Extreme Prematurity Research Articles

Extreme prematurity: Risk and resiliency

Individuals born extremely preterm (before 28 weeks of gestation) comprise only about 0.7% of births in the United States and an even lower proportion in other high resource countries. However, these individuals account for a disproportionate number of children with cerebral palsy, intellectual deficit, autism spectrum disorder, attention deficit hyperactivity disorder, and epilepsy. This review describes two large multiple center cohorts comprised of individuals born extremely preterm: the EPICURE cohort, recruited 1995 in the United Kingdom and the Republic of Ireland, and the Extremely Low Gestational Age Newborn (ELGAN), recruited 2002-2004 in five states in the United States. The primary focus of these studies has been neurodevelopmental disorders, but also of interest are growth, respiratory illness, and parent- and self-reported global health and well-being. Both of these studies indicate that among individuals born extremely preterm the risks of most neurodevelopmental disorders are increased. Early life factors that contribute to this risk include perinatal brain damage, some of which can be identified using neonatal head ultrasound, bronchopulmonary dysplasia, and neonatal systemic inflammation. Prenatal factors, particularly the family's socioeconomic position, also appear to contribute to risk. For most adverse outcomes, the risk is higher in males. Young adults born extremely preterm who have neurodevelopmental impairment, as compared to those without such impairment, rate their quality of life lower. However, young adults born extremely preterm who do not have neurodevelopmental impairments rate their quality of life as being similar to that of young adults born at term. Finally, we summarize the current state of interventions designed to improve the life course of extremely premature infants, with particular focus on efforts to prevent premature birth and on postnatal efforts to prevent adverse neurodevelopmental outcomes.

The EXTrauterine Environment for Neonatal Development: Present and Future.

Despite advances in clinical care and modest improvement in mortality rates for extreme prematurity, morbidity remains a significant challenge. The ideal environment to support prematurity would be fluidic and rely on natural fetal circulation to mimic the natural fetal amniotic environment, yet such an environment has been unsuccessful in long-term support until recently. Our group has succeeded in developing such a support system to foster fetal growth in the premature lamb model that shows promise for clinical translation. Here, we describe the EXTrauterine Environment for Neonatal Development (EXTEND) from its conception onwards, review published literature on fetal development and support of the premature lamb model in EXTEND, and discuss future applications.

Functional Ophthalmic Factors Associated With Extreme Prematurity in Young Adults

Children born preterm (<37 weeks' gestation) have a higher risk of visual impairment and ocular morbidities compared peers born at full term. However, the long-term ocular sequelae in adulthood for those born extremely preterm (EP), who have the highest risk of neonatal retinopathy, are unknown. To evaluate visual function and ocular morbidity in young adults born EP compared with controls born full term. This prospective cohort study of a geographically based birth cohort in the UK and Ireland born from March 1 through December 31, 1995, included 128 participants aged 19 years (born at 22-25 weeks' gestation) and 65 age-matched controls born at full term. Statistical analysis was performed from March 1, 2020, to November 26, 2021. Participants underwent eye examinations as part of a comprehensive outcome evaluation. Best-corrected visual acuity, refractive status, contrast sensitivity, color vision, prevalence of strabismus and nystagmus, and patient-reported visual function, measured using the Health Utilities Index Mark 3. The study comprised 128 participants (256 eyes; 68 female participants [53%]; mean [SD] age, 19.3 [0.5] years) and 65 age-matched controls born at full term (130 eyes; 40 female participants [62%]; mean [SD] age, 19.2 [0.5] years). Compared with control eyes, the mean (SD) best-corrected visual acuity among eyes in the EP group was significantly worse (monocular vision: -0.06 [0.14] logMAR in the control group vs 0.14 [0.38] logMAR in the EP group; P < .001; binocular vision: -0.14 [0.15] logMAR in the control group vs 0.06 [0.37] logMAR in the EP group; P < .001). Participants in the EP group had a significantly higher prevalence of strabismus (36% [46 of 127] vs 0%; P < .001), abnormal ocular motility (15% [19 of 125] vs 0%; P < .001), and nystagmus (13% [16 of 127] vs 0%; P < .001) than the control group. No significant differences between participants in the EP group and controls were observed for refractive error, contrast sensitivity, color vision, or patient-reported visual function. Among the participants in the EP group, 48% of eyes (120 of 250) had no retinopathy of prematurity (ROP), 39% (98 of 250) had ROP not requiring neonatal treatment, and 13% (32 of 250) received cryotherapy or laser ablation for ROP. Within the EP group, there was no significant difference in binocular visual function parameters, prevalence of ocular morbidity, and patient-reported visual function by neonatal ROP status. Extreme prematurity is associated with an increased prevalence of visual and ocular deficits in young adulthood; this study suggests that, for individuals born EP, visual and ocular deficits appear to be partially independent of ROP status in the neonatal period but reports similar overall visual function.

Prognostic Role of Biomarkers for Pulmonary Arterial Hypertension Associated with Bronchopulmonary Dysplasia in Extremely Premature Infants

To explore the association of the biochemical markers after birth with BPD-PAH, factors independently predicting BPD-PAH risk were identified by multivariate logistic regression. Cut off values were determined by plotting receiver-operator curve (ROC), for the sake of dichotomizing continuous variables that showed independent relation with BPD-PAH risk. The results show that uric acid (UC) and blood urea nitrogen (BUN) contents markedly increased among infants experiencing BPD-PAH in comparison with those without BPD-PAH (11.6 vs. 9.7 mmol/L, P = 0.006 and 482.0 vs. 249.0 μmol/L, P < 0.001, separately). As shown by multivariate logistic regression, serum BUN levels (OR = 1.143) and uric acid levels (OR = 1.034) were important risk factors for BPD-PAH. Through a lot of experiments, the effectiveness and the advanced nature of the framework proposed in this paper are proved effectively. The framework proposed in this paper can provide some reference and thinking for follow-up research.

Postoperative sepsis in premature neonates requires careful attention to the antibiogram

One of the great successes in neonatology has been the steady improvement in survival for infants born with extreme prematurity. In this volume of The Journal, Vohr et al address how current medical and nonmedical NICU practices affect the neurodevelopmental outcomes of these infants. The authors highlight existing standards and best practices, but also point out that future progress demands collaborative work with all caregivers of mothers and their preterm infants.

Increased Risk of Meconium-Related Ileus in Extremely Premature Infants Exposed to Antenatal Magnesium Sulfate

Introduction: We experienced an increased incidence of meconium-related ileus (MRI) in extremely premature infants (EPIs) while adopting the antenatal magnesium sulfate (MgSO4) protocol for fetal neuroprotection in our neonatal intensive care unit. This study aimed to test whether antenatal MgSO4 use was associated with increased risk of MRI in EPIs. Methods: The incidences of complicated MRI requiring aggressive enema or surgical intervention and other intestinal complications were compared among period 1 (January 2012–December 2013, n = 79), before adoption of the antenatal MgSO4 protocol for fetal neuroprotection; period 2 (January 2014–March 2016, n = 72), when the protocol was adopted; and period 3 (April 2016–September 2018, n = 75), when the protocol was temporarily withdrawn due to concern regarding intestinal complications in EPIs. Results: Despite similar baseline clinical characteristics among infants across the study periods, the MRI and MRI with surgical treatment incidences were higher in period 2 than those in periods 1 and 3 (13% vs. 8% and 6%, p = 0.391, and 11% vs. 0% and 1%, p = 0.001, respectively). In multivariable analysis, exposure to antenatal MgSO4 independently increased the risk of MRI (adjusted odds ratio, 3.8; 95% confidence interval, 1.4, 10.6). Conclusion: Antenatal MgSO4 may increase the risk of MRI, frequently requiring surgical intervention, in EPIs with a gestational age of 25 weeks or less.

Digital decision aid for prenatal counseling in imminent extreme premature labor: development and pilot testing

BackgroundIn case of extreme premature delivery at 24 weeks of gestation, both early intensive care and palliative comfort care for the neonate are considered treatment options. Prenatal counseling, preferably using shared decision making, is needed to agree on the treatment option in case labor progresses. This article described the development of a digital decision aid (DA) to support pregnant women, partners and clinicians in prenatal counseling for imminent extreme premature labor.MethodsThis DA is developed following the International Patient Decision Aid Standards. The Dutch treatment guideline and the Dutch recommendations for prenatal counseling in extreme prematurity were used as basis. Development of the first prototype was done by expert clinicians and patients, further improvements were done after alpha testing with involved clinicians, patients and other experts (n = 12), and beta testing with non-involved clinicians and patients (n = 15).ResultsThe final version includes information, probabilities and figures depending on users’ preferences. Furthermore, it elicits patient values and provides guidance to aid parents and professionals in making a decision for either early intensive care or palliative comfort care in threatening extreme premature delivery.ConclusionA decision aid was developed to support prenatal counseling regarding the decision on early intensive care versus palliative comfort care in case of extreme premature delivery at 24 weeks gestation. It was well accepted by parents and healthcare professionals. Our multimedia, digital DA is openly available online to support prenatal counseling and personalized, shared decision-making in imminent extreme premature labor.

Implementation of Universal Newborn Screening for Severe Combined Immunodeficiency in Singapore While Continuing Routine Bacille-Calmette-Guerin Vaccination Given at Birth.

IntroductionSevere Combined Immunodeficiency (SCID) is generally fatal if untreated; it predisposes to severe infections, including disseminated Bacille-Calmette-Guerin (BCG) disease from BCG vaccination at birth. However, delaying BCG vaccination can be detrimental to the population in tuberculosis-endemic regions. Early diagnosis of SCID through newborn screening followed by pre-emptive treatment with anti-mycobacterial therapy may be an alternative strategy to delaying routine BCG vaccination. We report the results of the first year of newborn SCID screening in Singapore while continuing routine BCG vaccination at birth.MethodNewborn screening using a T-cell receptor excision circle (TREC) assay was performed in dried blood spots received between 10 October 2019 to 9 October 2020 using the Enlite Neonatal TREC kit. Patients with low TREC had lymphocyte subset analysis and full blood count performed to determine the severity of lymphopenia and likelihood of SCID to guide further management.ResultsOf the 35888 newborns screened in 1 year, no SCID cases were detected, while 13 cases of non-SCID T-cell lymphopenia (TCL) were picked up. Using a threshold for normal TREC to be >18 copies/μL, the retest rate was 0.1% and referral rate to immunologist was 0.04%. Initial low TREC correlated with low absolute lymphocyte counts (ALC), and subsequent normal ALC corresponded with increases in TREC, thus patients with normal first CD3+ T cell counts were considered to have transient idiopathic TCL instead of false positive results. 7/13 (54%) had secondary TCL (from sepsis, Trisomy 21 with hydrops and stoma losses or chylothorax, extreme prematurity, or partial DiGeorge Syndrome) and 6/13 (46%) had idiopathic TCL. No cases of SCID were diagnosed clinically in Singapore during this period and for 10 months after, indicating that no cases were missed by the screening program. 8/9 (89%) of term infants with abnormal TREC results received BCG vaccination within the first 6 days of life when TREC and ALC were low. No patients developed BCG complications after a median follow-up of 17 months.ConclusionNewborn screening for SCID can be implemented while continuing routine BCG vaccination at birth. Patients with transient TCL and no underlying primary immunodeficiency are able to tolerate BCG vaccination.

Evaluation of Neonatal Intensive Care Unit Mortality

Objective: To evaluate neonatal intensive care unit (NICU) deaths in one of the largest obstetrics centers in Turkey in order to determine the causes of death in this high-risk group. Materials and Methods: We retrospectively analyzed all NICU deaths occurring between 2013 and 2018. The study included infants born alive at 22 weeks of gestation or older. Results: Of 102374 babies born in our hospital, 14768 infants (14.4%) were admitted to the NICU and 957 (6.48%) of those infants died before discharge. The most common causes of death were extreme prematurity or extremely low birth weight (31.5%), lethal anomalies (13.1%), and sepsis (8.2%). At younger gestational ages, causes associated with extreme prematurity and complications of prematurity were most common, while the death rate due to perinatal asphyxia and genetic or structural anomalies increased at older gestational ages. Conclusion: The causes of NICU deaths are multifactorial and vary with gestational age. Efforts to reduce NICU mortality should include preventing or delaying preterm delivery and identifying the most appropriate treatment modalities that may reduce the risk of respiratory distress, intracranial hemorrhage, necrotizing enterocolitis, and sepsis. In more mature infants, the main goal should be to prevent and treat perinatal asphyxia and determine the most appropriate treatment modalities for non-lethal anomalies.

Effects of Ponderal Index on Neonatal Mortality and Morbidities in Extremely Premature Infants.

BackgroundTo evaluate how intrauterine stress affects extremely premature infants in terms of intrauterine growth restriction. We hypothesized that extremely premature infants with mildly-low ponderal index (MPI) would have better neonatal outcomes.MethodsWe selected 2,721 subjects of 23 to 28 weeks of gestation between 2013 and 2015 from Korean Neonatal Network database. They were divided into 4 groups based on ponderal index (PI) percentile; PI ≤ 3rd as severely-low PI (SPI, n = 82), 3rd < PI ≤ 10th as MPI (n = 190), 10th < PI ≤ 90th as adequate PI (API, n = 2,179), and PI > 90th as high PI (HPI, n = 270).ResultsThe mortality in MPI and API groups was comparable (16.3% vs. 16.9%). It was significantly lower than that in the SPI and HPI groups (30.5% and 24.9%, respectively; P = 0.001). The MPI and API groups had better neonatal morbidities compared with the SPI and/or HPI groups, while the MPI group (8.2%) showed a lower incidence of severe intraventricular hemorrhage (IVH) than the other groups (SPI, 21.3%; API, 15.0%; HPI, 19.7%, respectively; P = 0.004). The MPI group had a trend of a bottom in neonatal mortality and morbidities in extremely premature infants.ConclusionThe MPI and API groups had lower mortality, massive pulmonary hemorrhage, severe bronchopulmonary dysplasia or death, pulmonary hypertension and neonatal seizure rates than the SPI and/or HPI groups, while the MPI group showed a lower incidence of severe IVH than the other groups. We speculate that the lower incidence of neonatal morbidities and mortality in the MPI group indicating mild intrauterine stress might accelerate fetal maturation resulting in better outcomes in extremely premature infants.

The Sword of King Solomon

Conjoined twin pregnancies are one of the greatest dilemmas we face in healthcare practice. Thanks to scientific knowledge and evolution, technology and the higher level of wealth in our society, conjoined twins have a chance to survive, albeit with the risk of major consequences on their lifespan and quality of life. Particularly, in the case of newborns with extreme prematurity or congenital malformations, special care must be taken in the use of treatments that offer little to no benefit. This is especially the case with procedures and techniques of unproven efficacy that could create unfounded expectations and hopes in parents and health professionals. It is within this conceptual framework that the author presents a case submitted to a bioethics committee at a pediatric hospital in a Latin American metropolis and analyzes the ethical challenges posed to the treating team and the consensual approach determined by the team.

Survival Status and Predictors of Mortality Among Low Birthweight Neonates Admitted in Amhara Region Referral Hospitals of Ethiopia: Retrospective Follow-Up Study.

BackgroundBeing born with low birthweight is a major determinant of perinatal, neonatal, and infant survival. Even though low birthweight-related neonatal mortality is high, there is an information gap regarding the survival status of low birthweight neonates and their predictors of mortality in Ethiopia.ObjectiveThis study was conducted to assess the survival status and predictors of mortality among low birthweight neonates admitted to Amhara region referral hospitals in Ethiopia.Methods and MaterialsA retrospective follow-up study was conducted on randomly selected low birthweight neonates admitted to the Amhara region referral hospital between January 01-2017 and December 30-2018. Data were entered into Epi-data 4.4.2.1 and exported to Stata 14 for cleaning and analysis. A cox regression model was used to analyze the data. Tables, charts, and text were used to report the results.ResultsThis study revealed that 35.2% of participants died with incidence rates of 37.86 per 1000 person-day observations (95%CI: 31.79-45.10). Sepsis (AHR:1.72(95% CI: 1.05-2.81), respiratory distress (AHR: 2.03 (95% CI:1.36-3.03), necrotizing enterocolitis (AHR: 2.47 (95% CI: 1.17-5.20), congenital anomalies (AHR:2.37 (95% CI: 1.36-4.13), extreme low birth weight (AHR:2.62 (95% CI:1.54-4.44) and prematurity (AHR: 2.55 (95% CI:1.10-5.92) were independent predictors of mortality.ConclusionSepsis, respiratory distress, necrotizing enterocolitis, congenital anomalies, extremely low birth weight, and premature birth were the independent predictors of mortality. Therefore, it is better for all stakeholders to focus more on the early diagnosis and management of low birth weight neonates with the factors associated with mortality.

Neuroprotection&amp;nbsp;Care Bundle Implementation is Associated with Improved Long-Term Neurodevelopmental Outcomes in Extremely Premature Infants

Neuroprotection&amp;nbsp;Care Bundle Implementation is Associated with Improved Long-Term Neurodevelopmental Outcomes in Extremely Premature Infants

Age at Surgical Ligation of Patent Ductus Arteriosus Affects Prognosis in Extremely Premature Infants

Background: This study aimed to evaluate outcomes, prognosis, and safety associated with the timing of surgical ligation for patent ductus arteriosus (PDA) in extremely premature infants (EPI). Methods: We reviewed the clinical data of 44 EPI (gestational age at birth 26.8 ± 0.67 weeks; birth weight 997 ± 152 g) who received surgical ligation for hemodynamically significant PDA (hsPDA) in the Neonatal Intensive Care Unit (NICU) of the Seventh Medical Center of PLA General Hospital in China between January 2021 and December 2014. We compared the general characteristics, underlying diseases, postoperative surgical complications, and prognoses in two groups of patients who received early ligation (≤ 14 days after birth) and late ligation (&gt; 14 days after birth). Results: The gender, gestational age at birth, birth weight, Apgar score, postoperative surgical complications, rates of bronchopulmonary dysplasia (BPD), retinopathy of prematurity, necrotic enterocolitis, periventricular leukomalacia, total hospitalization, and medical costs of both groups were compared. According to the results, the late ligation group had a higher rate of severe BPD (66.3% cf. 35%) and required significantly longer time to reach total enteral feeding and weaning of respiratory support compared with the early ligation group. Conclusions: In EPI with hsPDA, for whom medical treatment failed or is contraindicated, early surgical closure of the ductus arteriosus can promote earlier total enteral feeding, shorten the duration of mechanical ventilation, and reduce the rates of severe BPD.

Home management by remote self-monitoring in intermediate- and high-risk pregnancies: A retrospective study of 400 consecutive women.

Home management in general is considered to improve patient well-being, patient involvement and cost-effectiveness, for obstetric patients as well. But concerns regarding inclusion of intermediate- and high-risk pregnant women are an issue and a limitation for clinical implementation. This retrospective study evaluated the outcome and safety of extended remote self-monitoring of maternal and fetal health in intermediate- and high-risk pregnancies. The study reports on 400 singleton pregnancies complicated by preterm premature rupture of membranes (PPROM), fetal growth restriction, preeclampsia, gestational diabetes mellitus, high-risk of preeclampsia, or a history of previous fetal or neonatal loss. Remote self-monitoring was performed by pregnant women and included C-reactive protein, non-stress test by cardiotocography, temperature, blood pressure, heart rate, and a questionnaire concerning maternal and fetal wellbeing. Data were transferred to the hospital using a mobile device platform and evaluated by healthcare professionals. In case of non-reassuring registrations, the pregnant women were invited for assessment at the hospital. Primary outcome was perinatal death. Secondary outcomes were other maternal and perinatal complications. No severe maternal complications were observed. Nine fetal or neonatal deaths occurred, all secondary to malformations, severe fetal growth restriction, extreme prematurity or lung hypoplasia in cases of PPROM before 24weeks. Even in the latter group, fetal and neonatal survival was 78% (18/23) and rose to 97% (60/62) when PPROM occurred after a gestational age 23+6 weeks. None of the fetal or neonatal deaths were attributable to the home-management setting. Home-monitoring including remote self-monitoring of fetal and maternal well-being in intermediate- and high-risk pregnancies seems to be a safe alternative to inpatient or frequent outpatient care, which sets the stage for a new way of thinking of hospital care. The implementation process included staff training workshops and development of patient enrollment practice with clarification of expectations and responsibilities, which can be crucial to the results.

Premature rupture of membrane and perinatal outcome

Objective: To find out the complications of a pregnant woman with premature rupture of membrane (PROM) and assess the outcome of it. Materials and Methods: This prospective study was carried out at the Department of Obstetrics &amp; gynecology of Coronel Malek Medical College Hospital, Manikgonj, Bangladesh from January 2020 to December 2020. All pregnant women admitted with PROM during this period were taken as the study population. After taking proper history they were categorized as a term or preterm PROM on the basis of duration of gestation estimated from 1st day of last menstrual period (LMP), previous antenatal records, clinical examination &amp; also previous ultrasonography (USG) reports. Out of sociodemographic characteristics, age distribution and gravidity were noted. The diagnosis was done on the basis of examination and investigations. All the women with PROM were then followed up, management was given according to protocol and a cesarean section was performed according to indication. Birth weight and Apgar score of newborns were noted after delivery. Results: There were 297 cases of PROM recorded among 4461 admitted obstetrical patients over one year period. The hospital incidence of PROM was found to be 6.6%. Among them, 57.6% of patients were admitted at term and 42.4% of patients came before 37 completed weeks of gestation. Most of the pregnant women were between 20-24 years of age (43.7%), 43.2% were primigravida (56.6%) were multigravida. About 48.5% of women presented with different complications associated with PROM. Among which 15.7% of patients had oligohydramnios, 8.5% of patients presented with chorioamnionitis suggested by culture report of the high vaginal swab. Urine for culture and sensitivity was also done. About five (5.2%) developed premature labor before the 37th week of gestation. About 10% of women developed obstetric complications (failed trials) associated with medical diseases. Seventy-seven patients were delivered by cesarean section, 16.2% vaginally, 4.04% patients responded to conservative management and 2.5% patients were referred to a tertiary center for extreme prematurity with associated complicating factors. Most of the babies (38.4%) were born with birth weight between 2.1- 2.5kg and 10.3% of babies were less than 1.5kg. Conclusion: Term PROM was more in comparison to PPROM and most of them were multigravida. The cesarean section rate was high. Most common complication of was subclinical urogenital infection (53%) next oligohydramnios (25%) &amp; (13.5%) women presented with chorioamnionitis.

Abstract 16932: Primary Hyperaldosteronism And Resistant Hypertension In Pregnancy

Case Presentation: A 42-year-old woman with history of primary hyperaldosteronism (PA), IDDM and chronic kidney disease stage 3b (baseline Cr 2.5 mg/dl) presented at 10 weeks gestation with uncontrolled hypertension during pregnancy. Given prior difficulties conceiving and lack of discussions surrounding pregnancy risks, preconception counseling had not been done. She was taking carvedilol, spironolactone, and furosemide at pregnancy diagnosis. Given unclear safety profile in pregnancy, her spironolactone was discontinued. Her regimen was uptitrated to nifedipine 90 mmHg, carvedilol 50mg BID, hydralazine 50mg TID and furosemide 80mg BID. At 18 weeks gestation, she was readmitted with severe range hypertension and fluid overload unresponsive to escalating diuretic dosing. Due to poor urine output and creatinine to 5.5 mg/dl, she was initiated on dialysis. Her fetus was diagnosed with severe intrauterine growth restriction (IUGR) and umbilical doppler noted reversal of umbilical artery end-diastolic flow indicating severely elevated arterial resistance (Figure). During admission, she developed resistant hypertension requiring nicardipine and esmolol drips and severe headache, concerning for superimposed preeclampsia (SIPE). At 25 weeks gestation, she was taken for urgent c-section. Given extreme prematurity and growth restriction, her newborn baby passed away shortly after delivery. Discussion: This case highlights complications which arise from PA and antepartum persistent hypertension including progression of kidney disease, heart failure, IUGR, SIPE, and preterm delivery. It further highlights unique challenges using targeted therapies of mineralocorticoid receptor antagonists in PA in pregnancy. This information is crucial as PA is an increasingly recognized cause of resistant hypertension in young adults. Both PA and preeclampsia involve pathophysiologic mechanisms in the RAAS pathway and deserve further attention and research.

Perinatal complications and maximising lamb survival in an adolescent paradigm characterised by premature delivery and low birthweight.

The competition for nutrients in overnourished and still-growing adolescent sheep negatively impacts gestation length, colostrum supply and lamb birthweight, all of which may affect neonatal morbidity and survival to weaning. Herein perinatal complications and the requirement for supplementary feeding were analysed in relation to gestational-intake, and the degree of premature delivery and prenatal growth-restriction exhibited. Pregnancies were established by embryo transfer and the mean/standard deviation (SD) gestation length and birthweight of the optimally-fed control group (n = 100) was used to define early delivery and reduced birthweight categories (1.5 and 3.0 SDs below the control mean for each aspect). Control lambs were largely delivered at term (94%), and had a normal birthweight (92%), while very preterm (≤139days, 18.5%) and preterm delivery (140-142days, 54.8%), extremely low birthweight (ELBW; females ≤2838g and males ≤3216g, 21.1%) and low birthweight (LBW; females 2839 to ≤4001g and males 3217 to ≤4372g, 32.2%), were common in the overnourished group (n = 270, P<0.001). Accordingly, overnourished dams were more likely to lamb without assistance while the incidence of major dystocia was greater in controls. Initial lamb vigour at birth was independent of gestational-intake, delivery or birthweight category but both ELBW and very premature lambs required more assistance with feeding in the first 24h postnatal, primarily reflecting low colostrum availability. Indeed, relative to normal, ELBW lambs had a greater risk of experiencing mismothering, and enhanced likelihood of requiring supplementary feeding throughout the neonatal period (P<0.001). ELBW lambs also had a greater possibility of respiratory issues at birth (P<0.01) and renal complications (P<0.001), while very preterm delivery was associated with an increased risk of gastrointestinal tract problems (P<0.01). In spite of these complications, all-cause mortality was low (5.4%) suggesting that our proactive neonatal care regime can overcome many of the issues associated with extreme prematurity and low birthweight.

Decision making at extreme prematurity: Innovation in clinician education

Decision-making at extreme prematurity remains ethically and practically challenging and can result in parental and clinician distress. It is vital that clinicians learn the necessary skills integral to counseling and decision-making with families in these situations. A pedagogical approach to teaching counseling should incorporate adult learning theory, emphasize multidisciplinary team in-situ simulation that links to counseling clinicians' daily practice, and includes critical reflection, debriefing, and program assessment. Multiple educational strategies that train clinicians in advanced communication and decision-making offer promising results to optimize antenatal counseling and shared decision-making for families facing possible delivery at extreme prematurity. Continued process evaluation and innovation in these educational domains are needed while also assessing the effect on patient-centered outcomes.

Exceeding expectations after perinatal risks for poor development: associations in term- and preterm-born preschoolers.

To define parenting/social characteristics associated with better-than-expected cognitive and motor outcomes in preschoolers at similar perinatal biological risk-level including various gestational ages at birth (GA) and perinatal complications. Prospective cohort study (n = 87) of children at four years, median GA 29 weeks (IQR 26, 38). Assessments included Differential Ability Scales, Movement Assessment Battery, parenting styles, and social risk scores. Perinatal risk factors were weighted based on regression models for each outcome; individual calculated risk scores became predictors to extract standardized residuals from the mean (>1 SD above mean = better-than-expected). Mixed-effect regressions examined associations between positive adaptation and parenting/social factors. Perinatal risk scores explained 21-53% outcome variability. Children across all GA displayed positive adaptation. Children of parents with higher authoritarian scores had higher odds of better-than-expected outcomes (OR 1.17, p = 0.0002). Parental structure may promote positive adaptation at preschool age in children with perinatal risk factors for poor development, including extreme prematurity.