Gestational assessment assessed

A Multifunctional, Low Cost and Sustainable Neonatal Database System

Continuous improvement in the clinical performance of neonatal intensive care units (NICU) depends on the use of locally relevant, reliable data. However, neonatal databases with these characteristics are typically unavailable in NICUs using paper-based records, while in those using electronic records, the inaccuracy of data and the inability to customize commercial data systems limit their usability for quality improvement or research purposes. We describe the characteristics and uses of a simple, neonatologist-centered data system that has been successfully maintained for 30 years, with minimal resources and serving multiple purposes, including quality improvement, administrative, research support and educational functions. Structurally, our system comprises customized paper and electronic components, while key functional aspects include the attending-based recording of diagnoses, integration into clinical workflows, multilevel data accuracy and validation checks, and periodic reporting on both data quality and NICU performance results. We provide examples of data validation methods and trends observed over three decades, and discuss essential elements for the successful implementation of this system. This database is reliable and easily maintained; it can be developed from simple paper-based forms or used to supplement the functionality and end-user customizability of existing electronic medical records. This system should be readily adaptable to NICUs in either high- or limited-resource environments.

Newborn joint mechanics

INTRODUCTION

We aimed to evaluate joint mechanics in newborn by goniometric assessment of major joints in healthy babies born at different gestational ages (GAs).

MATERIALS AND METHODS

An institution based observational study was carried out on healthy newborn babies within two days of birth. Study subjects were born at 28-41 completed weeks of gestation. The major joints of upper and lower limbs were assessed with manual goniometer for joint angles in relation to specific passive movements and range of motion (ROM) calculated where applicable. All measurements were made by a single observer with careful consideration of plane of movement and axes involved. Strength of association between joint angles and GA was quantified by Pearson's r coefficient.

RESULTS

Six major joints (shoulder, elbow, wrist, hip, knee, and ankle) were evaluated on either side in 433 babies. No significant differences were found between male and female babies and left or right side of the body. For most joints, a secular declining trend of joint angle or ROM was noted with good to strong inverse correlation with GA. The strongest associations were for flexion-extension ROM and adduction-abduction ROM at shoulder, palmar flexion at wrist and dorsiflexion at ankle joint with r values of -0.76, -0.75, -0.75, and -0.75, respectively.

CONCLUSIONS

The reading of a specific joint angle in the newborn infants was found to be dependent on GA. Precise calibration of gestation appropriate joint angles had laid down the foundation for functional assessment of multimodal joint mechanics.HighlightsEvaluation of newborn joint angles require stringent attention toward the plane and axis of the particular joint movement being assessed.Major joint angles and range of motion in newborn infants were observed to follow a secular declining trend according to the gestational age.Precise estimation of gestation appropriate joint angle will be helpful to understand the mechanics of musculoskeletal medicine in newborn.

Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers

Objective

Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria.

Methods

We conducted a retrospective analysis of maternity register data from March–September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3^rd and 97^th birth weight percentiles for GA of the INTERGROWTH-21^st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks.

Results

In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.

Conclusions

Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.

Determining gestational age using genome methylation profile: A novel approach for fetal medicine

Gestational age determination by traditional tools (last menstrual period, ultrasonography measurements and Ballard Maturational Assessment in newborns) has major limitations and therefore there is a need to find different approaches. In this study, we looked for a molecular marker that can be used to determine the accurate gestational age of the newborn. To this end, we performed reduced representation bisulfite sequencing (RRBS) on 41 cord blood and matching placenta samples from women between 25 and 40 weeks of gestation and generated an epigenetic clock based on the methylation level at different loci in the genome. We identified a set of 332 differentially methylated regions (DMRs) that undergo demethylation in late gestational age in cord blood cells and can predict the gestational age (r = -.7, P = 2E-05). Once the set of 411 DMRs that undergo de novo methylation in late gestational age was used in combination with the first set, it generated a more accurate clock (R = .77, P = 1.87E-05). We have compared gestational age determined by Ballard score assessment with our epigenetic clock and found high concordance. Taken together, this study demonstrates that DNA methylation can accurately predict gestational age and thus may serve as a good clinical predictor.

Evolution of clinical method for new-born infant maturity assessment

In the routine practice of neonatology, differentiating preterm premature new-born from small-for-date (SFD) new-born infant is an essential aspect to anticipate different clinical scenarios and monitor accordingly. Clinical assessment of new-born maturity is an invincible tool in resource poor areas for the purpose, without any prior investment. Over the past decades, clinical method for new-born infant maturity assessment has evolved intricately. From defining prematures with a mere statement of birth weight to clinical assessment of new-born as per gestational age with a comprehensive scheme based on neural and physical maturity characteristics of a new-born, clinical method for new-born maturity assessment has evolved substantially to the present where we stand. A complete review on the evolutionary history of clinical method for new-born infant maturity assessment will enable researchers in this field to get acquainted with the trend of past research work in accordance to the recent advancement all over the world. In the process, the lacunae still present in this area of study can be spotted which will invite new research proposals. Looking into the recent context, clinical method for assessing new-born infant maturity is making further forward shift with an attempt to quantify neuromuscular maturity criteria with further precision and incorporation of additional criteria."What is known - What is New" (Authors' summary)What is knownNeuro-muscular and external physical characteristic assessment together has greater significance for evaluating new-born infant's maturity as per gestational age over using individual one of them.Evaluation of brain maturity through passive muscle tone assessment of new-born infants with different maneuvers has the imperative role in determining new-born infant maturity.What is newClinical method for determining new-born infant maturity as per gestational age is being made explicit with the incorporation of criteria like feeding behavior of the new-born and objective assessment of anthropometric parameters, beside neuro-muscular and external physical characteristics evaluation.Neuro-muscular maturity can be quantified further with absolute values or closer range of values of different maneuvers and signs used in the clinical method for evaluating new-born infant maturity as per gestational age with more precision.

Accurate prediction of gestational age using newborn screening analyte data

BACKGROUND

Identification of preterm births and accurate estimates of gestational age for newborn infants is vital to guide care. Unfortunately, in developing countries, it can be challenging to obtain estimates of gestational age. Routinely collected newborn infant screening metabolic analytes vary by gestational age and may be useful to estimate gestational age.

OBJECTIVE

We sought to develop an algorithm that could estimate gestational age at birth that is based on the analytes that are obtained from newborn infant screening.

STUDY DESIGN

We conducted a population-based cross-sectional study of all live births in the province of Ontario that included 249,700 infants who were born between April 2007 and March 2009 and who underwent newborn infant screening. We used multivariable linear and logistic regression analyses to build a model to predict gestational age using newborn infant screening metabolite measurements and readily available physical characteristics data (birthweight and sex).

RESULTS

The final model of our metabolic gestational dating algorithm had an average deviation between observed and expected gestational age of approximately 1 week, which suggests excellent predictive ability (adjusted R-square of 0.65; root mean square error, 1.06 weeks). Two-thirds of the gestational ages that were predicted by our model were accurate within ±1 week of the actual gestational age. Our logistic regression model was able to discriminate extremely well between term and increasingly premature categories of infants (c-statistic, >0.99).

CONCLUSION

Metabolic gestational dating is accurate for the prediction of gestational age and could have value in low resource settings.

Evaluation of gestational age estimate method on the calculation of preterm birth rates

The objectives of this study is to evaluate the impact of vital record gestational age estimation method on resulting preterm birth (PTB) rate calculations. This retrospective analysis reviewed three methods of gestational age estimation using all Ohio live birth records from 2006 to 2009. PTB rates were calculated using each gestational age representation and agreement between classifications of PTB was evaluated with respect to maternal age and race. For each of 608,530 births, gestational age estimates based on last menstrual period (LMP) were compared to clinically-based obstetric estimates. When gestational age estimates did not perfectly agree, differences in the consequential classification of PTB status were evaluated with respect to a third reconciliatory combined gestational age estimate. Mean birth weight at each week of gestation was calculated and compared for all three estimate methods. Substantial agreement was found in PTB classification among gestational age estimates (kappa: 0.748; 95% Confidence Interval: 0.745-0.750); agreement was weakest among black mothers and among mothers less than 20 years of age. LMP-based gestational age estimates did not perfectly agree with obstetric estimates in 238,262 records (39.2%). Disagreement in gestational age led to disagreement in PTB status in 32,033 records (5.3% of total cases) resulting in a 1.8 percentage point difference in PTB rate calculations (11.0% using obstetric and 12.8% using combined estimates). Researchers and policy makers need consistency in selecting which gestational age estimate method to use when calculating or comparing PTB rates.

15-year follow-up of recurrent "hypoglycemia" in preterm infants

BACKGROUND

Observational study of 543 infants who weighed <1850 g, published in 1988 reported seriously impaired motor and cognitive development at 18 months in those with recurrent, asymptomatic hypoglycemia (plasma glucose level ≤2.5 mmol/L on ≥3 days). No study has yet replicated this observation.

AIM

To quantify disability in a similar cohort of children followed up throughout childhood.

POPULATION

All children born at <32 weeks' gestation in the north of England in 1990-1991 and had laboratory blood glucose levels measured daily for the first 10 days of life.

RESULTS

Forty-seven index children of the 566 who survived to 2 years had a blood glucose level of ≤2.5 mmol/L on ≥3 days. All of these children and hypoglycemia-free controls, matched for hospital of care, gestation, and birth weight, were assessed at age 2. No differences in developmental progress or physical disability were detected. The families were seen again when the children were 15 years old, and 38 of the index children (81%) and matched controls agreed to detailed psychometric assessment. Findings in the 2 groups were nearly identical (mean full-scale IQ: 80.7 vs 81.2). Findings in the 21 children with a level of ≤2.5 mmol/L on ≥4 days, 7 children with a level this low on 5 days, and 11 children with a level of <2.0 mmol/L on 3 different days did not alter these conclusions.

CONCLUSIONS

This study found no evidence to support the belief that recurrent low blood glucose levels (≤2.5 mmol/L) in the first 10 days of life usually pose a hazard to preterm infants.

Neonatal mortality risk associated with preterm birth in East Africa, adjusted by weight for gestational age: individual participant level meta-analysis

BACKGROUND

Low birth weight and prematurity are amongst the strongest predictors of neonatal death. However, the extent to which they act independently is poorly understood. Our objective was to estimate the neonatal mortality risk associated with preterm birth when stratified by weight for gestational age in the high mortality setting of East Africa.

METHODS AND FINDINGS

Members and collaborators of the Malaria and the MARCH Centers, at the London School of Hygiene & Tropical Medicine, were contacted and protocols reviewed for East African studies that measured (1) birth weight, (2) gestational age at birth using antenatal ultrasound or neonatal assessment, and (3) neonatal mortality. Ten datasets were identified and four met the inclusion criteria. The four datasets (from Uganda, Kenya, and two from Tanzania) contained 5,727 births recorded between 1999-2010. 4,843 births had complete outcome data and were included in an individual participant level meta-analysis. 99% of 445 low birth weight (< 2,500 g) babies were either preterm (< 37 weeks gestation) or small for gestational age (below tenth percentile of weight for gestational age). 52% of 87 neonatal deaths occurred in preterm or small for gestational age babies. Babies born < 34 weeks gestation had the highest odds of death compared to term babies (odds ratio [OR] 58.7 [95% CI 28.4-121.4]), with little difference when stratified by weight for gestational age. Babies born 34-36 weeks gestation with appropriate weight for gestational age had just three times the likelihood of neonatal death compared to babies born term, (OR 3.2 [95% CI 1.0-10.7]), but the likelihood for babies born 34-36 weeks who were also small for gestational age was 20 times higher (OR 19.8 [95% CI 8.3-47.4]). Only 1% of babies were born moderately premature and small for gestational age, but this group suffered 8% of deaths. Individual level data on newborns are scarce in East Africa; potential biases arising due to the non-systematic selection of the individual studies, or due to the methods applied for estimating gestational age, are discussed.

CONCLUSIONS

Moderately preterm babies who are also small for gestational age experience a considerably increased likelihood of neonatal death in East Africa.

Growth of a cohort of very low birth weight infants in Johannesburg, South Africa

Background

Little is known about the growth of VLBW infants in South Africa. The aim of this study was to assess the growth of a cohort of VLBW infants in Johannesburg.

Methods

A secondary analysis of a prospective cohort was conducted on 139 VLBW infants (birth weight ≤1500 g) admitted to Charlotte Maxeke Johannesburg Academic Hospital. Growth measurements were obtained from patient files and compared with the World Health Organization Child Growth Standards (WHO-CGS) and with a previous cohort of South African VLBW infants. The sample size per analysis ranged from 11 to 81 infants.

Results

Comparison with the WHO-CGS showed initial poor growth followed by gradual catch up growth with mean Z scores of 0.0 at 20 months postmenstrual age for weight, -0.8 at 20 months postmenstrual age for length and 0.0 at 3 months postmenstrual age for head circumference. Growth was comparable with that of a previous cohort of South African VLBW infants in all parameters.

Conclusions

Initial poor growth in the study sample was followed by gradual catch up growth but with persistent deficits in length for age at 20 months postmenstrual age relative to healthy term infants.

Anthropometric measurements for neonates, 23 to 29 weeks gestation, in the 1990s

Reference data describing weight, length, and head circumference (anthropometric measurements) at birth were published by Lubchenco and Usher before 1970. Few attempts have been made to investigate whether these data are appropriate for today's cohort of preterm neonates. We analysed anthropometric data for neonates born between 23 and 29 weeks' gestation. Reference charts were developed from the measurements obtained from neonatal records, and gestational age, obtained from maternal charts, on 975 neonates delivered at four neonatal centres in Michigan during 1992 and 1997. The analysis was confined to children with gestational age that was consistent or within 7 days by last menstrual period, obstetric examination, ultrasound and neonatal determinations. At 23 to 29 weeks' gestation, ethnicity and multiple births did not have any significant impact on birthweight but girls were lighter. We compared our anthropometric charts with those presently being used at many neonatal centres. In our study, physical measurements at birth of preterm neonates born between 1992 and 1997 were significantly different from those currently used to assess growth status. Furthermore data derived from published studies that utilised birth certificates with gestational age based on last menstrual period seem to overestimate birthweight. For preterm infants, our findings are concordant with recently published values from 18 states of the US. Because of improved survival, gestational age assessment and perinatal care of preterm neonates, development of new reference anthropometric measurements for neonates is overdue. Our Michigan data of 23-29 weeks preterm provides new national reference values, which we recommend for use in US neonatal centres for extremely preterm neonates.

Assessment of gestational age and neuromaturation

Neuromaturation is the functional development of the central nervous system (CNS). It is by its very nature a dynamic process, a continuous interaction between the genome and first the intrauterine environment, then the extrauterine environment. Understanding neuromaturation and being able to measure it is fundamental to infant neurodevelopmental assessment. Fetal and preterm neuromaturation has become easier to observe with the advent of prenatal ultrasonography and neonatal intensive care units. A number of measures of degree of fetal maturation have been developed and used to estimate gestational age (GA) at birth. The most reliable measures of GA are prenatal measures, especially from the first trimester. Postnatal GA measurements tend to be least accurate at the extremes of gestation, that is, in extremely preterm and post-term infants. Observations of measures of neuromaturation in infants born to mothers with pregnancy complications, including intrauterine growth restriction, multiple gestation, and chronic hypertension, have led to the discovery that stressed pregnancies may accelerate fetal pulmonary and CNS maturation. This acceleration of neuromaturation does not occur before 30 weeks' gestation and has a cost with respect to cognitive limitations manifested in childhood. The ability to measure fetal and preterm neuromaturation provides an assessment of neurodevelopmental progress that can be used to reassure parents or identify at risk infants who would benefit from limited comprehensive follow-up and early intervention services. In addition, measures of neuromaturation have the potential to provide insight into mechanisms of CNS injury and recovery, much-needed early feedback in intervention or treatment trials and a measure of early CNS function for research into the relationships between CNS structure and function.

Birth weight by gestational age for Albertan liveborn infants, 1985 through 1998

OBJECTIVES

(1) To provide percentile tables and graphs of birth weight by gestational age and by gender, for singleton and twin liveborn neonates. (2) To determine changes in birth weight relative to gestational age over the study period.

METHODS

Data on 556,775 singletons and 12,125 twins, born alive in Alberta from 1985 through 1998, were obtained from Alberta Registries - Vital Statistics. Mean birth weights for individual and grouped years were compared by independent two-tailed t-tests. Linear trends in birth weight over the 14-year period were obtained using one-way analyses of variance.

RESULTS

Four tables and corresponding graphs showing birth weight for gestational age by gender for 21 through 44 completed weeks gestation provide data for the 1st to 99th percentile. Changes in birth weight for the combined gestational ages included an increase for singletons (male, F 17.6, p < 0.001; female, F 53.3, p < 0.001), and a decrease for female twins (F 5.8, 0.004). The increase for singletons was seen at 38 through 42 weeks gestation for both genders. No change occurred under 38 weeks except in singleton females of 33 to 35 weeks with a decrease in birth weight observed from 2636 +/- 539 g, 1985 to 2576 +/- 479 g, 1998; t 2.5, p = 0.002.

CONCLUSIONS

The graphs and tables established in this study represent a specific geographic area and population. They may be relevant as a reference for other geographic regions and populations. The clinical significance of the observed increased birth weight among term, but not preterm newborns, requires critical evaluation.

Hyaline membrane disease in a term neonate

Hyaline membrane disease is primarily a disorder of preterm infants. Its occurrence in term infants is very uncommon and therefore may escape attention. We describe a term infant who developed severe respiratory distress soon after birth. Diagnosis of hyaline membrane disease was revealed at autopsy.

[Outcome of 249 premature infants, less than 29 weeks gestational age]

The aim of this paper was to report the vital and neurological outcome of 249 preterm infants of less than 29 weeks born between 1990 and 1996, and included in a prospective study until two years of age.

RESULTS

The initial mortality rate was 19%. This was related to gestational age and severe transfontanellar ultrasonographically (TFU) detected abnormalities. The rate of follow-up at two years of age was 98%. Neurological sequelae amounted to 12.8%, including four cases of deafness. The possibility of survival without neurological sequelae increased from 52% at 24-25 weeks to 72% at 26-28 weeks of gestational age (p < 0.005). The presence of sequelae was significantly related to severe cranial ultrasonographically-detected abnormalities, to parental social level, and to early neonatal anemia. Normal TFU and/or isolated periventricular hyperechogenicity could not exclude the presence of neurological sequelae which, however, appeared to be less severe than at the onset.

CONCLUSION

Gestational age, severe TFU abnormalities and neonatal anemia play a major role in the rate of mortality and in the neurological sequelae in preterm infants, and can influence the decisions concerning the treatment of this pediatric population.

Pulse oximetry, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation

AIM

To determine whether differing policies with regard to the control of oxygen saturation have any impact on the number of babies who develop retinopathy of prematurity and the number surviving with or without signs of cerebral palsy at one year.

METHODS

An examination of the case notes of all the 295 babies who survived infancy after delivery before 28 weeks gestation in the north of England in 1990-1994.

RESULTS

Babies given enough supplemental oxygen to maintain an oxygen saturation of 88-98%, as measured by pulse oximetry, for at least the first 8 weeks of life developed retinopathy of prematurity severe enough to be treated with cryotherapy four times as often as babies only given enough oxygen to maintain an oxygen saturation of 70-90% (27.2% v 6.2%). Surviving babies were also ventilated longer (31.4 v 13.9 days), more likely to be in oxygen at a postmenstrual age of 36 weeks (46% v 18 %), and more likely to have a weight below the third centile at discharge (45% v 17%). There was no difference in the proportion who survived infancy (53% v 52%) or who later developed cerebral palsy (17% v 15%). The lowest incidence of retinopathy in the study was associated with a policy that made little use of arterial lines.

CONCLUSIONS

Attempts to keep oxygen saturation at a normal "physiological" level may do more harm than good in babies of less than 28 weeks gestation.

Ethnic differences in the growth of low-birthweight infants

Differences in growth were investigated among ethnic groups in low-birthweight babies (< 2500 g or < 32 weeks gestation) at birth and at 2-3 years. This prospective study was based on data for all 3091 low-birthweight live births in the South East Thames Region, UK, over a 1-year period, surviving to discharge from hospital. Weights were recorded at birth and at 2-3 years for 998 babies, and head circumferences for 859. These were compared with the UK 1990 reference standards. Ethnic differences were adjusted for parity, multiple birth, smoking and alcohol during pregnancy, mother's height, weight and age, marital status, partner's support and social class. At 2-3 years, there was substantial average catch-up growth only for the weight of infants of > or = 32 weeks' gestation. Babies < 32 weeks gestation had fallen behind. Head circumferences had failed to keep up or had fallen behind for both groups. The ethnic groups had similar birthweight standard deviation scores (SDS). At 2-3 years, Black babies of < 32 weeks' gestation had gained in weight and head circumference compared with White babies (adjusted difference in weight SDS: 0.71, [95% CI 0.28, 1.13]). Asian babies of at least 32 weeks' gestation had smaller heads than White, a difference that increased with time. It was concluded that ethnic differences in the growth of low-birthweight infants are related to gestational age. Although most of the babies born at < 28 weeks' gestation were close to their birthweight reference standards, only the Black infants had maintained their position at 2-3 years. Black infants, particularly when born preterm, tend to put on more weight than White.

Inaccuracy of Ballard scores before 28 weeks' gestation. National Institute of Child Health and Human Development Neonatal Research Network

OBJECTIVE

Ballard scores are commonly used to estimate gestational age (GA). The purpose of this study was to determine the accuracy of the New Ballard Score (NBS) for infants <28 weeks GA by accurate menstrual history and to evaluate NBS as an outcome predictor.

METHODS

Infants weighing 401 to 1500 g in 12 National Institute of Child Health and Human Development Neonatal Research Network centers had NBS performed before age 48 hours. Accuracy of NBS estimates of GA was assessed for infants with GA determined by accurate menstrual history. In a larger cohort of infants, NBS was included in regression models of the association of NBS and death, poor outcome, and duration of hospital stay.

RESULTS

At each week from 22 to 28 weeks GA by accurate menstrual history, NBS estimates exceeded GA by dates by 1.3 to 3.3 weeks, and estimates varied widely (range of widths of 95% CIs for the observations, 6.8 to 11.9 weeks). NBS did not contribute significantly to regression models of death, poor outcome, or duration of hospital stay.

CONCLUSIONS

Inaccuracies in GA determined by the NBS should be considered when treating extremely premature infants, particularly in decisions to forego or administer intensive care. Refinement of GA scoring systems is needed to optimize clinical benefit.