants, so that brain structures are close to the transducer, allowing for complete evaluation.    Conclusion: We propose the routine use of very high-frequency linear probes as a complementary scanning modality for cranial ultrasound in preterm infants ≤ 32 weeks gestation. What is Known: • Brain lesions in preterm infants may remain insufficiently defined through conventional cranial ultrasound scan. • Higher frequency probes  offer better spatial resolution but have a narrower filed of exploration and limited penetration capacity. What is New: • Very high-frequency probes were compared with standard medium-frequency probes for cranial ultrasound in infants  ≤ 32 weeks' gestation. • Thanks to the smaller skull size of preterm infants, the new very high-frequency transducers allowed a complete and accurate evaluation.

Electroencephalographic Patterns on Follow-Up Visits in Extremely Premature Infants With Periventricular Leukomalacia: An Observational Study

BACKGROUND

Periventricular leukomalacia (PVL) is a common brain injury in premature infants, and epilepsy remains a significant complication. One concerning electroencephalographic (EEG) pattern found is developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep (DEE-SWAS). This pattern is associated with persistent neuropsychological and motor deficits, even without a diagnosis of epilepsy. The purpose of this study is to identify the relationships between various PVL grades and EEG patterns in this population on follow-up visits, especially the occurrence of DEE-SWAS pattern on EEG.

METHODS

This is a retrospective study of <36 weeks gestational age newborns who were followed in the neurodevelopmental clinic at Corewell Health East/Corewell Health Children's Hospital in Royal Oak, Michigan, between 2020 and 2022. Patients' demographics along with prematurity complications, diagnostic head ultrasound (HUS), and EEG studies were reviewed and graded. EEG studies are usually ordered when seizures were suspected.

RESULTS

A total of 155 newborns met the inclusion criteria. Twenty-six patients had PVL. Nine patients had grade 2 to 3 PVL based on HUS review. EEG was performed on 15 patients with PVL at a mean age of 22 months. More severe PVL grades were significantly associated with worse EEG patterns (P = 0.005). Five patients had DEE-SWAS pattern on EEG, all of whom had grade 2 or 3 PVL. Epilepsy was eventually diagnosed in three infants with PVL.

CONCLUSIONS

EEG can help identify important abnormal electrographic patterns in premature infants with PVL early in life; this might give a window of opportunity to intervene early and improve long-term developmental outcomes in this population.

Regional cerebral oxygen saturation variability and brain injury in preterm infants

Objective

To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants.

Study design

A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury.

Results

The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury.

Conclusions

In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.

Role of Transcranial Ultrasound and Doppler Studies to Evaluate Intracranial Pathologies in Preterm and High-risk Term Neonates

Background

Transcranial grayscale neurosonography (NSG) and Doppler studies have major role in diagnosing neonate intracranial pathologies. The aim of the study is to evaluate the role of NSG and Doppler studies in correlation with clinical hypotonia and seizures in preterm neonates and high-risk term neonates. The prevalence of intracranial pathology is the second aim of this study.

Methods

The present cross-sectional study was done in a tertiary care teaching hospital for 2 years. The study population of 120 cases comprised two groups: one group of 60 preterm neonates and the other of 60 high-risk term neonates with a history of well-defined episode of fetal distress. The NSG and Doppler findings (resistance index ≤0.62 is the optimum cutoff point for diagnosing perinatal asphyxia) are recorded. The sensitivity and specificity values for the NSG study alone, the Doppler study alone, and the combined NSG and Doppler studies are calculated.

Results

The majority (46%) of preterm neonates had presented with germinal matrix hemorrhage, whereas a majority (46%) of high-risk term neonates had presented with periventricular and subcortical cysts. Comparison of the sensitivity of NSG versus Doppler versus combined NSG and Doppler in evaluating hypotonia and seizures in preterm (P = 0.0442) and high-risk term neonates (P = 0.0399) was significant.

Conclusion

NSG combined with the Doppler study has significantly higher sensitivity than NSG alone in both groups. The specificity of the Doppler study is also high in both groups. Thus, it is strongly recommended to include Doppler during every NSG study to increase the detection rate.

Corpus callosum long-term biometry in very preterm children related to cognitive and motor outcomes

BACKGROUND

The corpus callosum (CC) is suggested as an indirect biomarker of white matter volume, which is often affected in preterm birth. However, diagnosing mild white matter injury is challenging.

METHODS

We studied 124 children born preterm (mean age: 8.4 ± 1.1 years), using MRI to assess CC measurements and cognitive/motor outcomes based on the Wechsler Intelligence Scale for Children-V (WPPSI-V) and Movement Assessment Battery for Children-2 (MABC-2).

RESULTS

Children with normal outcomes exhibited greater height (10.2 ± 2.1 mm vs. 9.4 ± 2.3 mm; p = 0.01) and fractional anisotropy at splenium (895[680-1000] vs 860.5[342-1000]) and total CC length (69.1 ± 4.8 mm vs. 67.3 ± 5.1 mm; p = 0.02) compared to those with adverse outcomes. All measured CC areas were smaller in the adverse outcome group. Models incorporating posterior CC measurements demonstrated the highest specificity (83.3% Sp, AUC: 0.65) for predicting neurological outcomes. CC length and splenium height were the only linear measurements associated with manual dexterity and total MABC-2 score while both the latter and genu were related with Full-Scale Intelligence Quotient.

CONCLUSIONS

CC biometry in children born very preterm at school-age is associated with outcomes and exhibits a specific subregion alteration pattern. The posterior CC may serve as an important neurodevelopmental biomarker in very preterm infants.

IMPACT

The corpus callosum has the potential to serve as a reliable and easily measurable biomarker of white matter integrity in very preterm children. Estimating diffuse white matter injury in preterm infants using conventional MRI sequences is not always conclusive. The biometry of the posterior part of the corpus callosum is associated with cognitive and certain motor outcomes at school age in children born very preterm. Length and splenium measurements seem to serve as reliable biomarkers for assessing neurological outcomes in this population.

Neurosonographic Classification in Premature Infants Receiving Omega-3 Supplementation Using Convolutional Neural Networks

This study focuses on developing a model for the precise determination of ultrasound image density and classification using convolutional neural networks (CNNs) for rapid, timely, and accurate identification of hypoxic-ischemic encephalopathy (HIE). Image density is measured by comparing two regions of interest on ultrasound images of the choroid plexus and brain parenchyma using the Delta E CIE76 value. These regions are then combined and serve as input to the CNN model for classification. The classification results of images into three groups (Normal, Moderate, and Intensive) demonstrate high model efficiency, with an overall accuracy of 88.56%, precision of 90% for Normal, 85% for Moderate, and 88% for Intensive. The overall F-measure is 88.40%, indicating a successful combination of accuracy and completeness in classification. This study is significant as it enables rapid and accurate identification of hypoxic-ischemic encephalopathy in newborns, which is crucial for the timely implementation of appropriate therapeutic measures and improving long-term outcomes for these patients. The application of such advanced techniques allows medical personnel to manage treatment more efficiently, reducing the risk of complications and improving the quality of care for newborns with HIE.

Effect of Cerebral Oximetry-Guided Treatment on Brain Injury in Preterm Infants as Assessed by Magnetic Resonance Imaging at Term Equivalent Age: An Ancillary SafeBoosC-III Study

INTRODUCTION

The SafeBoosC-III trial investigated the effect of cerebral oximetry-guided treatment in the first 72 h after birth on mortality and severe brain injury diagnosed by cranial ultrasound in extremely preterm infants (EPIs). This ancillary study evaluated the effect of cerebral oximetry on global brain injury as assessed by magnetic resonance imaging (MRI) at term equivalent age (TEA).

METHODS

MRI scans were obtained between 36 and 44.9 weeks PMA. The Kidokoro score was independently evaluated by two blinded assessors. The intervention effect was assessed using the nonparametric Wilcoxon rank sum test for median difference and 95% Hodges-Lehmann (HL) confidence intervals (CIs). The intraclass correlation coefficient (ICC) was used to assess the agreement between the assessors.

RESULTS

A total of 210 patients from 8 centers were included, of whom 121 underwent MRI at TEA (75.6% of alive patients): 57 in the cerebral oximetry group and 64 in the usual care group. There was an excellent correlation between the assessors for the Kidokoro score (ICC agreement: 0.93, 95% CI: 0.91-0.95). The results showed no significant differences between the cerebral oximetry group (median 2, interquartile range [IQR]: 1-4) and the usual care group (median 3, IQR: 1-4; median difference -1 to 0, 95% HLCI: -1 to 0; p value 0.1196).

CONCLUSIONS

In EPI, the use of cerebral oximetry-guided treatment did not lead to significant alterations in brain injury, as determined by MRI at TEA. The strong correlation between the assessors highlights the potential of the Kidokoro score in multicenter trials.

Transfontanellar shear wave elastography of the neonatal brain for quantitative evaluation of white matter damage

Cerebral white matter damage (WMD) is the most frequent brain lesion observed in infants surviving premature birth. Qualitative B-mode cranial ultrasound (cUS) is widely used to assess brain integrity at bedside. Its limitations include lower discriminatory power to predict long-term outcomes compared to magnetic resonance imaging (MRI). Shear wave elastography (SWE), a promising ultrasound imaging modality, might improve this limitation by detecting quantitative differences in tissue stiffness. The study enrolled 90 neonates (52% female, mean gestational age = 30.1  ± 4.5 weeks), including 78 preterm and 12 term controls. Preterm neonates underwent B-mode and SWE assessments in frontal white matter (WM), parietal WM, and thalami on day of life (DOL) 3, DOL8, DOL21, 40 weeks, and MRI at term equivalent age (TEA). Term infants were assessed on DOL3 only. Our data revealed that brain stiffness increased with gestational age in preterm infants but remained lower at TEA compared to the control group. In the frontal WM, elasticity values were lower in preterm infants with WMD detected on B-mode or MRI at TEA and show a good predictive value at DOL3. Thus, brain stiffness measurement using SWE could be a useful screening method for early identification of preterm infants at high WMD risk.Registration numbers: EudraCT number ID-RCB: 2012-A01530-43, ClinicalTrial.gov number NCT02042716.

A Multiplanar Radiomics Model Based on Cranial Ultrasound to Predict the White Matter Injury in Premature Infants and an Analysis of its Correlation With Neurodevelopment

OBJECTIVES

To develop and evaluate a multiplanar radiomics model based on cranial ultrasound (CUS) to predict white matter injury (WMI) in premature infants and explore its correlation with neurodevelopment.

METHODS

We retrospectively reviewed 267 premature infants. The radiomics features were extracted from five standard sections of CUS. The Spearman's correlation coefficient combined with the least absolute shrinkage and selection operator (LASSO) was applied to select features and build radiomics signature, and a multiplanar radiomics model was constructed based on the radiomics signature of five planes. The performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC). Infants with WMI were re-examined by ultrasound at 2 and 4 weeks after birth, and the recovery degree of WMI was evaluated using multiplanar radiomics. The relationship between WMI and the recovery degree and neurodevelopment was analyzed.

RESULTS

The AUC of the multiplanar radiomics in the training and validation sets were 0.94 and 0.91, respectively. The neurodevelopmental function scores in infants with WMI were significantly lower than those in healthy preterm infants and full-term newborns (P < .001). There were statistically significant differences in the neurodevelopmental function scores of infants between the 2- and 4-week lesion disappearance and 4-week lesion persistence (P < .001).

CONCLUSIONS

The multiplanar radiomics model showed a good performance in predicting the WMI of premature infants. It can not only provide objective and accurate results but also dynamically monitor the degree of recovery of WMI to predict the prognosis of premature infants.

Delineating morbidity patterns in preterm infants at near-term age using a data-driven approach

BACKGROUND

Long-term survival after premature birth is significantly determined by development of morbidities, primarily affecting the cardio-respiratory or central nervous system. Existing studies are limited to pairwise morbidity associations, thereby lacking a holistic understanding of morbidity co-occurrence and respective risk profiles.

METHODS

Our study, for the first time, aimed at delineating and characterizing morbidity profiles at near-term age and investigated the most prevalent morbidities in preterm infants: bronchopulmonary dysplasia (BPD), pulmonary hypertension (PH), mild cardiac defects, perinatal brain pathology and retinopathy of prematurity (ROP). For analysis, we employed two independent, prospective cohorts, comprising a total of 530 very preterm infants: AIRR ("Attention to Infants at Respiratory Risks") and NEuroSIS ("Neonatal European Study of Inhaled Steroids"). Using a data-driven strategy, we successfully characterized morbidity profiles of preterm infants in a stepwise approach and (1) quantified pairwise morbidity correlations, (2) assessed the discriminatory power of BPD (complemented by imaging-based structural and functional lung phenotyping) in relation to these morbidities, (3) investigated collective co-occurrence patterns, and (4) identified infant subgroups who share similar morbidity profiles using machine learning techniques.

RESULTS

First, we showed that, in line with pathophysiologic understanding, BPD and ROP have the highest pairwise correlation, followed by BPD and PH as well as BPD and mild cardiac defects. Second, we revealed that BPD exhibits only limited capacity in discriminating morbidity occurrence, despite its prevalence and clinical indication as a driver of comorbidities. Further, we demonstrated that structural and functional lung phenotyping did not exhibit higher association with morbidity severity than BPD. Lastly, we identified patient clusters that share similar morbidity patterns using machine learning in AIRR (n=6 clusters) and NEuroSIS (n=8 clusters).

CONCLUSIONS

By capturing correlations as well as more complex morbidity relations, we provided a comprehensive characterization of morbidity profiles at discharge, linked to shared disease pathophysiology. Future studies could benefit from identifying risk profiles to thereby develop personalized monitoring strategies.

TRIAL REGISTRATION

AIRR: DRKS.de, DRKS00004600, 28/01/2013. NEuroSIS: ClinicalTrials.gov, NCT01035190, 18/12/2009.

Risk Factors and Outcomes for Cerebral Palsy With Hypoxic-Ischemic Brain Injury Patterns Without Documented Neonatal Encephalopathy

BACKGROUND AND OBJECTIVES

Perinatal hypoxic-ischemic brain injury is a leading cause of term-born cerebral palsy, the most common lifelong physical disability. Diagnosis is commonly made in the neonatal period by the combination of neonatal encephalopathy (NE) and typical neuroimaging findings. However, children without a history of neonatal encephalopathy may present later in childhood with motor disability and neuroimaging findings consistent with perinatal hypoxic-ischemic injury. We sought to determine the prevalence of such presentations using the retrospective viewpoint of a large multiregional cerebral palsy registry.

METHODS

Patient cases were extracted from the Canadian Cerebral Palsy Registry with gestational age >36 weeks, an MRI pattern consistent with hypoxic-ischemic injury (HII, acute total, partial prolonged, or combined), and an absence of postnatal cause for HII. Documentation of NE was noted. Maternal-fetal risk factors, labor and delivery, neonatal course, and clinical outcome were extracted. Comparisons were performed using χ2 tests and multivariable logistic regression with multiple imputation. Propensity scores were used to assess for bias.

RESULTS

Of the 170 children with MRI findings typical for HII, 140 (82.4%, 95% confidence interval [CI] 75.7%-87.7%) had documented NE and 29 (17.0%, 95% CI 11.7%-23.6%) did not. The group without NE had more abnormalities of amniotic fluid volume (odds ratio [OR] 15.8, 95% CI 1.2-835), had fetal growth restriction (OR 4.7, 95% CI 1.0-19.9), had less resuscitation (OR 0.03, 95% CI 0.007-0.08), had higher 5-minute Apgar scores (OR 2.2, 95% CI 1.6-3.0), were less likely to have neonatal seizures (OR 0.004, 95% CI 0.00009-0.03), and did not receive therapeutic hypothermia. MRI was performed at a median 1.1 months (interquartile range [IQR] 0.67-12.8 months) for those with NE and 12.2 months (IQR 6.6-25.9) for those without (p = 0.011). Patterns of injury on MRI were seen in similar proportions. Hemiplegia was more common in those without documented NE (OR 5.1, 95% CI 1.5-16.1); rates of preserved ambulatory function were similar.

DISCUSSION

Approximately one-sixth of term-born children with an eventual diagnosis of cerebral palsy and MRI findings consistent with perinatal hypoxic-ischemic brain injury do not have documented neonatal encephalopathy, which was associated with abnormalities of fetal growth and amniotic fluid volume, and a less complex neonatal course. Long-term outcomes seem comparable with their peers with encephalopathy. The absence of documented neonatal encephalopathy does not exclude perinatal hypoxic-ischemic injury, which may have occurred antenatally and must be carefully evaluated with MRI.

All but Small: miRNAs from Wharton's Jelly-Mesenchymal Stromal Cell Small Extracellular Vesicles Rescue Premature White Matter Injury after Intranasal Administration

White matter injury (WMI) is a common neurological issue in premature-born neonates, often causing long-term disabilities. We recently demonstrated a key beneficial role of Wharton's jelly mesenchymal stromal cell-derived small extracellular vesicles (WJ-MSC-sEVs) microRNAs (miRNAs) in WMI-related processes in vitro. Here, we studied the functions of WJ-MSC-sEV miRNAs in vivo using a preclinical rat model of premature WMI. Premature WMI was induced in rat pups through inflammation and hypoxia-ischemia. Small EVs were purified from the culture supernatant of human WJ-MSCs. The capacity of WJ-MSC-sEV-derived miRNAs to decrease microglia activation and promote oligodendrocyte maturation was evaluated by knocking down (k.d) DROSHA in WJ-MSCs, releasing sEVs containing significantly less mature miRNAs. Wharton's jelly MSC-sEVs intranasally administrated 24 h upon injury reached the brain within 1 h, remained detectable for at least 24 h, significantly reduced microglial activation, and promoted oligodendrocyte maturation. The DROSHA k.d in WJ-MSCs lowered the therapeutic capabilities of sEVs in experimental premature WMI. Our results strongly indicate the relevance of miRNAs in the therapeutic abilities of WJ-MSC-sEVs in premature WMI in vivo, opening the path to clinical application.

On punctate white matter lesions in preterm infants: Is ultrasound diagnosis feasible?

OBJECTIVES

To observe hyperechoic nodular or punctate white matter lesions (HNPL) in a population of preterm infants using routine cranial ultrasound (cUS), to describe the characteristics of HNPL, and to compare them with punctate white matter lesions (PWML) detected in magnetic resonance imaging (MRI).

DESIGN

Retrospective observational single-center cohort study.

SETTING

Level 2B neonatal unit in France.

PATIENTS

307 infants born <33 weeks gestation undergoing routine cUS with a total of 961 cUS performed.

MAIN OUTCOME MEASURES

Description of lesions (HNPL/PWML): presence or absence, number, size, location, and structural distribution.

RESULTS

Among the 307 included infants, 63 (20.5%) had at least one cerebral lesion, with 453 HNPL for 63 infants. HNPL were numerous (more than three in 66.6% of cases), primarily grouped in clusters (76.2%), located near the lateral ventricles (96.8%), and measuring more than 2 mm (79%). HNPL were diagnosed on day 29 on average and persisted until term. Overall, 43 MRI were performed in 307 infants, on average 18.9 days after last cUS, in 21 of those the indication was presence of HPNL on cUS. Of these 21 MRI, 14/21 presented 118 PWML compared to 173 HNPL on cUS. In the remaining MRI (7/21), no PWML were detected compared to 47 HNPL on cUS.

CONCLUSIONS

In our population of 307 preterm infants, cUS allowed the diagnosis of HNPL, with a large similarity to PWML in MRI and a better sensitivity. But in the absence of data on inter-observer variability, we cannot exclude overdiagnosis of HNPL.

Predicting the effectiveness of drugs used for treating cardiovascular conditions in newborn infants

BACKGROUND

Cardiovascular support (CVS) treatment failure (TF) is associated with a poor prognosis in preterm infants.

METHODS

Medical charts of infants with a birth weight <1500 g who received either dopamine (Dp) or dobutamine (Db), were reviewed. Treatment response (TR) occurred if blood pressure increased >3rd centile for gestational age or superior vena cava flow was maintained >55 ml/kg/min, with decreased lactate or less negative base excess, without additional CVS. A predictive model of Dp and Db on TR was designed and the impact of TR on survival was analyzed.

RESULTS

Sixty-six infants (median gestational age 27.3 weeks, median birth weight 864 g) received Dp (n = 44) or Db (n = 22). TR occurred in 59% of the cases treated with Dp and 31% with Db, p = 0.04. Machine learning identified a model that correctly labeled Db response in 90% of the cases and Dp response in 61.4%. Sixteen infants died (9% of the TR group, 39% of the TF group; p = 0.004). Brain or gut morbidity-free survival was observed in 52% vs 30% in the TR and TF groups, respectively (p = 0.08).

CONCLUSIONS

New predictive models can anticipate Db but not Dp effectiveness in preterm infants. These algorithms may help the clinicians in the decision-making process.

IMPACT

Failure of cardiovascular support treatment increases the risk of mortality in very low birth weight infants. A predictive model built with machine learning techniques can help anticipate treatment response to dobutamine with high accuracy. Predictive models based on artificial intelligence may guide the clinicians in the decision-making process.

Changes in circMyt1l/rno-let-7d-5p/brain-derived neurotrophic factor. A damaged periventricular white matter damage model in neonatal rats

OBJECTIVES

To investigate the function of circMyt1l/rno-let-7d-5p/BDNF in the white matter damage of premature rats.

METHODS

Bioinformatic analysis was used to analyze the differential expression of circMyt1l and its interacting miRNAs and mRNAs in rats with periventricular white matter damage. Rats at postnatal day 3 had their right common carotid artery permanently ligated, and were then exposed for 2 h to 6 % O2, or sham surgery and exposure to normal O2 levels (sham). CircMyt1l and rno-let-7d-5p expression was detected and BDNF protein levels were analyzed at 24, 48, and 72 h post hypoxia-ischemia.

RESULTS

Bioinformatic analysis suggested that circMyt1l, rno-let-7d-5p and BDNF interact. CircMyt1l expression decreased significantly relative to the sham-operated rats (p<0.01) in an exposure time-dependent manner. Contrastingly, rno-let-7d-5p increased significantly relative to the sham-operated rats (p<0.01) in an exposure time dependent manner. BDNF protein levels decreased significantly relative to the sham-operated rats (p<0.05) in an exposure time dependent manner.

CONCLUSIONS

The expression levels of circMyt1l/rno-let-7d-5p/BDNF are interrelated in periventricular white matter damage. Decreased circMyt1l expression of promoted the effect of rno-let-7d-5p and decreased the level of its target, BDNF.

A Call for Early Detection of Cerebral Palsy

Cerebral palsy (CP) is the most common physical disability across the lifespan, but historically, CP has not been diagnosed before the age of 2 years. Barriers to early diagnosis ranged from lack of available biomarkers, absence of curative treatments, perceived stigma associated with a lifelong diagnosis, and a desire to rule out other diagnoses first. Most importantly, the fundamental question that remained was whether children would benefit from earlier detection and intervention given the paucity of research. However, evidence-based guidelines published in 2017 demonstrated that the General Movements Assessment, the Hammersmith Infant Neurological Examination, and neuroimaging can be combined with other elements such as a clinical history and standardized motor assessments to provide the highest predictive value for diagnosing CP as early as age 3 months in high-risk newborns. Implementation of these guidelines has been successful in decreasing the age at CP diagnosis, particularly in high-risk infant follow-up clinics with expertise in performing these assessments. Early detection of CP allows for clinical and research opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of improving developmental trajectories for children and their families. New guidelines and research are now being developed with a focus on early, targeted interventions that continue to be studied, along with global detection initiatives.

Neurodevelopmental Outcome and Neuroimaging of Very Low Birth Weight Infants from an Italian NICU Adopting the Family-Centered Care Model

BACKGROUND

Improvements in perinatal care have substantially decreased mortality rates among preterm infants, yet their neurodevelopmental outcomes and quality of life persist as a pertinent public health concern. Family-centered care has emerged as a holistic philosophy that promotes effective alliances among patients, families, and healthcare providers to improve the quality of care.

AIMS

This longitudinal prospective study aims to evaluate the neurodevelopmental outcomes and brain MRI findings in a cohort of preterm newborns admitted to a neonatal intensive care unit (NICU) adopting a family-centered care model.

METHODS

Very low birth weight (VLBW) infants admitted to the NICU of Modena between 2015 and 2020 were enrolled. Infants who underwent conventional brain magnetic resonance imaging (MRI) at term-equivalent age were included. Neurodevelopmental follow-up was performed until the age of 24 months by a multidisciplinary team using the Amiel-Tison neurological assessment and the Griffiths Mental Developmental Scales (GMDS-R). Neurodevelopmental outcomes were classified as major sequelae (cerebral palsy, DQ ≤ 70, severe sensory impairment), minor sequelae (minor neurological signs such as clumsiness or DQ between 71 and 85), and normal outcomes (no neurological signs and DQ > 85). Risk factors for severe outcomes were assessed.

RESULTS

In total, 49 of the 356 infants (13.8%) died before hospital discharge, and 2 were excluded because of congenital disorders. Of the remaining 305 infants, 222 (72.8%) completed the 24 month follow-up and were included in the study. Neurodevelopmental outcomes were classified as normal (n = 173, 77.9%), minor (n = 34, 15.3%), and major sequelae (n = 15, 6.8%). Among 221 infants undergoing brain MRI, 76 (34.4%) had major lesions (intraventricular hemorrhage, hemorrhagic parenchymal infarction, periventricular leukomalacia, and large cerebellar hemorrhage). In the multivariate regression model, the retinopathy of prematurity (OR 1.8; p value 0.016) and periventricular-intraventricular hemorrhage (OR 5.6; p value < 0.004) were associated with major sequelae.

CONCLUSIONS

We reported low rates of severe neurodevelopmental outcomes in VLBW infants born in an Italian NICU with FCC. Identifying the risk factors for severe outcomes can assist in tailoring and optimizing early interventions on an individual basis, both within the NICU and after discharge.

Lung UltrasouNd Guided surfactant therapy in preterm infants: an international multicenter randomized control trial (LUNG study)

BACKGROUND

The management of respiratory distress syndrome (RDS) in premature newborns is based on different types of non-invasive respiratory support and on surfactant replacement therapy (SRT) to avoid mechanical ventilation as it may eventually result in lung damage. European guidelines currently recommend SRT only when the fraction of inspired oxygen (FiO2) exceeds 0.30. The literature describes that early SRT decreases the risk of bronchopulmonary dysplasia (BPD) and mortality. Lung ultrasound score (LUS) in preterm infants affected by RDS has proven to be able to predict the need for SRT and different single-center studies have shown that LUS may increase the proportion of infants that received early SRT. Therefore, the aim of this study is to determine if the use of LUS as a decision tool for SRT in preterm infants affected by RDS allows for the reduction of the incidence of BPD or death in the study group.

METHODS/DESIGN

In this study, 668 spontaneously-breathing preterm infants, born at 25+0 to 29+6 weeks' gestation, in nasal continuous positive airway pressure (nCPAP) will be randomized to receive SRT only when the FiO2 cut-off exceeds 0.3 (control group) or if the LUS score is higher than 8 or the FiO2 requirements exceed 0.3 (study group) (334 infants per arm). The primary outcome will be the difference in proportion of infants with BPD or death in the study group managed compared to the control group.

DISCUSSION

Based on previous published studies, it seems that LUS may decrease the time to administer surfactant therapy. It is known that early surfactant administration decreases BPD and mortality. Therefore, there is rationale for hypothesizing a reduction in BPD or death in the group of patients in which the decision to administer exogenous surfactant is based on lung ultrasound scores.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05198375 . Registered on 20 January 2022.

Effect of different courses and durations of invasive mechanical ventilation on respiratory outcomes in very low birth weight infants

This multicenter retrospective study was conducted to explore the effects of different courses and durations of invasive mechanical ventilation (MV) on the respiratory outcomes of very low birth weight infants (VLBWI) in China. The population for this study consisted of infants with birth weight less than 1500 g needing at least 1 course of invasive MV and admitted to the neonatal intensive care units affiliated with the Chinese Neonatal Network within 6 h of life from January 1st, 2019 to December 31st, 2020. Univariate and multivariate logistic regression analyses were performed to evaluate associations between invasive MV and respiratory outcomes. Adjusted odds ratios (ORs) were computed with the effects of potential confounders. (1) Among the 3183 VLBWs with a history of at least one course of invasive MV, 3155 (99.1%) met inclusion criteria and were assessed for the primary outcome. Most infants received one course (76.8%) and a shorter duration of invasive MV (62.16% with ventilation for 7 days or less). (2) In terms of the incidence of all bronchopulmonary dysplasia (BPD) (mild, moderate, and severe BPD), there were no significant differences between different invasive MV courses [For 2 courses, adjusted OR = 1.11 (0.88, 1.39); For 3 courses or more, adjusted OR = 1.07 (0.72, 1.60)]. But, with the duration of invasive MV prolonging, the OR of BPD increased [8-21 days, adjusted OR = 1.98 (1.59, 2.45); 22-35 days, adjusted OR = 4.37 (3.17, 6.03); ≥ 36 days, adjusted OR = 18.44 (10.98, 30.99)]. Concerning severe BPD, the OR increased not only with the course of invasive MV but also with the duration of invasive MV [For 2 courses, adjusted OR = 2.17 (1.07, 4.40); For 3 courses or more, adjusted OR = 2.59 (1.02, 6.61). 8-21 days, adjusted OR = 8.42 (3.22, 22.01); 22-35 days, adjusted OR = 27.82 (9.08, 85.22); ≥ 36 days, adjusted OR = 616.45 (195.79, > 999.999)]. (3) When the interaction effect between invasive MV duration and invasive MV course was considered, it was found that there were no interactive effects in BPD and severe BPD. Greater than or equal to three courses would increase the chance of severe BPD, death, and the requirement of home oxygen therapy. Compared with distinct courses of invasive MV, a longer duration of invasive MV (> 7 days) has a greater effect on the risk of BPD, severe BPD, death, and the requirement of home oxygen therapy.

Acquired Brain Injuries Across the Perinatal Spectrum: Pathophysiology and Emerging Therapies

The development of the central nervous system can be directly disrupted by a variety of acquired factors, including infectious, inflammatory, hypoxic-ischemic, and toxic insults. Influences external to the fetus also impact neurodevelopment, including placental health, maternal comorbidities, adverse experiences, environmental exposures, and social determinants of health. Acquired perinatal brain insults tend to affect the developing brain in a stage-specific manner that reflects the susceptible cell types, developmental processes, and risk factors present at the time of the insult. In this review, we discuss the pathophysiology, neurodevelopmental outcomes, and management of common acquired perinatal brain conditions. In the fetal brain, we divide insults based on trimester, and in the postnatal brain, we focus on common pathologies that have a presentation dependent on gestational age at birth: white matter injury and germinal matrix hemorrhage/intraventricular hemorrhage in preterm infants and hypoxic-ischemic encephalopathy in term infants. Although specific treatments for fetal and newborn brain disorders are currently limited, we emphasize therapies in preclinical or early clinical phases of the development pipeline. The growing number of novel cell type- and stage-specific emerging therapies suggests that in the near future we may have a dramatically improved ability to treat acquired perinatal brain disorders and to mitigate the associated neurodevelopmental consequences.

[Recent research on the long-term neurodevelopmental outcomes of very preterm infants]

With the increase in the survival rate of very preterm infants, the long-term neurodevelopmental outcomes of such infants have attracted more and more attention. Very preterm infants tend to develop movement disorders and psychological and behavioral problems, including cerebral palsy, developmental coordination disorders, autism spectrum disorders, attention deficit hyperactivity disorders, specific learning disorders, and intellectual developmental disorders. It is of vital importance to improve the long-term prognosis of very preterm infants, and early comprehensive intervention measures can minimize disability and achieve optimal parenting outcomes. This article provides a review of the research progress on the long-term neurodevelopmental outcomes in extremely preterm infants.

Quantitative ultrasonographic examination of cerebral white matter by pixel brightness intensity as marker of middle-term neurodevelopment: a prospective observational study

Non-cystic white matter (WM) injury has become prevalent among preterm newborns and is associated with long-term neurodevelopmental impairment. Magnetic resonance is the gold-standard for diagnosis; however, cranial ultrasound (CUS) is more easily available but limited by subjective interpretation of images. To overcome this problem, we enrolled in a prospective observational study, patients with gestational age at birth < 32 weeks with normal CUS scans or grade 1 WM injury. Patients underwent CUS examinations at 0-7 days of life (T0), 14-35 days of life (T1), 370/7-416/7 weeks' postmenstrual age (T2), and 420/7-520/7 weeks' postmenstrual age (T3). The echogenicity of parieto-occipital periventricular WM relative to that of homolateral choroid plexus (RECP) was calculated on parasagittal scans by means of pixel brightness intensity and its relationship with Bayley-III assessment at 12 months' corrected age was evaluated. We demonstrated that: (1) Left RECP values at T1 negatively correlated with cognitive composite scores; (2) Right RECP values at T2 and T3 negatively correlated with language composite scores; (3) Left RECP values at T1 and T2 negatively correlated with motor composite scores. Thus, this technique may be used as screening method to early identify patients at risk of neurodevelopmental issues and promptly initiate preventive and therapeutic interventions.

Acute Diffusion-Weighted Imaging Signaling Severe Periventricular Leukomalacia in Preterm Infants: Case Report and Review of Literature

Introduction: Periventricular leukomalacia occurs in up to 25% of very preterm infants resulting in adverse neurodevelopmental outcomes. In its acute phase, periventricular leukomalacia is clinically silent. Although ultrasonography is widely available, its sensitivity in the early detection of periventricular leukomalacia is low. Case Report and Published Literature: We identified a preterm infant with early diffusion-weighted imaging changes that later evolved to periventricular leukomalacia. Thirty-two cases of abnormal diffusion-weighted imaging reliably heralding severe periventricular leukomalacia in the preterm infant have been published in the literature. Notable features include the following: (1) infants were more mature preterm infants (29-36 weeks' gestation); (2) findings were often serendipitous with benign clinical courses; (3) diffusion-weighted imaging changes only were evident in the first weeks of life with later evolution to more classical abnormalities on conventional magnetic resonance imaging (MRI) or ultrasonography. Conclusion: Diffusion-weighted imaging in the first week of life may be a reliable early marker of severe periventricular leukomalacia injury in more mature preterm infants.

The Prevalence of Small for Gestational Age and Extrauterine Growth Restriction among Extremely and Very Preterm Neonates, Using Different Growth Curves, and Its Association with Clinical and Nutritional Factors

Monitoring the growth of neonates in the Neonatal Intensive Care Unit (NICU) using growth charts constitutes an essential part of preterm infant care. Preterm infants are at increased risk for extrauterine growth restriction (EUGR) due to increased energy needs and clinical complications. This retrospective study compares the prevalence of small for gestational age (SGA) at birth and EUGR at discharge in extremely and very preterm neonates hospitalized in the NICU of a tertiary hospital in Greece, using different growth curves, and it examines the associated nutritional and clinical factors. Fenton2013 and INTERGROWTH-21st growth curves were used to calculate z-scores of birth weight (BW) and weight, length, and head circumference at discharge. The study includes 462 newborns with a mean BW of 1341.5 g and mean GA of 29.6 weeks. At birth, 6.3% of neonates were classified as SGA based on Fenton2013 curves compared to 9.3% with INTERGROWTH-21st growth curves. At discharge, 45.9% of neonates were characterized as having EUGR based on the Fenton2013 weight curves and 29.2% were characterized based οn INTERGROWTH-21st curves. Nutritional factors such as the day of initiation, attainment of full enteral feeding, and the duration of parenteral nutrition were associated with EUGR by both curves. The prevalence of SGA and EUGR neonates differs between the two growth references. This shows that further evaluation of these charts is needed to determine the most appropriate way to monitor infant growth.

Intrauterine desensitization enables long term survival of human oligodendrocyte progenitor cells without immunosuppression

Immune rejection can be reduced using immunosuppressants which are not viable for premature infants. However, desensitization can induce immune tolerance for premature infants because of underdeveloped immune system. The fetuses of Wistar rats at 15-17 days gestation were injected via hOPCs-1 into brain, muscles, and abdomen ex utero and then returned while the fetuses of control without injection. After 6 weeks of desensitization, the brain and muscles were transplanted with hOPCs-1, hNSCs-1, and hOPCs-2. After 10 and 34 weeks of desensitization, hOPCs-1 and hNSCs-1 in desensitized groups was higher than that in the control group while hOPCs-2 were rejected. Treg, CD4CD28, CD8CD28, and CD45RC between the desensitization and the control group differed significantly. Inflammatory cells in group with hOPCs-1 and hNSCs-1 was lower than that in the control group. hOPCs-1 can differentiate into myelin in desensitized groups. Wistar rats with desensitization developed immune tolerance to desensitized and transplanted cells.

White matter injury detection based on preterm infant cranial ultrasound images

Introduction

White matter injury (WMI) is now the major disease that seriously affects the quality of life of preterm infants and causes cerebral palsy of children, which also causes periventricular leuko-malacia (PVL) in severe cases. The study aimed to develop a method based on cranial ultrasound images to evaluate the risk of WMI.

Methods

This study proposed an ultrasound radiomics diagnostic system to predict the WMI risk. A multi-task deep learning model was used to segment white matter and predict the WMI risk simultaneously. In total, 158 preterm infants with 807 cranial ultrasound images were enrolled. WMI occurred in 32preterm infants (20.3%, 32/158).

Results

Ultrasound radiomics diagnostic system implemented a great result with AUC of 0.845 in the testing set. Meanwhile, multi-task deep learning model preformed a promising result both in segmentation of white matter with a Dice coefficient of 0.78 and prediction of WMI risk with AUC of 0.863 in the testing cohort.

Discussion

In this study, we presented a data-driven diagnostic system for white matter injury in preterm infants. The system combined multi-task deep learning and traditional radiomics features to achieve automatic detection of white matter regions on the one hand, and design a fusion strategy of deep learning features and manual radiomics features on the other hand to obtain stable and efficient diagnostic performance.

Ultrasonographic evaluation of the early brain growth pattern in very low birth weight infants

BACKGROUND

Preterm infants develop smaller brain volumes compared to term newborns. Our aim is to study early brain growth related to perinatal factors in very low birth weight infants (VLBWI).

METHODS

Manual segmentation of total brain volume (TBV) was performed in weekly 3D-ultrasonographies in our cohort of VLBWI. We studied the brain growth pattern related to term magnetic resonance image (term-MRI).

RESULTS

We found different brain growth trajectories, with smaller brain volumes and a decrease in brain growth rate in those VLBWI who would later have an abnormal term-MRI (mean TBV 190.68 vs. 213.9 cm3; P = 0.0001 and mean TBV growth rate 14.35 (±1.27) vs. 16.94 (±2.29) cm3/week; P = 0.0001). TBV in those with normal term-MRI was related to gestational age (GA), being small for gestational age (SGA), sex, and duration of parenteral nutrition (TPN) while in those with abnormal term-MRI findings it was related to GA, SGA, TPN, and comorbidities. We found a deceleration in brain growth rate in those with ≥3 comorbidities.

CONCLUSIONS

An altered brain growth pattern in VLBWI who subsequently present worst scores on term-MRI is related to GA, being SGA and comorbidities. Early ultrasonographic monitoring of TBV could be useful to detect deviated patterns of brain growth.

IMPACT STATEMENT

We describe the brain growth pattern in very low birth weight infants during their first postnatal weeks. Brain growth may be affected in the presence of certain perinatal factors and comorbidities, conditioning a deviation of the normal growth pattern. The serial ultrasound follow-up of these at-risk patients allows identifying these brain growth patterns early, which offers a window of opportunity for implementing earlier interventions.

The association of γδT lymphocytes with cystic leukomalacia in premature infants

Background

Periventricular leukomalacia (PVL) is an essential cause of cerebral palsy in preterm infants, and cystic PVL (cPVL) is the most severe form of the disease. The pathogenesis of cPVL is complex, and immune imbalances and inflammatory responses may play an essential role in it.

Objective

This study aimed to investigate the correlation between peripheral blood lymphocyte subsets, especially γδT cells with the pathogenesis of cPVL in preterm infants.

Methods

Peripheral blood from preterm infants with GA < 32 weeks and BW < 1,500 g was used in this study and was collected at 34 weeks corrected gestational age and within 24 h after the diagnosis with cranial MRI or cranial ultrasound. The infants were divided into cPVL groups and control groups. Flow cytometry was used to detect peripheral blood γδT, CD3+, CD4+, CD8+, and the proportion of total lymphocytes. Multiplex cell assays were used to detect the concentration of extracellular serum cytokines IL-6, IL-2, IL-8, IL-17A, IL-10, IL-1RA, eotaxin (CCL11), MCP-1 (CCL2), CXCL1, G-CSF, and IFNγ. A follow-up visit was carried out when the patient was 3 years old.

Results

After correcting for confounding factors, the proportion of peripheral blood γδT in the cPVL group was significantly lower than that in the control group (β: 0.216; 95% CI: 0.058-0.800, P < 0.022). Peripheral blood γδT (AUC: 0.722, P=0.006) and multivariate binary regression model (AUC: 0.865, P < 0.000) have good diagnostic values for cPVL. Peripheral blood γδT has some predictive power for neurodevelopmental outcomes in preterm infants (AUC: 0.743, P = 0.002).

Conclusion

It seems that peripheral blood γδT cells are inversely correlated with cPVL, which is not only a risk factor for cPVL disease but also neurodevelopmental outcomes in preterm infants. However, the causality of cPVL and various lymphocytes is unclear and needs further study.

Optimizing timing and frequency of head ultrasound screening for severe brain injury among preterm infants born <32 weeks' gestation

OBJECTIVE

To develop a head ultrasound (HUS) screening protocol for infants born <32 weeks gestational age (GA) that accurately identifies severe brain injury (SBI) while minimizing resource use.

STUDY DESIGN

Retrospective cohort study of infants born <32 weeks GA, admitted to a level 3 neonatal intensive care unit between 2011 and 2017. Timing and results of each HUS were reviewed. SBI was defined as intraventricular hemorrhage grade ≥3 and/or periventricular leukomalacia. Logistic regression models were used to identify risk factors and evaluate the predictive value of HUS at different time points during hospitalization.

RESULTS

Of 651 included infants, 71 (11%) developed SBI. Risk factors for SBI were GA at birth <29 weeks (adjusted odds ratio (aOR) 2.87, 95% confidence interval (CI) 1.50-5.48), vasopressors on admission (aOR 3.08, 95%CI 1.38-6.88) and mechanical ventilation on admission (aOR 2.50, 95%CI 1.33-4.68). Infants were classified into three risk groups based on these risk factors, and combinations of 1-5 HUS time points were evaluated to determine the optimal number and timing of HUS for each group. The optimal number of screening HUS ranged from 1 for low-risk to 2 for high-risk infants. Adopting a screening protocol using the number and timing of HUS optimized by risk group could reduce the total number of HUS performed by 40% and the median number of HUS per infant from 3 (IQR 2-4) to 2 (IQR 1-3) (p < .01).

CONCLUSIONS

Implementation of a risk factor-based HUS screening protocol can help reduce resource use while maintaining high sensitivity for detecting SBI.

Posthemorrhagic ventricular dilatation late intervention threshold and associated brain injury

OBJECTIVE

To systematically assess white matter injury (WMI) in preterm infants with posthemorrhagic ventricular dilatation (PHVD) using a high-threshold intervention strategy.

STUDY DESIGN

This retrospective analysis included 85 preterm infants (≤34 weeks of gestation) with grade 2-3 germinal matrix-intraventricular hemorrhage. Cranial ultrasound (cUS) scans were assessed for WMI and ventricular width and shape. Forty-eight infants developed PHVD, 21 of whom (intervention group) underwent cerebrospinal fluid drainage according to a predefined threshold (ventricular index ≥p97+4 mm or anterior horn width >10 mm, and the presence of frontal horn ballooning). The other 27 infants underwent a conservative approach (non-intervention group). The two PHVD groups were compared regarding ventricular width at two stages: the worst cUS for the non-intervention group (scans showing the largest ventricular measurements) versus pre-intervention cUS in the intervention group, and at term equivalent age. WMI was classified as normal/mild, moderate and severe.

RESULTS

The intervention group showed significantly larger ventricular index, anterior horn width and thalamo-occipital diameter than the non-intervention group at the two timepoints. Moderate and severe WMI were more frequent in the infants with PHVD (p<0.001), regardless of management (intervention or conservative management). There was a linear relationship between the severity of PHVD and WMI (p<0.001).

CONCLUSIONS

Preterm infants with PHVD who undergo a high-threshold intervention strategy associate an increased risk of WMI.

PGC-1α activity and mitochondrial dysfunction in preterm infants

Extremely low gestational age neonates (ELGANs) are born in a relatively hyperoxic environment with weak antioxidant defenses, placing them at high risk for mitochondrial dysfunction affecting multiple organ systems including the nervous, respiratory, ocular, and gastrointestinal systems. The brain and lungs are highly affected by mitochondrial dysfunction and dysregulation in the neonate, causing white matter injury (WMI) and bronchopulmonary dysplasia (BPD), respectively. Adequate mitochondrial function is important in providing sufficient energy for organ development as it relates to alveolarization and axonal myelination and decreasing oxidative stress via reactive oxygen species (ROS) and reactive nitrogen species (RNS) detoxification. Peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1α) is a master regulator of mitochondrial biogenesis and function. Since mitochondrial dysfunction is at the root of WMI and BPD pathobiology, exploring therapies that can regulate PGC-1α activity may be beneficial. This review article describes several promising therapeutic agents that can mitigate mitochondrial dysfunction through direct and indirect activation and upregulation of the PGC-1α pathway. Metformin, resveratrol, omega 3 fatty acids, montelukast, L-citrulline, and adiponectin are promising candidates that require further pre-clinical and clinical studies to understand their efficacy in decreasing the burden of disease from WMI and BPD in preterm infants.