SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores

Adverse events associated with umbilical vascular catheters in neonatal intensive care: Development of a risk prediction model

BACKGROUND

Adverse events associated with umbilical vascular catheters occur frequently in the neonatal intensive care unit. International guidelines recommend limiting catheter dwell time to reduce the risk of adverse events, and this drives clinical decision-making regarding catheter removal, yet other risk factors may also influence the risk of adverse events.

OBJECTIVES

The aim of this study was to develop a clinically useful risk prediction model that could be utilised in the neonatal intensive care unit to identify infants at a greater risk of developing an adverse event associated with umbilical vascular catheters.

METHODS

A risk prediction model was developed for the umbilical venous catheter and umbilical arterial catheter based on the dataset of a published retrospective cohort study in a South Australian neonatal intensive care unit. Least absolute shrinkage and selection operator regression was used to develop the model. Deviance was used to evaluate the model's goodness of fit, and the Hosmer-Lemeshow test and calibration plot were used to assess calibration. The area under the receiver operating characteristic curve evaluated the model's discrimination.

RESULTS

For adverse events associated with umbilical venous catheters, the least absolute shrinkage and selection operator model selected none of the potential predictor variables. Five predictors of adverse events were identified for umbilical arterial catheters: thrombocytopaenia, intrauterine growth restriction/small for gestational age, congenital heart disease/defects including patent ductus arteriosus, maternal diabetes, and a dwell time of >7 days. The area under the receiver operating characteristic curve was 0.68 (95% confidence interval: 0.61-0.74). A link test found that the model was properly specified, and a Hosmer-Lemeshow test demonstrated that the model was well calibrated (p = 0.104).

CONCLUSIONS

A risk prediction model has been developed to identify infants at a greater risk of an adverse event associated with umbilical arterial catheters. The model needs to be externally validated before it can be implemented into clinical practice.

Outcomes of Patent Ductus Arteriosus Closure by Availability of Cardiac Surgeons for Infants Born Preterm

OBJECTIVE

To evaluate the treatment strategies for closure of patent ductus arteriosus (PDA) and clinical outcomes among very preterm infants based upon the availability of cardiac surgeons in neonatal intensive care units (NICUs).

STUDY DESIGN

This study retrospectively assessed infants born at 23-29 weeks of gestation who participated in a prior prospective cohort study in Japan. The primary outcome was PDA surgery. The secondary outcomes included mortality and various morbidities, such as intraventricular hemorrhage and chronic lung disease (CLD). Outcomes were compared between with-surgeon and no-surgeon NICUs using generalized linear mixed effect models, adjusted for gestational age, antenatal corticosteroid, small-for-gestational age, and unit patient volume.

RESULTS

This study included 613 infants from 27 NICUs, including 245 from 9 no-surgeon NICUs and 368 from 18 with-surgeon NICUs. Infants received significantly more prophylactic indomethacin in the no-surgeon NICUs than those in the with-surgeon NICUs. The frequency of PDA surgery showed no significant difference between the groups (9.0% vs 12%, adjusted odds ratio [aOR]: 0.56 [95% confidence interval: 0.21-1.51]). CLD was significantly more frequent in no-surgeon NICUs than in with-surgeon NICUs (55% vs 40%, aOR: 3.24 [95% CI 1.45-7.29]).

CONCLUSIONS

The frequency of PDA surgery did not differ significantly according to the availability of surgeons. The incidence of CLD was higher in no-surgeon NICUs; however, the risk of unmeasured confounding cannot be excluded due to the observational study design.

Sex-differences in Mothers' own milk and neurodevelopmental outcomes in preterm infants

Objective

To identify sex-specific feeding patterns and associations with growth and neurodevelopment in preterm infants during NICU through 2 years of corrected age (CA).

Methods

A cohort study was conducted with 216 preterm infants (gestational age 28 0/7 to 32 0/7 weeks). Daily feeding regimens, including mother's own milk (MOM), human donor milk, and formula; daily growth; acute and chronic pain/stress were documented during NICU. NICU Network Neurobehavioral Scale (NNNS) (36 to 38 postmenstrual age), and Bayley Scales of Infant and Toddler Development (Bayley) Edition III (1 and 2 years of CA) were measured.

Results

Between week 9 to 16 after birth, only females showed a positive association between growth z-score and proportion of MOM intake before week 8 (p < 0.05). Sex-differentiated associations between MOM and stress were observed (p < 0.05). MOM proportion was positively correlated with language or cognitive scores at 2 years of CA in females (p = 0.01), this correlation not evident in males.

Conclusions

We discovered a sex-specific "window of opportunity" for feeding, growth and risk predictors for neurodevelopment up to 2 years of CA. These insights may inform development of tailored feeding regimens, potentially mitigating growth and development differences observed between males and females.

Association of Enteral Feed Type with Neurodevelopmental and Neonatal Outcomes among Infants Born Preterm

OBJECTIVE

To examine associations between enteral feed type with neurodevelopmental and neonatal outcomes among infants born preterm.

STUDY DESIGN

This was a retrospective study of enteral feeds in the first 28 postnatal days in infants born <29 weeks of gestation from 2015 through 2020 in neonatal units of the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network. Feeds were examined as a compositional variable comprised of the proportion of days fed mother's milk, donor milk, mixed feeds, and nil per os (NPO), the proportions of which sum to 1. Associations between enteral feed type with neurodevelopmental outcomes at 18 to 24 months of corrected age and neonatal morbidities were examined.

RESULTS

Our cohort included 2104 infants with a mean (SD) gestational age of 26.2 (1.5) weeks (52.9% male). Compositional data analysis revealed a 1-day reallocation from mother's milk to donor milk was associated with greater odds of cognitive (aOR 1.028, 95% CI 1.001-1.056) and language impairment (aOR 1.024, 95% CI 1.002-1.047). Replacing 1 day of mixed feeds, donor milk or NPO with mother's milk was associated with improved cognitive, language and motor development. A 1-day reallocation of NPO to either mother's milk, mixed feeds or donor milk decreased odds of significant neurodevelopmental impairment, cerebral palsy and/or necrotizing enterocolitis.

CONCLUSIONS

Donor milk in place of mother's milk was associated with poorer cognitive and language development. Providing any human milk reduced neurodevelopmental impairment and necrotizing enterocolitis with reallocations involving mother's milk yielding the most benefit. Promoting early enteral nutrition with mother's milk should be a priority in the care of infants born preterm.

Energy Utilization in Premature Neonates Undergoing Screening for Retinopathy of Prematurity

BACKGROUND/OBJECTIVES

Premature neonates are at risk for retinopathy of prematurity (ROP) and routinely undergo screening exams that involve substantial physical manipulation, often causing significant signs of pain, despite pain-relieving interventions. It remains unclear whether these exams affect energy utilization, cellular hypoxia, and clinically significant events, and whether receiving supplemental oxygen affects these relationships. This work examines the effects of ROP screening on (1) urinary uric acid-to-creatinine concentration ratios ([UA]/[Cr]), a known marker of ATP degradation, hypoxia, and oxidative stress; and (2) clinically significant events (apnea, bradycardia, gastric residuals, and oxygen desaturations) in premature neonates on room air or oxygen support.

METHODS

This prospective pilot study included premature neonates requiring ROP screening examinations at Loma Linda University's NICU. Urinary [UA]/[Cr], measured by high-performance liquid chromatography, and clinical events, documented by prospective medical chart review, were analyzed pre- and post-exam in subjects on room air (n = 18) or on oxygen support (n = 20). Statistical analyses included a generalized linear mixed model for urinary [UA]/[Cr] and Wilcoxon signed rank tests for clinical events.

RESULTS

A significant time effect (p = 0.010) was observed for urinary [UA]/[Cr], with higher levels at 0-12 (p = 0.023) and 12-24 (p = 0.023) hours post-exam. Subjects receiving oxygen support had more total (p = 0.028) and more severe (p = 0.026) oxygen desaturations.

CONCLUSIONS

ROP examinations may increase energy utilization in premature neonates, with those receiving oxygen support being particularly susceptible to oxygen desaturations post-exam. Further research is needed to clarify the full impact of the procedure and to identify strategies to minimize stress associated with these screening examinations.

Effectiveness and Risks of Probiotics in Preterm Infants

OBJECTIVE

To evaluate the effectiveness and risks of probiotics among infants born before 34 weeks' gestation and with a birth weight less than 1000 g.

METHODS

A population-based retrospective cohort study of infants born before 34 weeks' gestation and admitted to 33 Canadian Neonatal Network (CNN) units between January 1, 2016, and December 31, 2022. We excluded infants who were moribund on admission, died within the first 2 days, were admitted to CNN sites more than 2 days after birth, had major congenital anomalies, or never received enteral feeds. Logistic regression, propensity score-matched, and inverse probability of treatment weighting analyses were applied.

RESULTS

Among 32 667 eligible infants born before 34 weeks' gestation, 18 793 (57.5%) (median [IQR] gestational age, 29 [27-31] weeks) received probiotics, and 13 874 (42.5%) (median [IQR] gestational age, 31 [29-33] weeks) did not receive probiotics. In these infants, probiotics were associated with decreased mortality rates (adjusted odds ratio [aOR], 0.62; 98.3% CI, 0.53-0.73) but not decreased rates of necrotizing enterocolitis (NEC) (aOR, 0.92; 98.3% CI, 0.78-1.09) or late-onset sepsis (aOR, 0.90; 98.3% CI, 0.80-1.01). In 7401 infants with a birth weight less than 1000 g, probiotics were associated with decreased mortality rates (aOR, 0.58; 98.3% CI, 0.47-0.71) but not decreased NEC (aOR, 0.90; 98.3% CI. 0.71-1.13) or late-onset sepsis rates (aOR, 1.01; 98.3% CI, 0.86-1.18). Probiotic sepsis occurred in 27 (1.4/1000) infants born before 34 weeks' gestation and 20 (4/1000) infants with a birth weight less than 1000 g. Three infants with probiotic sepsis died, with probiotic sepsis deemed a possible cause in 2 cases.

CONCLUSION

Probiotics used in Canadian neonatal units were associated with decreased mortality in infants born before 34 weeks' gestation and with a birth weight less than 1000 g with limited effects on NEC and late-onset sepsis. Probiotic sepsis was rare.

Outcomes of Preterm Infants Admitted to Canadian NICUs Before and During the SARS-COV Pandemic

BACKGROUND

To better elucidate the impact of the SARS-COV pandemic on neonatal outcomes, we compared the health outcomes of infants born preterm requiring care in a Canadian NICU before and during the SARS-COV pandemic.

METHODS

Using a retrospective cohort study, infants born between 23 and 32 weeks gestation who were admitted to tertiary Canadian NICUs before and during the pandemic were included. A total of 7280 infants were in the pre-pandemic cohort (admitted 1 April 2018-31 December 2019), and 7088 infants were in the pandemic cohort (admitted 1 April 2020-31 December 2021). The primary outcomes included major morbidity or mortality rates. Care strategies and treatments were compared across the two periods. The relative risk (RR) for the pandemic period, compared to the pre-pandemic period, was calculated using a Poisson regression model, adjusted for identified risk factors.

RESULTS

There were no significant differences in infant characteristics between the pre-pandemic and pandemic cohorts. The risk of mortality or major morbidity was comparable before and during the pandemic (37% pre-pandemic, 36% pandemic; RR = 1.01, 95% CI 0.92, 1.01). Individual risks for morbidity and mortality did not differ significantly between periods. There was a clinically significant decline in the receipt of the mothers' own milk exclusively at discharge during the pandemic (45% before and 37% during; RR 0.85, 95% CI 0.68, 1.06).

CONCLUSIONS

There were no significant differences in major morbidity or mortality rates in preterm infants between pre-pandemic and pandemic cohorts in Canadian NICUs.

Explore the factors related to the death of offspring under age five and appraise the hazard of child mortality using machine learning techniques in Bangladesh

BACKGROUND

Child mortality is a reliable and significant indicator of a nation's health. Although the child mortality rate in Bangladesh is declining over time, it still needs to drop even more in order to meet the Sustainable Development Goals (SDGs). Machine Learning models are one of the best tools for making more accurate and efficient forecasts and gaining in-depth knowledge. A deeper understanding is crucial for significantly reducing child mortality rates. Accurate predictions using machine learning models can empower authorities to implement timely interventions and raise awareness. So, the study aimed to explore the factors related to child mortality and assess the efficacy of various machine-learning models in predicting child mortality in Bangladesh.

METHODS AND MATERIALS

About Forty-two thousand observations, except the missing observations, were extracted for this study from the Bangladesh Demographic and Health Survey (BDHS) data conducted in 2017-18. The survey utilized a two-stage stratified sampling method, selecting 675 enumeration areas-250 in urban settings and 425 in rural areas-resulting in effective data collection from 672 clusters and 20160 households. The Chi-square test and recursive feature elimination (RFE) are used to find the relevant risk factors of child mortality among the number of factors. Six ML-based algorithms were implemented for predicting child mortality, such as Naïve Bayes, Classification and Regression Trees, Random Forest, C5.0 Classification, Gradient Boosting Machine, and Logistic Regression. Model evaluation metrics like accuracy, specificity, sensitivity, negative predictive value, F 1 score, positive predictive value, k-fold cross-validation, and area under the curve (AUC) techniques were used to evaluate the performance of the models.

RESULTS AND DISCUSSION

The child mortality rate is 8.2%, according to the data. The bivariate analysis showed that the child mortality rate was higher among the children whose mothers were uneducated, impoverished, underweight, aged 35-49, and gave birth before age 20. Families' water sources and religious connections had no statistically significant impact on child mortality. The prediction of child mortality using machine learning models is the main objective of this study. None of the machine learning models correctly classified dead occurrences. Therefore, this study conducted over-sampling and under-sampling analysis. Approximately 76727 and 6910 observations were sampled for over-sampling and under-sampling techniques, respectively. According to the findings of the over-sampling data, the Random Forest outperformed all the other models in terms of total performance based on training and testing sets, with an accuracy of seventy percent. The k-fold cross-validation approach demonstrated the Random Forest model's superior performance, and achieved the highest AUC (0.701). On the other hand, the Gradient Boosting Machine has the highest assessment for predicting child mortality in under-sampling analysis. The k-fold cross-validation also illustrated the better performance of the Gradient Boosting Machine.

CONCLUSION

The Gradient Boosting Machine and Random Forest produce the best predictive power for classifying child mortality and may help to ameliorate policy decision-making in this regard.

Short and mid-term neonatal outcomes in high-risk infants undergoing FICare: a case control study

BACKGROUND

FICare model has been evaluated mostly on the stable preterm infant.We have scaled the model to two implementation levels(basic/advanced),making it suitable for all high-risk neonates.We report on the short- and mid-term outcomes of infants enrolled in a pilot on FICare implementation at our NICU.

METHODS

During 52 months study period,families were invited to join the program if their newborns' admission required neonatal specialized care for at least 3 weeks,and trained according to the program's curricula.Following a rigorous sequential admission order,each case(FICare group:134 < 34 weeks;52 term newborns)was matched by a contemporary control(CC:134 < 34 weeks;52 term newborns)and 2 historical controls born within the 3 years prior to FICare site implementation(HC:268 < 34 weeks;104 term newborns),cared as usual RESULTS: FICare intervention started by the end of first week of postnatal life.Rates of breastfeeding during admission and at discharge,and direct breastfeeding upon discharge were higher in FICare compared to CC and HC.Duration of intermediate care hospitalization(preterm and term cohorts)and total hospital length of stay (term cohorts)were shorter in FICare group.Use of Emergency Services after discharge was also lower in the FICare group CONCLUSIONS: Short and mid-term efficacy of FICare on health outcomes and family empowerment in a broader and highly-vulnerable neonatal population supports its generalization in complex healthcare neonatal services.

IMPACT STATEMENT

Scaling the FICare model to the critically ill, unstable premature and term infant is feasible and safe. The early intervention shows similar benefits in the short- and mid-term infants' outcomes in the whole spectrum of neonatal specialized care.

Noninvasive Respiratory Support or Intubation during Stabilization after Birth and Neonatal and Neurodevelopmental Outcomes in Infants Born Preterm at 23-25 Weeks of Gestation

OBJECTIVE

To examine the association between noninvasive respiratory support (NRS) or tracheal intubation (TI) during stabilization in infants born at 23-25 weeks of gestation and severe brain injury (sBI) or death, and significant neurodevelopmental impairment (sNDI).

STUDY DESIGN

A retrospective cohort study of infants born at 23°/7-256/7 weeks of gestation in Canada. We compared infants successfully managed with NRS or TI during 30 minutes after birth. The primary outcomes were sBI or death before discharge, and sNDI among survivors with follow-up data at 18-24 months corrected age. The associations between exposures and outcomes were assessed using logistic regression models, and propensity score-matched analyses.

RESULTS

The mean (SD) of gestational age and birth weight were 24.6 (0.6), 24.3 (0.7) weeks [P < .01], and 757 (173), 705 (130) grams [P < .01] in the NRS, and tracheal intubation (TI) groups, respectively, and 77% of infants in the NRS group were intubated by 7 days of age. sBI or death occurred in 25% (283/1118), and 36% (722/2012) of infants in the NRS and TI groups, respectively (aOR and 95% CI 0.74 [0.60, 0.91]). Among survivors with follow-up data, sNDI occurred in 17% (96/551), and 23% (218/937) of infants in the NRS and TI groups, respectively (aOR [95% CI] 0.77 [0.60, 0.99]). In the propensity score-matched analyses (NRS vs TI), results were consistent for sBI or death (OR [95% CI] 0.72 [0.60, 0.86]), but not for sNDI (OR [95% CI] 0.78 [0.58, 1.05]).

CONCLUSIONS

Infants born at 23-25 weeks who were successfully managed with NRS, compared with TI, in the first 30 minutes after birth had lower odds of sBI or death before discharge, but had no significant differences in neurodevelopmental outcomes among survivors.

Maternal Diabetes and Neurodevelopmental Outcomes of Infants Born Before 29 Weeks' Gestation

OBJECTIVE

To compare the neurodevelopmental outcomes of infants born at <29 weeks' gestation and exposed to diabetes in pregnancy with those unexposed.

STUDY DESIGN

This was a retrospective cohort study using the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network databases. Infants born <29 weeks' gestation and admitted to a level 3 neonatal intensive care unit from 2009 through 2018 who had neurodevelopmental assessments at 18-24 months corrected age were eligible. The 2 primary outcomes were as follows: (1) Neurodevelopmental impairment (NDI) (≥1 of Bayley-III scores < 85 in any domain, cerebral palsy, or vision or hearing impairment); and (2) significant NDI (sNDI) (≥1 of Bayley-III scores < 70 in any domain, cerebral palsy Gross Motor Function Classification System ≥ 3, bilateral blindness, or need for hearing aids or cochlear implants). Secondary outcomes were the individual components of NDI and sNDI. Adjusted odds ratios with 95% CIs were calculated to determine outcomes between groups.

RESULTS

Of 13 988 eligible infants, 55% attended neurodevelopmental follow-up assessments. Infants exposed to diabetes had increased odds of NDI compared with those unexposed (aOR 1.09 (95% CI 1.08-1.54); there was no difference in sNDI (aOR 1.07 (95% CI 0.84-1.36). Language and motor delays were more common in those exposed to maternal diabetes.

CONCLUSIONS

Higher rates of NDI, language, or motor delays were present in infants born at <29 weeks' gestation exposed to diabetes in utero. Future research is needed to determine the etiology and clinical significance of these findings.

The Physiological Impact of Neonatal Air Transport: A Review of The Literature

OBJECTIVE

This review aims to enhance our understanding around whether neonatal air transport has an adverse physiological impact on patients.

METHODS

A literature search included articles describing both ground and air transport. Eligible studies had to include patient outcome and/or response to the journey in such a way that the physiological impact of neonatal transport could be compared between the 2 groups.

RESULTS

The search produced 13 eligible studies. Six were prospective observational cohort studies, and the remainder were retrospective. When assessing outcome, studies used a physiological stability score, the rate and severity of intraventricular hemorrhage, the type and frequency of clinical interventions during the journey, or a specific clinical parameter. Three of the studies sought to understand the physiological impact of transport by investigating the variation in the physical forces experienced.

CONCLUSION

The current published evidence does not suggest one mode of transport is preferable to another when considering patient stability and outcome. Neonatal fixed wing or helicopter transport has not been shown to be more physiologically challenging for the patient than road transport, even by teams who are regularly flying patients in the highest-risk groups (extremely preterm, in the first hours of life).

Mortality Prediction in Newborns With Persistent Pulmonary Hypertension: A Comparison of Four Illness Severity Scores

OBJECTIVE

This study aimed to compare the accuracy of four neonatal illness severity scores for predicting mortality in persistent pulmonary hypertension of the newborn (PPHN).

STUDY DESIGN

This retrospective study included neonates diagnosed with PPHN between 2013 and 2022. The illness severity scores of four commonly used tools were completed for each infant: the Clinical Risk Index for Babies-II (CRIB-II), the Score for Neonatal Acute Physiology-Perinatal Extension version II (SNAPPE-II) in the first 12 h after admission and maximum oxygenation index (OI) and Vasoactive-Inotropic score (VIS) during the first 24 h (OI24max and VIS24max), 48 h (OI48max and VIS48max), and 72 h (OI72max and VIS72max) after admission. We constructed a receiver operating characteristic (ROC) curve to assess the discrimination and accuracy of the scores and determine the cutoff values for predicting mortality.

RESULTS

We enrolled 146 neonates (131 survivors and 15 nonsurvivors). The CRIB-II, SNAPPE-II, maximum OI, and VIS were significantly higher in nonsurvivors than in survivors. An OI72max score of 41 showed the highest accuracy in predicting mortality (area under the ROC curve [AUC] of 0.88) with an OI48max score of 31 (AUC: 0.86) and VIS72max score of 430 (AUC: 0.80) showing good accuracy. The best CRIB-II and SNAPPE-II cutoff scores for predicting mortality were 4 (AUC: 0.74) and 32 (AUC: 0.84), respectively.

CONCLUSIONS

The most accurate illness severity score for predicting mortality was OI72max score of 41. However, the OI48max, SNAPPE-II, and VIS72max scores also showed good accuracy. Mortality prediction using these scores can guide early management and close monitoring.

Neonatal Sepsis: A Comprehensive Review

Neonatal sepsis remains a significant cause of neonatal morbidity and mortality globally. At present, no clear consensus definition for sepsis in neonates exists, even though a positive blood culture is considered as the gold standard for definitive diagnosis. The accurate and timely diagnosis of sepsis in neonates presents significant difficulties, since "culture negative" or "suspected" sepsis varies widely worldwide. Antibiotic overuse and resistance are emerging problems, but on the other hand, under-recognition of sepsis and delayed antibiotic treatment could have serious or even fatal adverse outcomes in this vulnerable population. In the context of rapid recognition of sepsis and timely initiation of appropriate antibiotic therapy, various sepsis risk assessment tools have been developed, a variety of biomarkers are in clinical use or under research for future use, and new diagnostic techniques are under evaluation. In this review, we summarize the most recent data on neonatal sepsis, the utility of sepsis risk assessment tools for term and preterm infants with sepsis, and current diagnostic and preventive tools.

Neonatal death prediction scores: a systematic review and meta-analysis

OBJECTIVE

To compare, through a systematic review and meta-analysis of observational accuracy studies, the main existing neonatal death prediction scores.

METHOD

Systematic review and meta-analysis of observational accuracy studies. The databases accessed were MEDLINE, ELSEVIER, LILACS, SciELO, OpenGrey, Open Access Thesis and Dissertations, EMBASE, Web of Science, SCOPUS and Cochrane Library. For qualitative analysis, Quality Assessment of Diagnostic Accuracy Studies 2 was used. For the quantitative analysis, the area under the curve and the SE were used, as well as the inverse of the variance as a weight measure, DerSimonian and Laird as a measure of random effects, Higgins' I² as an estimate of heterogeneity, Z as a final measure with a 95% confidence level.

RESULTS

55 studies were analysed, 8 scores were compared in a total of 193 849 newborns included. The most accurate neonatal death prediction score was Score for Neonatal Acute Physiology Perinatal Extension II (SNAPPE II) (0.89 (95% CI 0.86 to 0.92)) and the least accurate was gestational age (0.75 (95% CI 0.71 to 0.79)).

CONCLUSION

SNAPPE II was the most accurate score found in this study. Despite this, the choice of score depends on the situation and setting in which the newborn is inserted, and it is up to the researcher to analyse and decide which one to use based on practicality and the possibility of local implementation. Given this, it is interesting to carry out new prospective studies to improve the prediction of neonatal deaths around the world.

PROSPERO REGISTRATION NUMBER

CRD42023462425.

Predictors of outcomes in infants with gastroschisis treated with a preformed silo

PURPOSE

To describe the outcomes of infants with gastroschisis treated with a preformed silo (PFS) and determine whether routinely measured early physiological parameters, sepsis (blood culture positive), gastroschisis complexity or location of birth influenced the length of stay (LOS) and duration of parenteral nutrition (PN).

METHODS

Infants cared for in a tertiary surgical neonatal intensive care unit during a 10-year period were identified.

RESULTS

Seventy-seven infants were assessed [median gestational age 36 + 6 (IQR 35 + 3 to 38 + 0)] weeks. All survived; 82% were inborn. The median LOS was 37 (IQR 28-76.5) days and duration of PN was 28 (IQR 21-53) days. In the first 72 h, the worst median lactate, base excess and 'toe-core' gap were 4.2 (IQR 3.0-5.8) mmol/l, -7.0 (IQR - 5.55 to - 9.35), 3.4 (IQR 3.0-4.2) °C respectively. There were no significant correlations between early physiological parameters or place of birth and LOS or PN days, but sepsis (n = 18 infants) and complex gastroschisis (n = 13 infants) were associated with an increased LOS and PN duration (both p < 0.001).

CONCLUSIONS

Survival was 100% in infants with gastroschisis who were managed with PFS, sepsis and gastroschisis complexity were associated with a longer hospital stay and duration of parenteral nutrition. Level of Evidence (I-V): IV.

Antimicrobial utilisation patterns between 2013 and 2022 in Canadian neonates born at less than 33 weeks gestation: a retrospective cohort study

Background

Excessive antimicrobial exposure is associated with an increase in neonatal mortality, morbidities and adverse neurodevelopment. Canadian Neonatal Network has been promoting judicious antimicrobial use through the Evidence-based Practice for Improving Quality processes. Our objective was to evaluate the antimicrobial consumption among neonates in tertiary neonatal intensive care units (NICU) in Canada in the recent decade.

Methods

This is a retrospective cohort study including data from very preterm infants (born at <33 weeks gestational age) admitted to all NICUs in Canada between January 1, 2013, and December 31, 2022. Nationwide antimicrobial utilization rate (AUR) benchmarking started in 2016, and quality improvement initiatives were continued in the subsequent years to promote judicious use of antimicrobials across the network. AUR is defined as the number of days with ≥1 antimicrobial divided by the total patient days (PD). Culture-proven sepsis refers to a neonate with positive culture of pathogens in blood and/or cerebrospinal fluid. The outcomes were evaluated during pre- (2013-2017) and post-intervention periods (2018-2022). Interrupted time-series analysis was used, and comparison of AUR calculated per each 3-month time block and the slope changes were conducted across the pre- and post-intervention periods regarding total patients and subgroups.

Findings

A total of 41,253 infants were included, with 22,644 (55%) being male. The AUR was significantly lower among infants from the post- vs. those from the pre-intervention periods (152 vs. 184, p < 0.0001). Among 35,670 infants without culture-proven sepsis or necrotizing enterocolitis ≥ Stage 2, AUR was significantly lower in the post-intervention group vs. the pre-intervention group (110 vs. 136, p < 0.0001). Interrupted time-series showed significant reduction in AUR during both pre- and post-intervention periods among all infants with and without culture proven sepsis or necrotizing enterocolitis ≥ Stage 2 (all p < 0.0001), as well as those born at <29 weeks gestational age.

Interpretation

A comprehensive, network-wide quality improvement initiatives led to a significant and sustained reduction in antimicrobial use among preterm infants born at <33 weeks gestational age with and without culture-proven sepsis or necrotizing enterocolitis ≥ Stage 2.

Funding

This study was supported by the Canadian Institutes of Health Research Project Grant 2019 (201903PJT-420294-CA2-CAAA-245530), matched funding from the British Columbia Women's Health Foundation and start-up funding from the Women and Children's Health Research Institute, University of Alberta. The coordinating center in Toronto is funded by the Canadian Institutes of Health Research grant for the Canadian Preterm Birth Network (PBN 150642).

Comparing nSOFA, CRIB-II, and SNAPPE-II for predicting mortality and short-term morbidities in preterm infants ≤32 weeks gestation

BACKGROUND

Neonatal illness severity scores are not extensively studied for their ability to predict mortality or morbidity in preterm infants. The aim of this study was to compare the Neonatal Sequential Organ Failure Assessment (nSOFA), Clinical Risk Index for Babies-II (CRIB-II), and Score for Neonatal Acute Physiology with Perinatal extension-II (SNAPPE-II) for predicting mortality and short-term morbidities in preterm infants ≤32 weeks.

METHODS

In this retrospective study, infants born in 2017-2018 with gestational age (GA) ≤32 weeks were evaluated. nSOFA, CRIB-II, and SNAPPE-II scores were calculated for each patient, and the ability of these scores to predict mortality and morbidities was compared. The morbidities were categorized as mod/sev bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC) requiring surgery, early-onset sepsis (EOS), late-onset sepsis (LOS), retinopathy of prematurity (ROP) requiring treatment, and severe intraventricular hemorrhage (IVH). Calculating the area under the curve (AUC) on receiver operating characteristic curves (ROC) analysis to predict and compare scoring systems' accuracy.

RESULTS

A total of 759 preterm infants were enrolled, of whom 88 deceased. The median nSOFA, CRIB-II, and SNAPPE-II scores were 2 (0, 3), 6 (4, 8), and 13 (5, 26), respectively. Compared with infants who survived, these three scores were significantly higher in those who deceased (p < 0.05). For predicting mortality, the AUC of the nSOFA, SNAPPE-II, and CRIB-II were 0.90, 0.82, and 0.79, respectively. The nSOFA scoring system had significantly higher AUC than CRIB-II and SNAPPE-II (p < 0.05). However, short-term morbidities were not strongly correlated with these three scoring systems.

CONCLUSION

In infants ≤32 weeks gestation, nSOFA scoring system is more valuable in predicting mortality than SNAPPE-II and CRIB-II. However, further studies are required to assess the predictive power of neonatal illness severity scores for morbidity.

Relationships between cortisol levels across early childhood and processing speed at age 4.5 years in children born very preterm

Children born very low gestational age (VLGA, 29-32 weeks gestational age [GA]) display slower processing speed and altered hypothalamic pituitary adrenal (HPA) axis function, with greater effects in those born extremely low gestational age (ELGA; 24-28 weeks GA). We investigated trajectories of HPA axis activity as indexed by cortisol output and patterns across cognitive assessment at ages 1.5, 3 and 4.5 years, comparing children born ELGA and VLGA and associations with 4.5-year processing speed. In a prospective longitudinal cohort study, infants born very preterm (<33 weeks gestation) returned for developmental assessment at ages 1.5, 3, and 4.5 years. At each age, children completed standardized cognitive testing and saliva samples collected before (Pretest), during (During) and after (End) challenging cognitive tasks were assayed for cortisol. For the total group (n = 188), cortisol area under the curve with respect to ground (AUCg) decreased, while cortisol reactivity to challenge (Pre-test to During) increased from 1.5 to 3 years, remaining stable to 4.5 years. This longitudinal pattern was related to higher Processing Speed (WPPSI-IV) scores at 4.5 years. Children born ELGA displayed higher AUCg than VLGA, particularly at age 3, driven by higher Pre-test cortisol levels. Overall, relative to those born VLGA, children born ELGA displayed greater cortisol responsivity to cognitive challenge. A higher setpoint of cortisol levels at age 3-years in children born ELGA may reflect altered HPA axis regulation more broadly and may contribute to difficulties with information processing in this population, critical for academic and social success.

Predictive modeling of bronchopulmonary dysplasia in premature infants: the impact of new diagnostic standards

Aim

To provide a risk prediction for bronchopulmonary dysplasia (BPD) in premature infants under the new diagnostic criteria and establish a prediction model.

Methods

In this study, we retrospectively collected case data on preterm infants admitted to the NICU from August 2015 to August 2018. A lasso analysis was performed to identify the risk factors associated with the development of BPD. A nomogram predictive model was constructed in accordance with the new diagnostic criteria for BPD.

Result

A total of 276 preterm infants were included in the study.The incidence of BPD under the 2018 diagnostic criteria was 11.2%. Mortality was significantly higher in the BPD group than the non-BPD group under the 2018 diagnostic criteria (P < 0.05). Fourteen possible variables were selected by the Lasso method, with a penalty coefficient λ=0.0154. The factors that eventually entered the logistic regression model included birth weight [BW, OR = 0.9945, 95% CI: 0.9904-0.9979], resuscitation way (OR = 4.8249, 95% CI: 1.3990-19.4752), intrauterine distress (OR = 8.0586, 95% CI: 1.7810-39.5696), score for SNAPPE-II (OR = 1.0880, 95% CI: 1.0210-1.1639), hematocrit (OR = 1.1554, 95% CI: 1.0469-1.2751) and apnea (OR = 7.6916, 95% CI: 1.4180-52.1236). The C-index after adjusting for fitting deviation was 0.894.

Conclusion

This study made a preliminary exploration of the risk model for early prediction of BPD and indicated good discrimination and calibration in premature infants.

Assessment of intraventricular hemorrhage risk in preterm infants using mathematically simulated cerebral blood flow

Intraventricular hemorrhage (IVH)4 is one of the most threatening neurological complications associated with preterm birth which can lead to long-term sequela such as cerebral palsy. Early recognition of IVH risk may prevent its occurrence and/or reduce its severity. Using multivariate logistic regression analysis, risk factors significantly associated with IVH were identified and integrated into risk scales. A special aspect of this study was the inclusion of mathematically calculated cerebral blood flow (CBF) as an independent predictive variable in the risk score. Statistical analysis was based on clinical data from 254 preterm infants with gestational age between 23 and 30 weeks of pregnancy. Several risk scores were developed for different clinical situations. Their efficacy was tested using ROC analysis, and validation of the best scores was performed on an independent cohort of 63 preterm infants with equivalent gestational age. The inclusion of routinely measured clinical parameters significantly improved IVH prediction compared to models that included only obstetric parameters and medical diagnoses. In addition, risk assessment with numerically calculated CBF demonstrated higher predictive power than risk assessments based on standard clinical parameters alone. The best performance in the validation cohort (with AUC = 0.85 and TPR = 0.94 for severe IVH, AUC = 0.79 and TPR = 0.75 for all IVH grades and FPR = 0.48 for cases without IVH) was demonstrated by the risk score based on the MAP, pH, CRP, CBF and leukocytes count.

Early prediction of mortality and morbidities in VLBW preterm neonates using machine learning

BACKGROUND

Predicting mortality and specific morbidities before they occur may allow for interventions that may improve health trajectories.

HYPOTHESIS

Integrating key maternal and postnatal infant variables in the first 2 weeks of age into machine learning (ML) algorithms will reliably predict survival and specific morbidities in VLBW preterm infants.

METHODS

ML algorithms were developed to integrate 47 features for predicting mortality, bronchopulmonary dysplasia (BPD), neonatal sepsis, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), cystic periventricular leukomalacia (PVL), and retinopathy of prematurity (ROP). A retrospective cohort (n = 3341) was used to train and validate the models with a repeated 10-fold cross-validation strategy. These models were then tested on a separate cohort (n = 447) to evaluate the final model performance.

RESULTS

Among the seven ML algorithms employed, tree-based ensemble models, specifically Random Forest (RF) and XGBoost, had the best performance metrics. The area under the receiver operating characteristic curve (AUROC) of sepsis with or without meningitis (0.73), NEC (0.73), BPD (0.71), and mortality (0.74) exceeded 0.7, while the area under Precision-Recall curve (AUPRC) for all outcomes was greater than the prevalence, demonstrating effective risk stratification in VLBW preterm infants.

CONCLUSIONS

Our study demonstrates the potential of predictive analytics leveraging ML techniques in advancing precision medicine.

IMPACT

Reliable prediction of adverse outcomes before they occur has the potential to institute interventions and possibly improve health trajectories in VLBW preterm infants. We used machine learning to develop and test predictive models for mortality and five major morbidities in VLBW preterm infants. Individualized prediction of outcomes and individualized interventions will advance Precision Medicine in Neonatology.

Predictive Accuracy of Infant Clinical Sign Algorithms for Mortality in Young Infants Aged 0 to 59 Days: A Systematic Review

CONTEXT

Clinical sign algorithms are a key strategy to identify young infants at risk of mortality.

OBJECTIVE

Synthesize the evidence on the accuracy of clinical sign algorithms to predict all-cause mortality in young infants 0-59 days.

DATA SOURCES

MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials.

STUDY SELECTION

Studies evaluating the accuracy of infant clinical sign algorithms to predict mortality.

DATA EXTRACTION

We used Cochrane methods for study screening, data extraction, and risk of bias assessment. We determined certainty of evidence using Grading of Recommendations Assessment Development and Evaluation.

RESULTS

We included 11 studies examining 26 algorithms. Three studies from non-hospital/community settings examined sign-based checklists (n = 13). Eight hospital-based studies validated regression models (n = 13), which were administered as weighted scores (n = 8), regression formulas (n = 4), and a nomogram (n = 1). One checklist from India had a sensitivity of 98% (95% CI: 88%-100%) and specificity of 94% (93%-95%) for predicting sepsis-related deaths. However, external validation in Bangladesh showed very low sensitivity of 3% (0%-10%) with specificity of 99% (99%-99%) for all-cause mortality (ages 0-9 days). For hospital-based prediction models, area under the curve (AUC) ranged from 0.76-0.93 (n = 13). The Score for Essential Neonatal Symptoms and Signs had an AUC of 0.89 (0.84-0.93) in the derivation cohort for mortality, and external validation showed an AUC of 0.83 (0.83-0.84).

LIMITATIONS

Heterogeneity of algorithms and lack of external validation limited the evidence.

CONCLUSIONS

Clinical sign algorithms may help identify at-risk young infants, particularly in hospital settings; however, overall certainty of evidence is low with limited external validation.

Compliance with the Golden Hour bundle in deliveries attended by a specialized neonatal transport team compared with staff at non-tertiary centres

Background

Preterm infants born at <32 weeks gestational age (GA) have increased morbidity if they are born outside tertiary centres (outborn). Stabilization and resuscitation after birth consistent with the neonatal Golden Hour practices (NGHP) are required to optimize outcomes.

Objectives

To evaluate physiological outcomes of hypothermia and hypoglycaemia, and compliance with NGHP by neonatal transport team (NTT) compared with referral hospital team (RHT) during the stabilization of infants born at <32 weeks GA.

Methods

A retrospective case-control study of infants born at <32 weeks GA during 2016-2019 at non-tertiary perinatal centres where the NTT attended the delivery (cases) were matched to infants where the RHT team attended the delivery (controls).

Results

During the 4-year period, NTT team received 437 requests to attend deliveries at <32 weeks GA and attended 76 (17%) prior to delivery. These cases were matched 1:1 with controls composed of deliveries attended by the RHT. The rate of hypothermia was 15% versus 29% in the NTT and RHT groups, respectively (P = 0.01). The rate of hypoglycaemia (<2.2 mmol/L) was 5% versus 12% in the NTT and RHT groups, respectively (P = 0.64). For compliance with the NGHP, use of fluid boluses was 8% versus 33%, use of thermoregulation practices, that is, plastic bag, was 76% versus 21%, and establishment of intravenous access was 20 min versus 47 min, in the NTT and RHT groups, respectively.

Conclusions

High-risk preterm deliveries attended by the NTT compared with the RHT had increased compliance and earlier implementation of the NGHP elements, associated with improved physiological stability and lower hypothermia rates. Outreach education for RHT should ensure that these key elements are included during the training in the stabilization of high-risk preterm deliveries.

Artificial intelligence in early detection and prediction of pediatric/neonatal acute kidney injury: current status and future directions

Acute kidney injury (AKI) has a significant impact on the short-term and long-term clinical outcomes of pediatric and neonatal patients, and it is imperative in these populations to mitigate the pathways leading to AKI and be prepared for early diagnosis and treatment intervention of established AKI. Recently, artificial intelligence (AI) has provided more advent predictive models for early detection/prediction of AKI utilizing machine learning (ML). By providing strong detail and evidence from risk scores and electronic alerts, this review outlines a comprehensive and holistic insight into the current state of AI in AKI in pediatric/neonatal patients. In the pediatric population, AI models including XGBoost, logistic regression, support vector machines, decision trees, naïve Bayes, and risk stratification scores (Renal Angina Index (RAI), Nephrotoxic Injury Negated by Just-in-time Action (NINJA)) have shown success in predicting AKI using variables like serum creatinine, urine output, and electronic health record (EHR) alerts. Similarly, in the neonatal population, using the "Baby NINJA" model showed a decrease in nephrotoxic medication exposure by 42%, the rate of AKI by 78%, and the number of days with AKI by 68%. Furthermore, the "STARZ" risk stratification AI model showed a predictive ability of AKI within 7 days of NICU admission of AUC 0.93 and AUC of 0.96 in the validation and derivation cohorts, respectively. Many studies have reported the superiority of using biomarkers to predict AKI in pediatric patients and neonates as well. Future directions include the application of AI along with biomarkers (NGAL, CysC, OPN, IL-18, B2M, etc.) in a Labelbox configuration to create a more robust and accurate model for predicting and detecting pediatric/neonatal AKI.

Lactoferrin intake from maternal milk during the neonatal hospitalization and early brain development among preterm infants

BACKGROUND

Lactoferrin is an immuno-modulatory nutrient in human milk that may be neuroprotective.

METHODS

In 36 infants born <32 weeks' gestation, we sampled human milk at 14 and 28 days of chronologic age and measured lactoferrin by electrochemiluminescence multiplex immunoassay. Using 3T quantitative brain magnetic resonance imaging scans obtained at term equivalent, we estimated total and regional brain volumes. We compared outcomes between infants exposed to low (bottom tertile, range 0.06-0.13 mg/mL) vs. high (top tertile, range 0.22-0.35 mg/mL) lactoferrin using median regression in models adjusted for gestational age, birth weight z-score, sex, and postmenstrual age.

RESULTS

Compared to infants exposed to low lactoferrin, infants exposed to high lactoferrin had 43.9 cc (95% CI: 7.6, 80.4) larger total brain volume, 48.3 cc (95% CI: 12.1, 84.6) larger cortical gray matter, and 3.8 cc (95% CI: 0.7, 7.0) larger deep gray matter volume at term equivalent age. Other regional brain volumes were not statistically different between groups.

CONCLUSION

Higher lactoferrin exposure during the neonatal hospitalization was associated with larger total brain and gray matter volumes, suggesting that lactoferrin may have potential as a dietary supplement to enhance brain growth in the neonatal intensive care unit setting.

IMPACT

This study suggests that lactoferrin, a whey protein found in human milk, may be beneficial for preterm infant brain development, and therefore has potential as a dietary supplement in the neonatal intensive care unit setting.

Benefits and Risks of Preprepared Parenteral Nutrition for Early Amino Acid Administration in Premature Infants with Very Low Birth Weight

Purpose

Administering early parenteral amino acids to very low birth weight (VLBW) premature infants (birth body weight [BBW]<1,500 g) is challenging due to factors such as holidays, cost, and access to sterile compounding facilities. Using advance-prepared parenteral nutrition (PN) may address this issue and should be evaluated for its safety and potential benefits.

Methods

We extracted data from medical records collected between July 2015 and August 2019. VLBW infants received PN for at least seven days and were split into two groups: the traditional group (n=30), which initially received a glucose solution and then PN on workdays, and the pre-preparation group (n=16), which received advance-prepared PN immediately upon admission to the neonatal intensive care unit.

Results

The median BBWs of the traditional and pre-preparation groups were 1,180.0 vs. 1,210.0 g. In the initial two days, the pre-preparation group had a significantly higher amino acid intake (2.23 and 2.24 g/kg/d) than the traditional group (0 and 1.78 g/kg/d). The pre-preparation group exhibited greater head circumference growth ratio relative to birth (7th day: 1.21% vs. -3.57%, p=0.014; 21st day: 7.71% vs. 3.31%, p=0.017). No significant differences in metabolic tolerance were observed.

Conclusion

Advanced preparation of PN can be safely implemented in VLBW preterm infants, offering advantages such as early, higher amino acid intake and improved head circumference growth within the first 21 days post-birth. This strategy may serve as a viable alternative in settings where immediate provision of sterile compounding facilities is challenging.

Process and Outcome Measures for Infants Born Moderate and Late Preterm in Tertiary Canadian Neonatal Intensive Care Units

OBJECTIVE

To describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPIs) admitted to tertiary Canadian neonatal intensive care units (NICUs).

STUDY DESIGN

This was a retrospective cohort study including infants born at 320/7 through 366/7 weeks of gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics.

RESULTS

Among 25 669 infants (17% of MLPIs born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received noninvasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early-onset sepsis, late-onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures.

CONCLUSIONS

Care practices and outcomes of MLPIs varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.

Factors Associated with Low Volumes of Mother's Own Milk at Neonatal Intensive Care Unit Discharge of Very Low Birth Weight Infants-a Cohort Study

Background: Mother's own milk (MOM) provides health benefits for infants with very low birth weight (VLBW). This study aimed to describe the incidence and factors associated with low volumes of MOM (<50% of total diet volume) at discharge for VLBW infants. Methods: A prospective cohort study of infants with VLBW and gestational age of <30 weeks, who survived to discharge and had no contraindication to MOM. We conducted bivariate analyses to investigate associations with the volume of MOM at discharge, using chi-square, t, and Mann-Whitney tests. All p-value analyses were two-tailed. The variables significantly associated with "low volumes of MOM" entered the multivariable analysis. Univariate and multivariate relative risk (confidence interval [CI] 95%) estimates were obtained from Poisson regression with a robust estimate of variance and controlled by the length of hospital stay. Results: Of 414 infants included and followed until discharge, 32.9% (n = 136) received less than 50% of the total daily volume of MOM. This outcome was associated with gestational age <28 weeks, lower birth weight, multiple births, developing bronchopulmonary dysplasia, and longer lengths of stay. After Poisson regression, low volumes of MOM at discharge were associated only with being born multiples (RR 2.01; CI 95% 1.53-2.64, p < 0.001) and with longer length of stay (RR 1.07; CI 95% 1.01-1.14, p = 0.01). Conclusions: Most VLBW infants were discharged home receiving predominantly MOM. Each neonatal intensive care unit (NICU) should acknowledge which clinical characteristics of mothers and VLBW infants are associated with difficulties maintaining MOM volumes until discharge.

Association of low hemoglobin at birth and neurodevelopmental outcomes in preterm neonates ≤28 weeks' gestation: a retrospective cohort study

OBJECTIVE

To compare neurodevelopmental outcomes at 18-24 months corrected age (CA) for preterm infants who had hemoglobin levels <120 g/l versus those with hemoglobin level ≥120 g/l at birth.

METHODS

We included infants of ≤28 weeks gestational age (GA) born between January 2009 and June 2018. The primary outcome was neurodevelopmental impairment (NDI) at 18-24 months. Multivariable logistic regression was applied to determine the association.

RESULTS

Of the 2351 eligible neonates, 351 (14.9%) had hemoglobin levels <120 g/L at birth. Of the 2113 surviving infants, 1534 (72.5%) underwent developmental follow-up at 18-24 months CA. There was no statistically significant difference in ND outcomes between the two groups. The composite outcome of death or NDI was significantly higher in the low hemoglobin group.

CONCLUSION

In preterm infants ≤28 weeks GA, initial hemoglobin <120 g/L at birth was not associated with neurodevelopmental impairment at 18-24 months CA among survivors.

Predicting early mortality and severe intraventricular hemorrhage in very-low birth weight preterm infants: a nationwide, multicenter study using machine learning

Our aim was to develop a machine learning-based predictor for early mortality and severe intraventricular hemorrhage (IVH) in very-low birth weight (VLBW) preterm infants in Taiwan. We collected retrospective data from VLBW infants, dividing them into two cohorts: one for model development and internal validation (Cohort 1, 2016-2021), and another for external validation (Cohort 2, 2022). Primary outcomes included early mortality, severe IVH, and early poor outcomes (a combination of both). Data preprocessing involved 23 variables, with the top four predictors identified as gestational age, birth body weight, 5-min Apgar score, and endotracheal tube ventilation. Six machine learning algorithms were employed. Among 7471 infants analyzed, the selected predictors consistently performed well across all outcomes. Logistic regression and neural network models showed the highest predictive performance (AUC 0.81-0.90 in both internal and external validation) and were well-calibrated, confirmed by calibration plots and the lowest two mean Brier scores (0.0685 and 0.0691). We developed a robust machine learning-based outcome predictor using only four accessible variables, offering valuable prognostic information for parents and aiding healthcare providers in decision-making.

Early versus late parenteral nutrition in term and late preterm infants: a randomised controlled trial

BACKGROUND

There is limited evidence regarding the optimal time to commence parenteral nutrition (PN) in term and late preterm infants.

DESIGN

Single-centre, non-blinded, exploratory randomised controlled trial.

SETTING

A level-3 neonatal unit in a stand-alone paediatric hospital.

PATIENTS

Infants born ≥34 weeks of gestation and ≤28 days, who needed PN. Eligible infants were randomised on day 1 or day 2 of admission.

INTERVENTIONS

Early (day 1 or day 2 of admission, N=30) or late (day 6 of admission, N=30) PN.

MAIN OUTCOME MEASURES

Plasma phenylalanine and F2-isoprostane levels on day 4 and day 8 of admission. Secondary outcomes were amino-acid and fatty-acid profiles on day 4 and day 8, and clinical outcomes.

RESULTS

The postnatal age at randomisation was similar between the groups (2.3 (SD 0.8) vs 2.3 (0.7) days, p=0.90). On day 4, phenylalanine levels in early-PN infants were higher than in late-PN (mean (SD) 62.9 (26.7) vs 45.5 (15.3) µmol/L; baseline-adjusted percentage difference 25.8% (95% CI 11.6% to 39.9%), p<0.001). There was no significant difference in phenylalanine levels between the two groups on day 8. There was no significant difference between the groups for F2-isoprostane levels on day 4 (early-PN mean (SD) 389 (176) vs late-PN 419 (291) pg/mL; baseline-adjusted percentage difference: -4.4% (95% CI -21.5% to 12.8%) p=0.62) and day 8 (mean (SD) 305 (125) vs 354 (113) pg/mL; adjusted mean percentage difference -16.1 (95% CI -34.1 to 1.9) p=0.09).Postnatal growth restriction for weight was less severe in the early-PN group (change in weight z-score from baseline to discharge: -0.6 (0.6) vs -1.0 (0.6); p=0.02). The incidence of hyperglycaemia was greater in the early-PN group (20/30 (66.7%) vs 11/30 (36.7%), p=0.02).

CONCLUSIONS

The timing of the commencement of PN did not seem to affect the degree of oxidative stress in critically ill term and late preterm infants. The effect of transiently high plasma phenylalanine with early PN on clinical outcomes requires further investigation.

TRIAL REGISTRATION NUMBER

ACTRN12620000324910.

Late-Onset Sepsis in Very Low Birth Weight Premature Infants: A 10-Year Review of a Brazilian Tertiary University Hospital-the Challenge Remains

OBJECTIVES

This study aimed to assess the incidence of late-onset sepsis (LOS), associated risk factors, and short-term prognosis in very low birth weight (VLBW) infants in a 10-year period.

STUDY DESIGN

A cohort study was conducted with 752 VLBW preterm infants-23 to 33 gestational weeks and 400 to 1,500 g birth weight-admitted to a neonatal intensive care unit from 2008 to 2017 and who survived over 72 hours. LOS was defined as clinical and laboratory signs of infection, whether or not confirmed by blood culture. VLBW infants were divided into groups and compared: no LOS versus proven LOS versus clinical LOS. Study variables included maternal, birth, and neonatal data, morbidities, procedures, etiological agents, and outcome-death, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage, and retinopathy of prematurity (ROP). Analysis of variance with multiple Tukey's or Wald's comparison with gamma distribution, and stepwise multiple logistic regression model, adjusted for year, and gestational age, were used for statistical analysis.

RESULTS

LOS incidence was 39% (proven LOS: 29%; clinical LOS: 10%). Septic VLBW infants showed higher mortality (proven LOS: 23.2%; clinical LOS: 41.9%) compared with no LOS (8.9%). Coagulase-negative staphylococci (56%), Gram-negative (26%), and fungi (8%) were the most frequent etiological agents. In comparing the groups, septic VLBW infants had lower gestational age and birth weight, presented more morbidities, and underwent more invasive procedures. The risk factors for proven and clinical LOS were days of mechanical ventilation and parenteral nutrition. LOS was associated with increased risk of death, BPD, and ROP.

CONCLUSION

LOS showed high incidence and mortality, often caused by Gram-positive bacteria. Care interventions were the main risk factors associated. LOS had a major negative impact on short-term prognosis in VLBW infants. LOS reduction strategies are necessary and urgent.

KEY POINTS

· LOS is associated with clinically significant neonatal morbidities and death in VLBW premature infants.. · There is association between LOS and duration of intensive care interventions.. · Quality improvement initiatives can be a pathway for LOS reduction..

Urinary tract infections in very premature neonates: the definition dilemma

BACKGROUND AND OBJECTIVES

Data on urinary tract infections (UTIs) in very preterm neonates (VPTNs) are scarce. We aimed to (i) describe the characteristics of UTIs in VPTNs and (ii) compare the diagnostic practices of neonatal clinicians to established pediatric guidelines.

METHODS

All VPTNs (<29 weeks GA) with a suspected UTI at the CHU Sainte-Justine neonatal intensive care unit from January 1, 2014, and December 31, 2019, were included and divided into two definition categories: Possible UTI, and Definite UTI.

RESULTS

Most episodes were Possible UTI (87%). Symptoms of UTIs and pathogens varied based on the definition category. A positive urinalysis was obtained in 25%. Possible UTI episodes grew 2 organisms in 62% of cases and <50,000 CFU/mL in 62% of cases.

CONCLUSION

Characteristics of UTIs in VPTNs vary based on the definition category and case definitions used by clinicians differ from that of established pediatric guidelines.

Assessment of hemostatic profile in neonates with necrotizing enterocolitis using Rotational Thromboelastometry (ROTEM)

BACKGROUND

This study aimed to explore the hemostatic profile of neonates with necrotizing enterocolitis (NEC) using Rotational Thromboelastometry (ROTEM) and to investigate if ROTEM parameters have the capacity to play a role in the differentiation of NEC from sepsis at the disease onset.

METHODS

This observational study included 62 neonates (mean gestational age 31.6 weeks and mean birth weight 1620g) hospitalized in a neonatal intensive care unit. The neonates were categorized in three groups: neonates with NEC (Bell stage II and above), neonates with sepsis and healthy neonates and they were matched 1:1:1 with regards to gestational age, delivery mode, and sex. Clinical, laboratory data as well as measurements of ROTEM parameters at disease onset were recorded.

RESULTS

ROTEM parameters differed between neonates with NEC and neonates with sepsis, indicating that NEC results in accelerated clot formation and higher clot strength compared to sepsis. The EXTEM CFT and A10 parameters demonstrated the highest diagnostic performance for NEC in terms of discrimination between NEC and sepsis (AUC, 0.997; 95% CI: 0.991-1.000 and 0.973; 95% CI: 0.932-1.000, respectively).

CONCLUSIONS

Neonates with NEC manifested accelerated clot formation and higher clot strength compared to septic and healthy neonates, as these were expressed by ROTEM parameters.

IMPACT

This work reports data on the hemostatic profile of neonates with necrotizing enterocolitis (NEC) using Rotational Thromboelastometry (ROTEM) and the capacity of ROTEM parameters in differentiating of NEC from sepsis at the disease onset. Neonates with NEC present acceleration of coagulation and exhibit a hypercoagulable profile, as this is expressed by ROTEM parameters, in comparison to septic and healthy neonates. ROTEM parameters demonstrated a good diagnostic capacity in differentiating NEC from sepsis at the disease onset.

Ventilatory Assistance Before Umbilical Cord Clamping in Extremely Preterm Infants: A Randomized Clinical Trial

Importance

Providing assisted ventilation during delayed umbilical cord clamping may improve outcomes for extremely preterm infants.

Objective

To determine whether assisted ventilation in extremely preterm infants (23 0/7 to 28 6/7 weeks' gestational age [GA]) followed by cord clamping reduces intraventricular hemorrhage (IVH) or early death.

Design, Setting, and Participants

This phase 3, 1:1, parallel-stratified randomized clinical trial conducted at 12 perinatal centers across the US and Canada from September 2, 2016, through February 21, 2023, assessed IVH and early death outcomes of extremely preterm infants randomized to receive 120 seconds of assisted ventilation followed by cord clamping vs delayed cord clamping for 30 to 60 seconds with ventilatory assistance afterward. Two analysis cohorts, not breathing well and breathing well, were specified a priori based on assessment of breathing 30 seconds after birth.

Intervention

After birth, all infants received stimulation and suctioning if needed. From 30 to 120 seconds, infants randomized to the intervention received continuous positive airway pressure if breathing well or positive-pressure ventilation if not, with cord clamping at 120 seconds. Control infants received 30 to 60 seconds of delayed cord clamping followed by standard resuscitation.

Main Outcomes and Measures

The primary outcome was any grade IVH on head ultrasonography or death before day 7. Interpretation by site radiologists was confirmed by independent radiologists, all masked to study group. To estimate the association between study group and outcome, data were analyzed using the stratified Cochran-Mantel-Haenszel test for relative risk (RR), with associations summarized by point estimates and 95% CIs.

Results

Of 1110 women who consented to participate, 548 were randomized and delivered infants at GA less than 29 weeks. A total of 570 eligible infants were enrolled (median [IQR] GA, 26.6 [24.9-27.7] weeks; 297 male [52.1%]). Intraventricular hemorrhage or death occurred in 34.9% (97 of 278) of infants in the intervention group and 32.5% (95 of 292) in the control group (adjusted RR, 1.02; 95% CI, 0.81-1.27). In the prespecified not-breathing-well cohort (47.5% [271 of 570]; median [IQR] GA, 26.0 [24.7-27.4] weeks; 152 male [56.1%]), IVH or death occurred in 38.7% (58 of 150) of infants in the intervention group and 43.0% (52 of 121) in the control group (RR, 0.91; 95% CI, 0.68-1.21). There was no evidence of differences in death, severe brain injury, or major morbidities between the intervention and control groups in either breathing cohort.

Conclusions and Relevance

This study did not show that providing assisted ventilation before cord clamping in extremely preterm infants reduces IVH or early death. Additional study around the feasibility, safety, and efficacy of assisted ventilation before cord clamping may provide additional insight.

Trial Registration

ClinicalTrials.gov Identifier: NCT02742454.

Fatty acid concentrations in preterm infants fed the exclusive human milk diet: a prospective cohort study

OBJECTIVE

Quantify blood fatty acids and growth outcomes in preterm infants fed the exclusive human milk diet.

METHODS

A prospective cohort study of 30 infants 24-34 weeks gestation and ≤1250 g fed the exclusive human milk diet. Blood fatty acids were quantified at two time points. Comparisons were made using two-sample t-tests and Wilcoxon rank sum.

RESULTS

Donor human milk-fed (n = 12) compared to mother's own milk-fed infants (n = 18) from birth to after 28 days of life, had an increased interval change of linoleic to docosahexaenoic acid ratio (5.5 vs. -1.1 mole percent ratio, p = 0.034). Docosahexaenoic and eicosapentaenoic acid interval changes were similar between groups. The arachidonic acid change was similar between groups (-2.3 vs. -0.9 mole percent, p = 0.37), however, both experienced a negative change across time. At 36 weeks postmenstrual age, growth velocities were similar for groups.

CONCLUSION

An exclusive human milk diet maintains birth docosahexaenoic and eicosapentaenoic acid concentrations. However, the postnatal deficit in arachidonic acid was not prevented.

Bronchopulmonary dysplasia: temporal trend from 2010 to 2019 in the Brazilian Network on Neonatal Research

OBJECTIVE

To evaluate the temporal trend of bronchopulmonary dysplasia (BPD) in preterm infants who survived to at least 36 weeks' post-menstrual age (PMA) and BPD or death at 36 weeks' PMA, and to analyse variables associated with both outcomes.

DESIGN

Retrospective cohort with data retrieved from an ongoing national registry.

SETTING

19 Brazilian university public hospitals.

PATIENTS

Infants born between 2010 and 2019 with 23-31 weeks and birth weight 400-1499 g.

MAIN OUTCOME MEASURES

Temporal trend was evaluated by Prais-Winsten model and variables associated with BPD in survivors or BPD or death were analysed by logistic regression.

RESULTS

Of the 11 128 included infants, BPD in survivors occurred in 22%, being constant over time (annual per cent change (APC): -0.80%; 95% CI: -2.59%; 1.03%) and BPD or death in 45%, decreasing over time (APC: -1.05%; 95% CI: -1.67%; -0.43%). Being male, small for gestational age, presenting with respiratory distress syndrome, air leaks, needing longer duration of mechanical ventilation, presenting with treated patent ductus arteriosus and late-onset sepsis were associated with an increase in the chance of BPD. For the outcome BPD or death, maternal bleeding, multiple gestation, 5-minute Apgar <7, late-onset sepsis, necrotising enterocolitis and intraventricular haemorrhage were added to the variables reported above as increasing the chance of the outcome.

CONCLUSION

The frequency of BPD in survivors was constant and BPD or death decreased by 1.05% at each study year. These results show some improvement in perinatal care in Brazilian units which resulted in a reduction of BPD or death, but further improvements are still needed to reduce BPD in survivors.

Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants

OBJECTIVE

This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA).

STUDY DESIGN

Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders.

RESULTS

Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12-10.6 and aOR = 3.33, 95% CI: 1.44-7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants).

CONCLUSION

24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out.

KEY POINTS

· Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage. · The type of 24h in-house coverage was not associated with mortality and/or major morbidity.. · High-volume centers more often have 24h in-house neonatal fellow coverage.

Randomized Noninferiority Trial of Expectant Management versus Early Treatment of Patent Ductus Arteriosus in Preterm Infants

OBJECTIVE

The study aimed to investigate, whether expectant management is noninferior to early patent ductus arteriosus (PDA) treatment with regard to the composite of mortality and/or incidence of bronchopulmonary dysplasia (BPD) in very preterm infants.

STUDY DESIGN

A total of 208 very preterm infants of the gestational age <32 weeks, birth weight <1,500 g, chronological age <72 hours, and PDA >1.5 mm were randomized between the treatment or expectant management groups. Both, the intention-to-treat and per-protocol analyses were performed.

RESULTS

A total of 104 (50%) patients received rectal ibuprofen (n = 52) or intravenous acetaminophen (n = 52) within first 72 hours of life. In 104 (50%) infants, expectant management was used. Eight of them (8%) received rescue treatment at the median age of 7 (range: 6-13) days. PDA closure rates by the 10th day of life were 81% (n = 84) in the treatment arm, and 58% (n = 60) in the expectant management arm (p < 0.01). The median age at the time of ductus closure was 5 (range: 5-6) days in the treatment arm and 8 (range: 6-11) days in the expectant management arm (p < 0.01). At the time of discharge, ductus was closed in 83% of treated infants and in 78% of patients who were managed expectantly (p > 0.05). No significant difference between the groups was found for the primary clinical outcomes, BPD/death, or the secondary outcomes at a postmenstrual age of 36 weeks or discharge.

CONCLUSION

Expectant management is noninferior to early PDA treatment for reducing the incidence of death/BPD. Compared with the expectant management, early pharmacological treatment provides more frequent and faster PDA closure in preterm infants with gestational age <32 weeks, but it neither reduces morbidity nor improves survival rates.

KEY POINTS

· PDA persistence in very preterm infants is associated with an increased risk of BPD/death.. · PDA treatment accelerates ductus closure, but does not improve survival or reduce severe neonatal morbidity.. · Expectant management is not associated with a higher risk of BPD/death..

The impact of general anesthesia on the outcomes of preterm infants with gestational age less than 32 weeks delivered via cesarean section

Background

Recent advancements in China's perinatal and neonatal intensive care have significantly reduced neonatal mortality, yet preterm births before 32 weeks remain the primary cause of neonatal fatalities and contribute to long-term disabilities. The prognosis of very preterm infants (VPIs) is significantly affected by factors including the intrauterine environment, delivery method and neonatal intensive care. Cesarean section which often used for preterm births has implications that are not fully understood, particularly concerning the type of anesthesia used. This study examines the impact of general anesthesia (GA) during cesarean delivery on VPI outcomes, aiming to identify strategies for mitigating GA-associated risks.

Methods

This cohort study analyzed 1,029 VPIs born via cesarean section under 32 weeks' gestation at our single-center from 1 January 2018, to 31 December 2022. Detailed medical records, encompassing perioperative information, maternal data and neonatal outcomes were meticulously examined. The primary aim of this investigation was to compare maternal characteristics and neonatal outcomes between VPIs delivered under GA and neuraxial anesthesia (NA). A significance level of p < 0.05 was established.

Results

Of the 1,029 VPIs analyzed, 87.95% (n = 905) were delivered via NA and 12.05% (n = 124) via GA. Mothers with hypertensive pregnancy diseases and emergency operations were more inclined to choose GA. VPIs delivered under GA showed a lower Apgar score at one and 5 minutes (p < 0.01), increased need for tracheal intubation resuscitation (32.2% vs. 12.2%, p < 0.01) and a greater incidence of severe neurological injury (SNI) (14.5% vs. 5%, p < 0.01). Multivariable analysis revealed GA was significantly associated with lower Apgar scores at one (OR 6.321, 95% CI 3.729-10.714; p < 0.01) and 5 minutes (OR 4.535, 95% CI 2.975-6.913; p < 0.01), higher risk of tracheal intubation resuscitation (OR = 3.133, 95% CI = 1.939-5.061; p < 0.01) and SNI (OR = 3.019, 95% CI = 1.615-5.643; p < 0.01). Furthermore, for VPIs delivered under GA, a prolonged interval from skin incision to fetus delivery was associated with a lower 5-min Apgar score (p < 0.01).

Conclusion

This study revealed the significant impact of GA on adverse outcomes among VPIs. In cases when GA is required, proactive measures should be instituted for the care of VPIs such as expediting the interval from skin incision to fetal delivery.

Association between maternal stress and premature milk cortisol, milk IgA, and infant health: a cohort study

Background

Maternal stress is pervasive in the neonatal intensive care unit (NICU). Maternal stress is associated with changes in human milk (HM) immunomodulatory agents, which may impact neonatal health. We sought to determine the association between maternal stress, HM immunoglobulin A (IgA) and cortisol, and to assess how these milk components correlate with infant immune and neurodevelopmental outcomes. We then compared how these associations persist over time.

Methods

The study design involved a cohort study of exclusively breastfeeding mothers and their singleton moderately preterm (28-34 weeks) infants admitted to the NICU. We collected maternal serum, maternal saliva, and first-morning whole milk samples, and administered maternal stress questionnaires at 1 and 5 weeks postpartum. We analyzed the samples for HM IgA (using a customized immunoassay in skim milk) and for HM and salivary cortisol (using a chemiluminescent immunoassay). Infant illness was assessed using the Score for Neonatal Acute Physiology II (SNAP II) and SNAP II with Perinatal Extension (SNAPPE II), and infant neurodevelopment were assessed using the Test of Infant Motor Performance. We analyzed changes in HM IgA and cortisol over time using paired t-tests. Furthermore, we performed correlation and regression analyses after adjusting for gestational age (GA), corrected GA, and infant days of life.

Results

In our study, we enrolled 26 dyads, with a mean maternal age of 28.1 years, consisting of 69% white, 19% Black, and 8% Hispanic. Cortisol: Salivary and HM cortisol were closely associated in week 1 but not in week 5. Though mean salivary cortisol remained stable over time [2.41 ng/mL (SD 2.43) to 2.32 (SD 1.77), p = 0.17], mean HM cortisol increased [1.96 ng/mL (SD 1.93) to 5.93 ng/mL (SD 3.83), p < 0.001]. Stress measures were inversely associated with HM cortisol at week 1 but not at week 5. IgA: HM IgA decreased over time (mean = -0.14 mg/mL, SD 0.53, p < 0.0001). High maternal stress, as measured by the Parental Stressor Scale: neonatal intensive care unit (PSS:NICU), was positively associated with HM IgA at week 5 (r = 0.79, P ≤ 0.001). Higher IgA was associated with a lower (better) SNAP II score at week 1 (r = -0.74, p = 0.05). No associations were found between maternal stress, salivary cortisol, HM cortisol, or HM IgA and neurodevelopment at discharge (as assessed using the TIMP score). Furthermore, these relationships did not differ by infant sex.

Conclusion

Maternal stress showed associations with HM cortisol and HM IgA. In turn, HM IgA was associated with lower measures of infant illness.

Variations in Site-Specific Costs for Infants Born Extremely Preterm in Canadian Neonatal Intensive Care Units

OBJECTIVE

To quantify site-specific costs and their association with survival without major morbidity (SWMM) in Canada for neonates <28 weeks of gestation admitted to large tertiary neonatal intensive care units.

METHODS

We conducted a retrospective analysis of infants born at <28 weeks of gestation and admitted to Canadian Neonatal Network sites from 2010 through 2021. Sites that cared for at least 50 eligible infants by gestational age in weeks over the study period were included. Using a validated costing algorithm that assessed physician, nursing, respiratory therapy, diagnostic imaging, transfusions, procedural, medication, and certain indirect costs, we calculated site and resource-specific costs in 2017 Canadian dollars (CAD) and evaluated their relationship with SWMM.

RESULTS

Seven sites with 8180 (range 841-1605) eligible neonates with a mean (SD) gestation of 25.4 [1.3] weeks were included. Survival to discharge or transfer was 85.3% with a mean (SD) length of stay of 75 (46) days. The mean (SD) total and daily costs per neonate varied between $94 992 ($60 283) and $174 438 ($130 501) CAD and $1833 ($916) to $2307 ($1281) CAD, respectively. Between sites, there was no relationship between costs and SWMM.

CONCLUSIONS

There was marked variation in costs and SWMM between sites in Canada with universal health care. The lack of concordance between both outcomes and costs among sites may provide possibilities for outcomes improvement and cost containment.

The impact of a care bundle with an emphasis on hemodynamic assessment on the short-term outcomes in neonates with congenital diaphragmatic hernia

OBJECTIVE

To evaluate the short-term outcomes of implementing a care bundle emphasizing frequent hemodynamic assessments by echocardiography in neonates with congenital diaphragmatic hernia (CDH).

STUDY DESIGN

This was a retrospective cohort study of infants with CDH admitted to a quaternary perinatal unit from January 2013 to March 2021. The primary composite outcome was defined as mortality or use of extracorporeal membrane oxygenation or need for respiratory support at discharge.

RESULTS

We identified 37 and 20 CDH infants in Epoch I and II, respectively. More patch repairs (50% vs. 21.9%, p = 0.035) and echocardiograms (6[4-8] vs. 1[0-5], p = 0.003) were performed in Epoch II. While there were no differences in the primary outcome, there was a reduction in mortality in Epoch II (0% vs. 27%, p = 0.01).

CONCLUSION

With the implementation of a CDH care bundle with an emphasis on hemodynamic assessment, we demonstrated a significant reduction in mortality.

Improving Prediction of Survival for Extremely Premature Infants Born at 23 to 29 Weeks Gestational Age in the Neonatal Intensive Care Unit: Development and Evaluation of Machine Learning Models

BACKGROUND

Infants born at extremely preterm gestational ages are typically admitted to the neonatal intensive care unit (NICU) after initial resuscitation. The subsequent hospital course can be highly variable, and despite counseling aided by available risk calculators, there are significant challenges with shared decision-making regarding life support and transition to end-of-life care. Improving predictive models can help providers and families navigate these unique challenges.

OBJECTIVE

Machine learning methods have previously demonstrated added predictive value for determining intensive care unit outcomes, and their use allows consideration of a greater number of factors that potentially influence newborn outcomes, such as maternal characteristics. Machine learning-based models were analyzed for their ability to predict the survival of extremely preterm neonates at initial admission.

METHODS

Maternal and newborn information was extracted from the health records of infants born between 23 and 29 weeks of gestation in the Medical Information Mart for Intensive Care III (MIMIC-III) critical care database. Applicable machine learning models predicting survival during the initial NICU admission were developed and compared. The same type of model was also examined using only features that would be available prepartum for the purpose of survival prediction prior to an anticipated preterm birth. Features most correlated with the predicted outcome were determined when possible for each model.

RESULTS

Of included patients, 37 of 459 (8.1%) expired. The resulting random forest model showed higher predictive performance than the frequently used Score for Neonatal Acute Physiology With Perinatal Extension II (SNAPPE-II) NICU model when considering extremely preterm infants of very low birth weight. Several other machine learning models were found to have good performance but did not show a statistically significant difference from previously available models in this study. Feature importance varied by model, and those of greater importance included gestational age; birth weight; initial oxygenation level; elements of the APGAR (appearance, pulse, grimace, activity, and respiration) score; and amount of blood pressure support. Important prepartum features also included maternal age, steroid administration, and the presence of pregnancy complications.

CONCLUSIONS

Machine learning methods have the potential to provide robust prediction of survival in the context of extremely preterm births and allow for consideration of additional factors such as maternal clinical and socioeconomic information. Evaluation of larger, more diverse data sets may provide additional clarity on comparative performance.

Markers of platelet activation foR identification of late onset sEpsis in infaNTs: PARENT study protocol

BACKGROUND

Newborns are at high risk of sepsis. At present there is no definitive "rule in" blood test for sepsis at the point of clinical concern. A positive blood culture remains the gold standard test for neonatal sepsis, however laboratory markers that correlate prospectively with culture positive sepsis could aid clinicians in making decisions regarding administration of empiric antibiotic therapies.

METHODS

This multi-site, prospective observational study will take place in two neonatal intensive care units (National Maternity Hospital and Rotunda Hospital, Dublin). Neonates born at less than 34 weeks will be enroled and informed consent obtained prior to late onset sepsis work up. If at any point subsequently during their neonatal intensive care stay they develop signs and symptoms of possible sepsis requiring blood culture, an additional sodium citrate sample will be obtained. Infants will be categorised into three groups as follows: (i) culture positive sepsis, (ii) culture negative sepsis where an infant receives 5 days of antibiotics (iii) non sepsis. Our primary outcome is to establish if differential platelet/endothelial activation can prospectively identify neonatal culture positive late onset sepsis.

TRIAL REGISTRATION NUMBER

NCT05530330 IMPACT: Preterm infants are a high risk group for the development of sepsis which is a major cause of mortality in this population. Platelets have been associated with host response to invasive bacterial infections both in animal models and translational work. A positive blood culture is the gold standard test for neonatal sepsis but can be unreliable due to limited blood sampling in the very low birth weight population. This study hopes to establish if platelet/endothelial associated plasma proteins can prospectively identify late onset neonatal sepsis.

Ischemia modified albumin as a marker of hypoxia in preterm infants in the first week after birth

BACKGROUND

Tissue hypoxia remains a leading cause of morbidity and mortality in preterm infants. Current biomarkers often detect irreversible hypoxic cellular injury (i.e. lactate) and are non-specific. A new biomarker is needed which detects tissue hypoxia before irreversible damage occurs.

AIMS

To investigate the relation between serum ischemia modified albumin (IMA), a marker of hypoxia; and analytic variables, patient related variables and conditions associated with hypoxia, in preterm infants.

STUDY DESIGN

Retrospective cohort study.

SUBJECTS

Infants with a gestational age < 30 weeks and/or birth weight < 1000 g.

OUTCOME MEASURES

We collected two remnant blood samples in the first week after birth and measured IMA. IMA/albumin ratio (IMAR) was used to adjust for albumin. We assessed correlations between IMA(R) and analytic variables (albumin, lipemia- and haemolysis index); mean-2 h SpO2; mean-2 h variability of regional splanchnic oxygen saturation (rsSO2), measured using near-infrared spectroscopy; and patent ductus arteriosus (PDA).

RESULTS

Sixty-five infants were included. Albumin, the lipemia- and haemolysis index correlated negatively with IMA (r:-0.620, P<0.001; r:-0.458, P<0.001; and r:-0.337, P=0.002). IMAR correlated negatively with SpO2 (rho:-0.614, P<0.001). Lower rsSO2 variability correlated with higher IMAR values (rho:-0.785, n=14, P=0.001 and rho:-0.773, n=11, P=0.005). Infants with a hemodynamic significant PDA (hsPDA) had higher IMAR values than infants without PDA (0.13 [0.11-0.28], n=16 vs. 0.11 [0.08-0.20], n=29, P=0.005 and 0.11 [0.09-0.18], n=13 vs. 0.09 [0.06-0.17], n=37, P=0.026).

CONCLUSIONS

When adjusted for albumin, the lipemia- and haemolysis index, IMAR has potential value as a marker for systemic hypoxia in preterm infants, considering the associations with SpO2, variability of rsSO2, and hsPDA.

Pain/Stress, Mitochondrial Dysfunction, and Neurodevelopment in Preterm Infants

INTRODUCTION

Preterm infants experience tremendous early life pain/stress during their neonatal intensive care unit (NICU) hospitalization, which impacts their neurodevelopmental outcomes. Mitochondrial function/dysfunction may interface between perinatal stress events and neurodevelopment. Nevertheless, the specific proteins or pathways linking mitochondrial functions to pain-induced neurodevelopmental outcomes in infants remain unidentified. Our study aims to investigate the associations among pain/stress, proteins associated with mitochondrial function/dysfunction, and neurobehavioral responses in preterm infants.

METHODS

We conducted a prospective cohort study, enrolling 33 preterm infants between September 2017 and July 2022 at two affiliated NICUs located in Hartford and Farmington, CT. NICU Network Neurobehavioral Scale (NNNS) datasets were evaluated to explore potential association with neurobehavioral outcomes. The daily pain/stress experienced by infant's during their NICU stay was documented. At 36-38 weeks post-menstrual age (PMA), neurobehavioral outcomes were evaluated using the NNNS and buccal swabs were collected for further analysis. Mass spectrometry-based proteomics was conducted on epithelial cells obtained from buccal swabs to evaluate protein expression level. Lasso statistical methods were conducted to study the association between protein abundance and infants' NNNS summary scores. Multiple linear regression and Gene Ontology (GO) enrichment analyses were performed to examine how clinical characteristics and neurodevelopmental outcomes may be associated with protein levels and underlying molecular pathways.

RESULTS

During NICU hospitalization, preterm premature rupture of membrane (PPROM) was negatively associated with neurobehavioral outcomes. The protein functions including leptin receptor binding activity, glutathione disulfide oxidoreductase activity and response to oxidative stress, lipid metabolism, and phosphate and proton transmembrane transporter activity were negatively associated with neurobehavioral outcomes; in contrast, cytoskeletal regulation, epithelial barrier, and protection function were found to be associated with the optimal neurodevelopmental outcomes. In addition, mitochondrial function-associated proteins including SPRR2A, PAIP1, S100A3, MT-CO2, PiC, GLRX, PHB2, and BNIPL-2 demonstrated positive association with favorable neurodevelopmental outcomes, while proteins of ABLIM1, UNC45A, keratins, MUC1, and CYB5B showed positive association with adverse neurodevelopmental outcomes.

CONCLUSION

Mitochondrial function-related proteins were observed to be associated with early life pain/stress and neurodevelopmental outcomes in infants. Large-scale studies with longitudinal datasets are warranted. Buccal proteins could be used to predict potential neurobehavioral outcomes.

The effects of gestational age on neonatal cholestasis: A retrospective cohort study

BACKGROUND

Reference guidelines for neonatal conjugated hyperbilirubinemia (cholestasis) management use a uniform approach regardless of gestational age (GA). We hypothesize that the clinical pattern of neonatal cholestasis is tightly related to GA. The aim of this study was to describe the effects of GA on neonatal cholestasis.

METHODS

A retrospective 4-year cohort study in a 70-bed neonatal care unit. Neonates with conjugated bilirubin≥34.2μmol/L (2 mg/dL) were identified. The incidence, clinical characteristics, etiology, treatment, and prognosis were compared between infants <32 and≥32 weeks GA.

RESULTS

Overall incidence of cholestasis was 4% (125/3402). It was >5 times higher and the mean duration was >1.5 times longer in neonates <32 weeks GA (10% versus 1.8%, p <0.01 and 49 versus 31 days, p <0.01, respectively). The onset of cholestasis was later in neonates <32 weeks (22 versus 10 days of life, p <0.001). This later onset of cholestasis was associated with parenteral nutrition, whereas the earlier onset was associated with other causes. Treatment using fish oil lipids was more frequently administrated to infants <32 weeks GA, whereas Ursodeoxycholic acid was administrated more frequently in≥32 weeks GA. Cholestasis resolved during hospitalization in 73% of <32 versus 38% in≥32 weeks GA infants (p <0.01).

CONCLUSIONS

The incidence, clinical presentation, etiology, treatment, and clinical evolution of neonatal cholestasis were all significantly affected by GA. Our results support the use of a GA-oriented approach for the management of neonatal cholestasis.