Implications of racial/ethnic perinatal health inequities on long-term neurodevelopmental outcomes and health services utilization

Infants born preterm and with low birth weight have increased risk for neurodevelopmental challenges later in life compared to term-born peers. These include functional motor impairment, cognitive and speech delays, neurobehavioral disorders, and atypical social development. There are well-documented inequities in the population distributions of preterm birth and associated short-term morbidities by race, ethnicity, language, and nativity. Far less is known about how these inequities affect long-term outcomes, though the impact of unequal access to post-discharge support services for preterm infants raises concerns about widening gaps in health, development, and functioning. In this review, we describe what is currently known about the impact of race, ethnicity, nativity, and language on long-term outcomes. We provide a framework for understanding inequities in social, political, and historical context. And we offer guidance for next steps to delineate mechanistic pathways and to identify interventions to eliminate inequities in long-term neurodevelopmental outcomes through research, intervention, and advocacy.

Invasive mechanical ventilation and biomarkers as predictors of bronchopulmonary dysplasia in preterm infants

OBJECTIVES

To evaluate the impact of invasive mechanical ventilation associated with two serum inflammatory cytokines and clinical indicators, on the second day of life, as predictors of bronchopulmonary dysplasia in very low birth weight preterm infants. It was hypothesized that the use of invasive mechanical ventilation in the first hours of life is associated with biomarkers that may predict the chances of preterm infants to develop bronchopulmonary dysplasia.

METHODS

Prospective cohort of 40 preterm infants with gestational age <34 weeks and birth weight <1500 g. The following were analyzed: clinical variables; types of ventilator support used (there is a higher occurrence of bronchopulmonary dysplasia when oxygen supplementation is performed by long periods of invasive mechanical ventilation); hospitalization time; quantification of two cytokines (granulocyte and macrophage colony stimulating factor [GM-CSF] and eotaxin) in blood between 36 and 48 h of life. The preterm infants were divided in two groups: with and without bronchopulmonary dysplasia.

RESULTS

The GM-CSF levels presented a significantly higher value in the bronchopulmonary dysplasia group (p = 0.002), while eotaxin presented higher levels in the group without bronchopulmonary dysplasia (p = 0.02). The use of continuous invasive mechanical ventilation was associated with increased ratios between GM-CSF and eotaxin (100% sensitivity and 80% specificity; receiver operating characteristic area = 0.9013, CI = 0.7791-1.024, p < 0.0001).

CONCLUSIONS

The duration of invasive mechanical ventilation performed in the first 48 h of life in the very low birth weight infants is a significant clinical predictor of bronchopulmonary dysplasia. The use of continuous invasive mechanical ventilation was associated with increased ratios between GM-CSF and eotaxin, suggesting increased lung injury and consequent progression of the disease.

[Risk factors and prognosis of bronchopulmonary dysplasia associated pulmonary hypertension in preterm infants]

Objective: To analyze clinical features, prognosis and risk factors of bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (PH). Methods: Clinical data of 338 infants with BPD were collected from the neonatal intensive care unit (NICU) in Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University between January 2016 and December 2018. These infants were divided into PH group and non-PH group. The clinical features and prognosis were compared between these two groups by Chi-square test or nonparametric test. Risk factors for BPD-PH were analyzed with binary logistic regression model. Results: Among the 338 BPD infants, 314 had no PH (92.9%) and 24 had PH (7.1%), with an average gestational age of (27.1±1.8) weeks, and 206 were males and 132 females.PH infants had younger gestational age ((26.4±2.1) vs. (27.2±1.7) weeks, t=2.201, P=0.028) and lower birth weight ((798±255) vs. (1 003±240) g, t=4.030, P<0.01), compared to non-PH infants. Besides, duration of mechanical ventilation and non-invasive positive pressure ventilation were higher in PH group than that in non-PH group (14.3 (2.1, 43.7) vs. 0.5 (0, 4.7) d, Z=-4.553, P<0.01; 30.0 (22.5, 64.2) vs. 15.0 (7.0, 26.0) d, Z=-4.838, P<0.01). The proportions of maternal hypertension, small for gestational age (SGA), late onset sepsis, ventilator associated pneumonia, hemodynamically significant patent ductus arteriosus (hsPDA), patent ductus arteriosus (PDA) requiring ligation, severe BPD and severe extrauterine growth retardation (EUGR) were higher in PH group than those in non-PH group ((20.8% (5/24) vs. 6.4% (20/314), 33.3% (8/24) vs. 7.6% (24/314), 54.2% (13/24) vs. 7.3% (23/314), 25.0% (6/24) vs. 6.1% (19/314), 75.0% (18/24) vs. 39.2% (123/314), 45.8% (11/24) vs. 1.9% (6/314), 66.7% (16/24) vs. 7.3% (23/314), 75.0% (18/24) vs. 45.5% (143/314), all P<0.05). Multivariate logistic regression analysis showed that maternal hypertension (OR=12.950, 95%CI: 1.740-96.385), severe bronchopulmonary dysplasia (OR=10.160, 95%CI: 2.725-37.884), SGA (OR=4.992, 95%CI: 1.432-16.920), PDA requiring ligation (OR=19.802, 95%CI: 3.297-118.921), severe EUGR (OR=20.316, 95%CI: 2.221-185.853) were independent risk factors of BPD associated PH. In the 24 infants with PH, all 7 mild PH infants and 8 moderate PH infants survived, while 4 out of 9 severe PH infants died. Among the survivors, the longest duration of oxygen therapy was up to the corrected gestational age of 1 year and 2 months. Conclusions: PH is a severe complication of BPD, and associated with higher mortality and poor prognosis. Echocardiography screening and regular post-discharge follow up are recommended for BPD infants with risk factors of PH.

[Risk factors for extrauterine growth retardation in very low birth weight infants: a multicenter study]

Objective: To investigate the incidence and risk factors of extrauterine growth retardation (EUGR) in very low birth weight infants (VLBWI). Methods: This prospective, multicenter observational cohort study was conducted based on Shandong Neonatal Network (SNN). The clinical data of the VLBWI (n=1 051), who were admitted to 27 neonatal intensive care units from January 1, 2018 to December 31, 2018, were collected and analyzed. According to the weight at discharge or 36 weeks of postmenstrual age, all the enrolled VLBWI were assigned into EUGR group and non-EUGR group. Univariate and multivariate logistic regression analyses were used to detect the risk factors for EUGR in preterm small for gestational age (SGA) and non-SGA infants. Results: A total of 1 051 VLBWI were enrolled, with 51.7% (543/1 051) male. The incidence of EUGR in the whole group was 60.7% (638/1 051), and were 78.3% (90/115) and 46.9% (53/113) in extremely low birth weight infant (ELBWI) and extremely preterm infants (EPI), respectively. The incidence of EUGR in SGA and non-SGA infants were 87.6% (190/217) and 53.7% (448/834), respectively. Logistic regression analysis showed that, withholding feeds (OR=1.531, 1.237, 95%CI: 1.180-1.987, 1.132-1.353, both P<0.01) and time to achieve full enteral feeding (OR=1.090, 1.023, 95%CI: 1.017-1.167, 1.002-1.045, P=0.014, 0.034) were independent risk factors of EUGR in both SGA and non-SGA infants. For SGA infants, cesarean delivery was an independent risk factor for EUGR (OR=8.147, 95%CI: 2.127-31.212, P=0.002); while for non-SGA infants, hypertensive disorders during pregnancy (OR=2.572, 95%CI: 1.496-4.421, P=0.001) and the duration of invasive ventilation (OR=1.050, 95%CI: 1.009 - 1.092, P=0.016) were independent risk factors of EUGR. Besides, moderate and severe bronchopulmonary dysplasia (OR=2.241, 95%CI: 1.173-4.281, P=0.015), necrotizing enterocolitis (OR=5.633, 95%CI: 1.333-23.796, P=0.019) and retinopathy of prematurity (OR=2.219, 95%CI: 1.268-3.885, P=0.005) were associated with EUGR. Conclusions: The incidence of weight-defined EUGR is high in VLBWI, especially in preterm SGA infants. Avoiding delaying feeds after birth and achieving full enteral feeding early may reduce the incidence of EUGR.

[Evaluation of human milk feeding in hospitalized very low and extremely low birth weight infants]

Objective: To investigate the current situation of human milk (HM) feeding in hospitalized very low and extremely low birth weight infants. Methods: The study retrospectively extracted the data of 601 infants with birth weight <1 500 g, and admitted within 24 hours after birth to the Neonatal Intensive Care Unit of Nanjing Maternity and Child Health Care Hospital from January 2016 to December 2018. The infants were grouped into exclusive mother's-own-milk (MOM) group, donor human milk (DHM) group (partial or none MOM), and mixed (HM and formula) feeding group according to the feeding strategy. Qualitative and quantitative variables in the three groups were compared with One-way ANOVA, Kruskal-Wallis test, Chi-square test or Fisher exact test. Kappa and McNemar test were used for consistency testing. Results: Among the 601 infants (309 boys and 292 girls), 6 (1.0%) infants had never been fed with MOM. The gestational age and birth weight were (29.3±1.9) weeks and 1 260(1 115, 1 400) g in 601 infants. A total of 8 (1.3%) infants were grouped into MOM group, 542 (90.2%) were grouped into DHM group, and 51 (8.5%) were grouped into mixed feeding group. The percentage of enteral feedings with MOM in the stage of hospitalization 1-7 d, 8-14 d and 15-28 d were 73.6% (42.9%, 86.7%), 97.5% (78.6%, 100.0%) and 99.3% (93.0%, 100.0%), respectively (H=414.95, P<0.01), and the pairwise comparison suggested that the stage of hospitalization 1-7 d was the lowest (adjusted both P<0.05). The average weight adjusted daily dose of MOM were 9.7 (4.3, 18.2), 59.1 (26.5, 93.5) and 116.0 (60.3, 142.6) ml/(kg·d) in the stage of hospitalization 1-7 d, 8-14 d and 15-28 d, respectively (H=759.75, P<0.01), and the pairwise comparison suggested that the stage of hospitalization 1-7 d was the lowest (adjusted both P<0.05). The weight adjusted daily dose of MOM in exclusive MOM group, DHM and Mixed feeding group were 95.2 (40.0, 117.2), 82.9(53.6, 103.1) and 55.7 (16.6, 97.5) ml/(kg·d), respectively (H=10.78, P=0.005).Additionally, the percentage and weight adjusted daily dose of MOM showed a general consistency of 0.703 (P>0.05, Kappa=0.408). Conclusions: The rate of exclusive MOM feeding is low, especially during the first 7 days of hospitalization. The percentage of total enteral feedings with MOM and the average weight adjusted daily dose of MOM can well evaluate the situation of HM feeding during hospitalization quantitively.

SURVIVAL UNTIL DISCHARGE OF VERY-LOW-BIRTH-WEIGHT INFANTS IN TWO CROATIAN PERINATAL CARE REGIONS: A RETROSPECTIVE COHORT STUDY OF TIME AND CAUSE OF DEATH

We investigated mortality, causes, timing and risk factors for death until hospital discharge in very-low-birth-weight (VLBW) infants born in two Croatian perinatal care regions. This retrospective study included 252 live born VLBW infants. The mortality rate until hospital discharge was 30.5% (77/252). VLBW infants who died had by 4 weeks lower gestational age (GA) than surviving infants (median GA, 25 vs. 29 weeks), lower birth weight (BW) (mean BW, 756.4 vs. 1126.4 g), lower 5-minute Apgar score (median 5 vs. 8) and were more often resuscitated at birth (41.6 vs. 19.4%; p<0.001 all). Infants who survived were more often small-for-gestational age (SGA) (28.0 vs. 15.6%; p=0.04) and more often received continuous-positive-airway-pressure (CPAP) in delivery room (13.1 vs. 2.6%; p=0.01). Multivariate logistic regression revealed that parameters influencing death until hospital discharge were 5-minute Apgar score (OR 0.780, 95% CI 0.648-0.939) and higher Clinical Risk Index for Babies (CRIB) score (OR 1.677, 95% CI 1.456-1.931). ROC analysis showed that CRIB score (AUC 0.927, sensitivity 92.2, specificity 81.1; p<0.001) was the strongest predictor of death until hospital discharge. In infants who died within 12 hours, death was most commonly attributed to immaturity and in those surviving >12 hours to necrotizing enterocolitis.

Reduction of Infection in Chinese Neonatal Intensive Care Units Using the Evidence-based Practice for Improving Quality Study Group. [Incidence and risk factors of severe intraventricular hemorrhage in very low and extremely low birth weight infants: a multi-center study]

Objective: To investigate the incidence and risk factors of severe intraventricular hemorrhage (IVH) in very low birth weight infants (VLBWI) and extremely low birth weight infants (ELBWI). Methods: The data were from "reduction of infection in Chinese neonatal intensive care units using the evidence-based practice for improving quality"study, which prospectively enrolled infants with gestational age less than 34 weeks, and were admitted within the first seven days of life in 25 tertiary neonatal intensive care units from May 2015 to April 2018. Clinical data of VLBWI and ELBWI, who had neuroimage examination during the hospitalization, were retrospectively extracted from the standard database and were secondarily-analyzed. Patients with congenital malformations were excluded. A total of 8 835 VLBWI and ELBWI were enrolled with 52.6% (4 643 cases) male, who were divided into severe IVH group and without IVH or mild IVH group. Descriptive statistics were used to analyze the incidence of severe IVH. Comparison between two groups and risk factors were analyzed with univariate and multivariate Logistic regression analysis. Results: The incidence of severe IVH in the 8 835 infants was 7.4% (650/8 835). And the incidences of severe IVH in ELBWI and preterm infants with gestational age ≤28 weeks were 13.5% (160/1 185) and 13.1% (368/2 800), respectively. The incidences of severe IVH in preterm infants with birth weight<750 g, 750-999 g, 1 000-1 249 g, 1 250-1 499 g were 21.1% (31/147), 12.4% (129/1 038), 8.3% (246/2 966) and 5.2% (244/4 684), respectively; and were 25.2% (55/218), 12.1% (313/2 582), 5.2% (243/4 649) and 2.8% (39/1 386) in the preterm infants with gestational age<26 weeks, 26-28(+6) weeks, 29-31(+6) weeks, 32-33(+6) weeks, respectively. Logistic regression analysis revealed that gestation age (OR=0.752, 95%CI: 0.687-0.823, P=0.000) and cesarean delivery (OR=0.733, 95%CI: 0.592-0.907, P=0.004) decreased the risks of severe IVH; while Apgar score ≤3 at 5 minutes (OR=1.897, 95%CI: 1.194-3.013, P=0.007), use of invasive mechanical ventilation within the first week (OR=1.499, 95%CI: 1.207-1.862, P=0.000), use of inotropic medications within the first week (OR=2.093, 95%CI: 1.724-2.541, P=0.000) increased the risks of severe IVH. Conclusions: The incidence of severe IVH is still significantly high among VLBWI and ELBWI. Low gestation age, non-cesarean delivery, Apgar score ≤3 at 5 minutes, use of invasive mechanical ventilation and inotropic medications within the first week of life will increase the risk of severe IVH.

[Predictive effect of neonatal morbidities on the poor outcomes at 12 months corrected age in very low birth weight premature infants]

Objective: To investigate the prognostic effect of neonatal morbidities on poor outcomes at 12 months corrected age in very low birth weight (VLBW) premature infants . Method: From November 2013 to October 2014, a multi-center retrospective study was conducted in 8 tertiary Maternal and Children's hospitals in Guangdong, Hunan and Fujian. The premature infants survived to a postmenstrual age (PMA) of 36 weeks with birth weight less than 1 500 g and without congenital diseases were included, and divided into two groups according to poor outcomes. The birth weight, gestational age, morbidities and poor outcomes (death, cerebral palsy, cognitive delay, et al) were recorded. Data were analyzed with Chi-square test to investigate the relationship between morbidities and poor outcomes. And the predictive effect of the top three morbidities were analyzed by Logistic regression analysis. Result: Total of 834 VLBW premature infants (473 boys and 361 girls) finished the follow-up, whose average gestational age and birth weight were (30.6±1.8) weeks and (1 189±159)g. The incidences of BPD, severe ROP, NEC, brain injury and sepsis were 207 (24.8%), 119 (14.3%), 58 (7.0%), 281 (33.7%) and 124 (14.9%), respectively. There were significant differences between the two groups in the incidences of BPD, severe ROP, NEC, brain injury and sepsis(χ(2)=42.10, 47.20, 4.81, 44.28, 18.63, all P<0.01), which had significant correlation with poor outcomes at 12 months corrected age. The three top morbidities were severe ROP, BPD and brain injury(OR=3.82, 2.90, 2.80). Combined morbidities with BPD, severe ROP and brain injury correlated with higher risk of poor outcomes (one morbidity, OR=3.14, β=1.15; two morbidities, OR=7.31, β=1.99; three morbidities, OR=22.41, β=3.11; all P<0.01). Conclusion: BPD, severe ROP, NEC, brain injury and sepsis were the risk factors of poor outcomes at 12 months corrected age in VLBW infants. And the more combined morbidities with severe ROP, BPD and brain injury, the higher risk of poor outcomes in this population. Trial registration Clinical Trails, NCT03104946.

Chronic Placental Inflammation as a Risk Factor of Severe Retinopathy of Prematurity

Background

Chronic placental inflammation (CPI) has been implicated in the pathogenesis of diseases in premature infants, whereas retinopathy of prematurity (ROP) is a major complication primarily affecting preterm and very low-birth-weight (VLBW) infants. This study aims to investigate the association between CPI and ROP in VLBW infants.

Methods

We performed a retrospective review of clinical records of VLBW infants born between 2013 and 2016. Placental pathology findings including CPI cases were analyzed using logistic regression to study infants’ morbidities and other clinical characteristics.

Results

A total of 402 infants with a mean (standard deviation) gestational age of 28.5 (2.8) weeks and birth weight of 1,027.2 (304.4) g were included. The incidence of ROP was 24.1%. CPI was found in 90 infants (22.4%), among which 28.9% (26 of 90) developed ROP, and 21.1% (19 of 90) underwent laser photocoagulation. Lower gestational age, lower birth weight, longer duration of oxygen supply, and presence of CPI were associated with the development of ROP. After adjustment for gestational age, birth weight, sex, duration of oxygen supply, and other overlapping placental pathology, CPI was associated with the odds for type 1 ROP that required laser photocoagulation (adjusted odds ratio, 2.739; 95% confidence interval, 1.112 to 6.749; p = .029).

Conclusions

CPI was associated with severe ROP requiring treatment with laser photocoagulation in VLBW infants.

[Use of noninvasive high-frequency oscillatory ventilation in very low birth weight infants]

Objective: To evaluate the effectiveness and safety of the use of noninvasive high-frequency oscillation ventilation (nHFOV) in very low birth weight infants. Method: A total of 36 cases received nHFOV between January 2016 and October 2016 in Children's Hospital, Zhejiang University School of Medicine, including 24 males and 12 females, with the gestational age of (27.5±2.5) weeks and birth weight of(980±318)g. The data of the ventilator settings, side effects, and changes of the respiratory function before and after nHFOV were collected and analyzed retrospectively. Nonparametric tests or t tests or χ(2) tests were used. Result: Thirty-two (89%) out of the 36 cases successfully avoided intubation or re-intubation after using of nHFOV. nHFOV was used as the rescue treatment after failure of other noninvasive ventilation in 17 cases, and as the prophylactical treatment preventing re-intubation after extubation in the remaining 19 cases. There were significant decreases in the incidences of apnea and desaturation(SpO(2)<0.85), the level of PaCO(2, )and the FiO(2) 24 h after the initiation of the nHFOV as the rescue therapy((1.2±1.1)vs.(6.3±2.1)episodes , (1.1±1.2) vs.(4.3±1.5) episodes, (43±8) vs.(56±10) mmHg, 0.30±0.07 vs. 0.39±0.11, respectively; 1 mmHg=0.133 kPa, t=7.562, 8.913, 4.179, 3.437 respectively, all P<0.01). No significant changes were found in FiO(2) and PaCO(2) levels 24 h after initiation of nHFOV as the prophylactical therapy after extubation (0.42±0.12 vs.0.40±0.10, (49±8)vs.(48±7)mmHg, t=0.872 and 0.501 respectively, both P>0.05), except for the significant decreases in the mean airway pressure ((7.9±2.6)vs.(9.6±1.6)cmH(2)O, 1 cmH(2)0=0.098 kPa, t=2.198, P=0.041). There were 4 cases suffered from nasal septum injury, while no other nHFOV related complications were noted. Conclusion: nHFOV can be applied in preterm infants as a rescue treatment after the failure of other noninvasive ventilation, or prophylactically used in patients who have high risk of re-intubation.

Associations between maternal scaffolding and executive functioning in 3 and 4 year olds born very low birth weight and normal birth weight

BACKGROUND

Deficits in executive function, including measures of working memory, inhibition and cognitive flexibility, have been documented in preschoolers born very low birth weight (VLBW) compared with preschoolers born normal birth weight (NBW). Maternal verbal scaffolding has been associated with positive outcomes for both at-risk and typically developing preschoolers.

AIMS

The purpose of this study was to examine associations between maternal verbal scaffolding, Verbal IQ (VIQ) and executive function measures in preschoolers born VLBW.

SUBJECTS

A total of 64 VLBW and 40 NBW preschoolers ranging in age from 3 ½ to 4 years participated in the study.

OUTCOME MEASURES

VIQ was measured with the Wechsler Preschool and Primary Scale of Intelligence - Third Edition. Executive function tests included the Bear Dragon, Gift Delay Peek, Reverse Categorization and Dimensional Change Card Sort-Separated Dimensions.

STUDY DESIGN

Maternal verbal scaffolding was coded during a videotaped play session. Associations between maternal verbal scaffolding and preschoolers' measures of VIQ and executive function were compared. Covariates included test age, maternal education, and gender.

RESULTS

Preschoolers born VLBW performed significantly worse on VIQ and all executive function measures compared to those born NBW. Maternal verbal scaffolding was associated with VIQ for VLBW preschoolers and Gift Delay Peek for the NBW group. Girls born VLBW outperformed boys born VLBW on VIQ and Bear Dragon.

CONCLUSION

Integrating scaffolding skills training as part of parent-focused intervention may be both feasible and valuable for early verbal reasoning and EF development.

Successful resuscitation of an extremely low birth weight premature infant in delma island community hospital, United arab emirates

Because of their physical size and physiological immaturity, resuscitation of extremely very low birth weight premature infants is a big dilemma for neonatologists in any hospital. The resuscitation may present an additional challenge to the caregiver if it is undertaken in a remote community hospital with limited technical facilities and health personnel. We present the case of successful resuscitation of a 23-week-old premature infant, with a birth weight of 650 g, at Delma Island Community Hospital, United Arab Emirates. Despite the comparatively limited facilities for such a resuscitation, the rapid ethical decisions made when considering the resuscitation of such a borderline viable fetus, were key in avoiding long term neurological and pulmonary problems and contributed to the outcome of a healthy infant.