Intraventricular Hemorrhage Grade Research Articles

Thrombocytopenia and neonatal outcomes among extremely premature infants exposed to maternal hypertension.

Hypertensive disorders of pregnancy (HDP) are associated with neonatal hematological disturbances, such as thrombocytopenia. The association of HDP to platelet counts in the context of extreme prematurity, to trends of platelet counts during neonatal hospitalization, and to frequency of platelet transfusions remain to be explored. Retrospective study of infants born at less than 29weeks born between 2015 and 2019. Platelet counts were collected on initial complete blood count, at 2weeks, 32weeks post-menstrual age (PMA), 36weeks PMA, and closest to discharge. We examined the association between HDP and platelet counts at each time point, frequency of platelet transfusions and intraventricular hemorrhage (IVH) grade 3 or more. Total 296 infants were included, 43 exposed to HDP. Infants exposed had lower platelet counts at each time point, as well as a higher prevalence of platelet less than 150×109 /L on one of the time points (32% vs. 65%, p<.001). Infants exposed to maternal hypertension were more frequently exposed to platelet transfusions (63% vs. 18%, p<.001). Mixed effect model demonstrated an association between HDP and a lower trend in platelet counts at each time point (β=-94×103 /μl, p<.001). Although initial platelet count was associated with severe IVH, it was not associated to exposure to HDP. Premature infants exposed to HDP have a higher prevalence of thrombocytopenia, increased frequency of platelet transfusion, and an altered trend in platelet counts during neonatal hospitalization.

Interobserver reliability between pediatric radiologists and residents in ultrasound evaluation of intraventricular hemorrhage in premature infants.

Germinal matrix intraventricular hemorrhage (IVH) may contribute to significant morbidity and mortality in premature infants. Timely identification and grading of IVH affect decision-making and clinical outcomes. There is possibility of misinterpretation of the ultrasound appearances, and the interobserver variability has not been investigated between radiology resident and board-certified radiologist. To assess interobserver reliability between senior radiology residents performing bedside cranial ultrasound during on-call hours and pediatric radiologists. From June 2018 to June 2020, neonatal cranial ultrasound examinations were performed in neonatal intensive care unit. Ultrasound findings were recorded by the residents performing the ultrasound and the pediatric attending radiologists. In total, 200 neonates were included in the study, with a mean gestational age of 30.9 wk. Interobserver agreement for higher grade (Grade III & IV) IVH was excellent. There was substantial agreement for lower grade (Grade I & II) IVH. There is strong agreement between radiology residents and pediatric radiologists, which is higher for high grade IVHs.

Identification of risk factors in pre-term infants with abnormal general movements.

This study aimed to investigate the relationship between prenatal, perinatal, and postnatal risk factors for neurodevelopmental impairment (NDI) with the outcomes of General Movement (GM) Assessment (GMA) in pre-term infants at 3-5 months of age. We sought to identify the risk factors associated with the predictors of psychomotor development in pre-term newborns, such as normal fidgety movements (FMs), absent FMs, or abnormal FMs, assessed during the fidgety period of motor development. The SYNAGIS program (prophylactic of Respiratory Syncytial Virus Infection) was used to identify risk factors for the development of neuromotor deficits in 164 pre-term infants who were at high risk of developing these deficits. Based on the GMA, all participants were divided into three groups of infants who presented: (1) normal FMs; (2) absent FMs; and (3) abnormal FMs. The results of the current study suggest that abnormal GMs not only indicate commonly known factors like birth asphyxia (BA), respiratory distress syndrome (RDS), periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH) grades 3-4, but also predict the development of motor impairments. In the present study, several specific risk factors including bronchopulmonary dysplasia (BPD), infertility treatments, maternal acute viral/bacterial infections during pregnancy, and elevated bilirubin levels were identified as attributes of an atypical fidgety movement pattern. Additional clinical data, such as risk factors for NDI associated with early predictors of psychomotor development in pre-term newborns, i.e., absent or abnormal FMs, may be helpful in predicting neurological outcomes in pre-term infants with developmental concerns in the 1st month of life.

Preterm Brain Injury and Neurodevelopmental Outcomes: A Meta-analysis.

Preterm brain injuries are common; neurodevelopmental outcomes following contemporary neonatal care are continually evolving. To systematically review and meta-analyze neurodevelopmental outcomes among preterm infants after intraventricular hemorrhage (IVH) and white matter injury (WMI). Published and grey literature were searched across 10 databases between 2000 and 2021. Observational studies reporting 3-year neurodevelopmental outcomes for preterm infants with IVH or WMI compared with preterm infants without injury. Study characteristics, population characteristics, and outcome data were extracted. Thirty eight studies were included. There was an increased adjusted risk of moderate-severe neurodevelopmental impairment after IVH grade 1 to 2 (adjusted odds ratio 1.35 [95% confidence interval 1.05-1.75]) and IVH grade 3 to 4 (adjusted odds ratio 4.26 [3.25-5.59]). Children with IVH grade 1 to 2 had higher risks of cerebral palsy (odds ratio [OR] 1.76 [1.39-2.24]), cognitive (OR 1.79 [1.09-2.95]), hearing (OR 1.83 [1.03-3.24]), and visual impairment (OR 1.77 [1.08-2.9]). Children with IVH grade 3 to 4 had markedly higher risks ofcerebral palsy (OR 4.98 [4.13-6.00]), motor (OR 2.7 [1.52-4.8]), cognitive (OR 2.3 [1.67-3.15]), hearing (OR 2.44 [1.42-4.2]), and visual impairment (OR 5.42 [2.77-10.58]). Children with WMI had much higher risks of cerebral palsy (OR 14.91 [7.3-30.46]), motor (OR 5.3 [3-9.36]), and cognitive impairment (OR 3.48 [2.18-5.53]). Heterogeneity of outcome data. Mild IVH, severe IVH, and WMI are associated with adverse neurodevelopmental outcomes. Utilization of core outcome sets and availability of open-access study data would improve our understanding of the nuances of these outcomes.

Effects of prophylactic indomethacin on morbidity and mortality in infants

ObjectiveTo determine if prophylactic indomethacin (PINDO) decreases death or bronchopulmonary dysplasia-grades 2 and 3 (death/BPD) in newborns <25 weeks.Study designIntention-to-treat, cohort-controlled study of 106 infants admitted during three alternating epochs of PINDO or Expectant patent ductus arteriosus (PDA) management.ResultsAt 7–8 days 85% of Expectant Management epoch infants had a moderate/large PDA (median exposure was 23 days). Among PINDO epoch infants only 24% still had a PDA at 7–8 days. There were no significant differences in the incidence of death/BPD or of secondary outcomes (BPD, death, necrotizing enterocolitis/spontaneous perforations, or intraventricular hemorrhage (grades 3 or 4)) in either unadjusted or adjusted comparisons between infants born in a PINDO epoch and those born in the Expectant Management epoch.ConclusionDespite being at high risk for PDA-related morbidities, PINDO did not appear to alter the rates of our primary and secondary outcomes in infants <25 weeks.

Effectiveness of a care bundle for primary prevention of intraventricular hemorrhage in high-risk neonates: a Bayesian analysis.

To determine whether an intraventricular hemorrhage (IVH) prevention bundle featuring midline-elevated positioning reduced IVH among high-risk infants. In a retrospective study design, we compared outcomes of infants <1250 grams birth weight or <30 weeks gestation before (N = 205) and after (N = 360) implementation of an IVH prevention bundle, using Bayesian and frequentist logistic regression to determine whether the intervention decreased any grade IVH. In both the Bayesian and frequentist analyses, there was no difference in odds of any grade IVH before and after the implementation of the prevention bundle (OR 0.993; 95% Credible Interval 0.751-1.323 and OR 1.23; 95% Confidence Interval 0.818-1.864 respectively). Bias analyses suggested that these results were robust to bias from potential deaths attributable to IVH. In this retrospective analysis, we found no evidence for a protective effect of an IVH prevention bundle on IVH incidence among high-risk neonates at a level IV NICU.

21 Spontaneous resolution of post-hemorrhagic ventricular dilatation in preterm newborns and neurodevelopmental outcomes

Abstract Background Post-hemorrhagic ventricular dilatation (PHVD) is a serious complication of intraventricular hemorrhage (IVH) in preterm newborns and is associated with significant impairments. The natural evolution of PHVD and developmental implications of spontaneous resolution are not well established. Objectives To investigate the natural evolution of PHVD and compare neurodevelopmental impairments in newborns with (1) spontaneous resolution of PHVD; (2) persistent PHVD and (3) PHVD who underwent neurosurgical intervention. Design/Methods We conducted a multicenter retrospective cohort study of 5238 newborns born at ≤34 weeks’ gestational age (GA) admitted to two tertiary Neonatal Intensive Care Units (NICU) between 2012 and 2020. Head ultrasounds (HUS) of 476 newborns with IVH grade ≥2 were reviewed to identify PHVD, defined as ventricular index (VI) &amp;gt;97th centile (p97) for GA and anterior horn width (AHW) &amp;gt;6mm on any HUS in the first 6 weeks of life. Newborns with PHVD were divided into three groups, Group 1: newborns with spontaneous resolution of PHVD, defined as the regression of both lateral ventricles below the VI and AHW thresholds, Group 2: newborns with persistent PHVD absent neurosurgical intervention and Group 3: newborns who underwent any neurosurgical intervention. Neurodevelopmental outcomes at 18 months corrected, obtained through chart review, were compared. Results Of 108 newborns with PHVD, 88 survived to NICU discharge (mean GA 28.4 weeks, SD 2.8; median age at PHVD diagnosis 8.0 days, IQR 5.0-12.8). Overall, 34/88 (38.6%) newborns had spontaneous resolution of PHVD (Group 1). The median time between PHVD diagnosis and spontaneous resolution was 14.0 days (IQR 6.8-32.3) (Figure). In Group 3, the median time between PHVD diagnosis and the first neurosurgical intervention was 14.0 days (IQR 7.0-23.0). Group 1 had significantly smaller maximal VI (1.8, 3.4, and 11.1mm above p97, p&amp;lt;0.001) and AHW (7.2, 10.8, and 20.3mm, p&amp;lt;0.001) than Groups 2 and 3, respectively, and were less likely to have bilateral PHVD (OR 0.47, 95% CI 0.33-0.67) than Group 3. Neurodevelopmental outcome data at 18 month were available for 53/88 (60.2%) survivors (Table). Group 1 had lower rates of cerebral palsy (17.4% vs 45.8%; p=0.037), global developmental delay (17.4% vs 50.0%; p=0.018), epilepsy (4.3% vs 29.2%; p=0.048) and involvement of ≥3 allied health professionals (34.8% vs 70.8%; p=0.013) compared to Group 3. Conclusion Newborns with PHVD without spontaneous resolution are at higher risk for significant neurodevelopmental impairments despite neurosurgical interventions, which may be due to more prominent ventricular dilatation. Strategies aimed at mitigating the burden of impairments in patients without spontaneous resolution are needed.

Evaluation of the Association of Platelet Count, Mean Platelet Volume, and Platelet Transfusion With Intraventricular Hemorrhage and Death Among Preterm Infants

Platelet transfusion is commonly performed in infants to correct severe thrombocytopenia or prevent bleeding. Exploring the associations of platelet transfusion, platelet count (PC), and mean platelet volume (MPV) with intraventricular hemorrhage (IVH) and in-hospital mortality in preterm infants can provide evidence for the establishment of future practices. To evaluate the associations of platelet transfusion, PC, and MPV with IVH and in-hospital mortality and to explore whether platelet transfusion-associated IVH and mortality risks vary with PC and MPV levels at the time of transfusion. This retrospective cohort study included preterm infants who were transferred to the neonatal intensive care unit on their day of birth and received ventilation during their hospital stay. The study was conducted at a neonatal intensive care unit referral center in Beijing, China, between May 2016 and October 2017. Data were retrieved and analyzed from December 2020 to January 2022. Platelet transfusion, PC, and MPV. Any grade IVH, severe IVH (grade 3 or 4), and in-hospital mortality. Among the 1221 preterm infants (731 [59.9%] male; median [IQR] gestational age, 31.0 [29.0-33.0] weeks), 94 (7.7%) received 166 platelet transfusions. After adjustment for potential confounders, platelet transfusion was significantly associated with mortality (hazard ratio [HR], 1.48; 95% CI, 1.13-1.93; P = .004). A decreased PC was significantly associated with any grade IVH (HR per 50 × 103/μL, 1.13; 95% CI, 1.05-1.22; P = .001), severe IVH (HR per 50 × 103/μL, 1.16; 95% CI, 1.02-1.32; P = .02), and mortality (HR per 50 × 103/μL, 1.74; 95% CI, 1.48-2.03; P < .001). A higher MPV was associated with a lower risk of mortality (HR, 0.83; 95% CI, 0.69-0.98; P = .03). The platelet transfusion-associated risks for both IVH and mortality increased when transfusion was performed in infants with a higher PC level (eg, PC of 25 × 103/μL: HR, 1.20; 95% CI, 0.89-1.62; PC of 100 × 103/μL: HR, 1.40; 95% CI, 1.08-1.82). The platelet transfusion-associated risks of IVH and mortality varied with MPV level at the time of transfusion. In preterm infants, platelet transfusion, PC, and MPV were associated with mortality, and PC was also associated with any grade IVH and severe IVH. The findings suggest that a lower platelet transfusion threshold is preferred; however, the risk of a decreased PC should not be ignored.

Optimizing timing and frequency of head ultrasound screening for severe brain injury among preterm infants born

Objective To develop a head ultrasound (HUS) screening protocol for infants born <32 weeks gestational age (GA) that accurately identifies severe brain injury (SBI) while minimizing resource use. Study design Retrospective cohort study of infants born <32 weeks GA, admitted to a level 3 neonatal intensive care unit between 2011 and 2017. Timing and results of each HUS were reviewed. SBI was defined as intraventricular hemorrhage grade ≥3 and/or periventricular leukomalacia. Logistic regression models were used to identify risk factors and evaluate the predictive value of HUS at different time points during hospitalization. Results Of 651 included infants, 71 (11%) developed SBI. Risk factors for SBI were GA at birth <29 weeks (adjusted odds ratio (aOR) 2.87, 95% confidence interval (CI) 1.50–5.48), vasopressors on admission (aOR 3.08, 95%CI 1.38–6.88) and mechanical ventilation on admission (aOR 2.50, 95%CI 1.33–4.68). Infants were classified into three risk groups based on these risk factors, and combinations of 1–5 HUS time points were evaluated to determine the optimal number and timing of HUS for each group. The optimal number of screening HUS ranged from 1 for low-risk to 2 for high-risk infants. Adopting a screening protocol using the number and timing of HUS optimized by risk group could reduce the total number of HUS performed by 40% and the median number of HUS per infant from 3 (IQR 2–4) to 2 (IQR 1–3) (p < .01). Conclusions Implementation of a risk factor-based HUS screening protocol can help reduce resource use while maintaining high sensitivity for detecting SBI.

Growth phenotypes of very low birth weight infants for prediction of neonatal outcomes from a Brazilian cohort: comparison with INTERGROWTH

ObjectiveTo assess the predictive value of selected growth phenotypes for neonatal morbidity and mortality in preterm infants < 30 weeks and to compare them with INTERGROWTH-21st (IG21). MethodRetrospective analysis of data from the Brazilian Neonatal Research Network (BNRN) database for very low birth weight (VLBW) at 20 public tertiary-care university hospitals. Outcome: the composite neonatal morbidity and mortality (CNMM) consisted of in-hospital death, oxygen use at 36 weeks, intraventricular hemorrhage grade 3 or 4, and Bell stage 2 or 3 necrotizing enterocolitis. Selected growth phenotypes: small-for-gestational-age (SGA) defined as being < 3rd (SGA3) or 10th (SGA10) percentiles of BW, and large-for-gestational-age (LGA) as being > 97th percentile of BW. Stunting as being < 3rd percentile of the length and wasting as being < 3rd percentile of BMI. Single and multiple log-binomial regression models were fitted to estimate the relative risks of CNMM, comparing them to IG21. Results4,072 infants were included. The adjusted relative risks of CNMM associated with selected growth phenotypes were (BNRN/IG21): 1.45 (0.92–2.31)/1.60 (1.27–2.02) for SGA; 0.90 (0.55–1.47)/1.05 (0.55–1.99) for LGA; 1.65 (1.08–2.51)/1.58 (1.28–1.96) for stunting; and 1.48 (1.02–2.17) for wasting. Agreement between the two references was variable. The growth phenotypes had good specificity (>95%) and positive predictive value (70-90%), with poor sensitivity and low negative predictive value. ConclusionThe BNRN phenotypes at birth differed markedly from the IG21 standard and showed poor accuracy in predicting adverse neonatal outcomes.

Does acute funisitis predict worse neonatal outcomes among term newborns?

Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response to infection. Although acute funisitis has been associated with an increased risk of adverse outcomes among preterm neonates, there are limited and conflicting data with term deliveries. This study aimed to evaluate the association between acute funisitis and neonatal morbidity in neonates born at term to pregnant patients with a clinical diagnosis of intraamniotic infection. This was a retrospective cohort study of pregnant patients who had clinically diagnosed intraamniotic infection at term, delivered vaginally at a single tertiary institution from 2013 to 2019, and had histologic chorioamnionitis on placental pathology. Patients with intrauterine fetal demise or missing neonatal/placental pathology data were excluded. The primary outcome was a neonatal sepsis composite, defined as culture-positive bacteremia, neutropenia (absolute neutrophil count<3500/μL), or immature-to-total neutrophil ratio>0.2. The secondary outcomes included composite neonatal morbidity, defined as neonatal intensive care unit admission, 5-minute Apgar score <7, bacteremia, endotracheal intubation or need for continuous positive airway pressure, intraventricular hemorrhage (grade 3 or 4), necrotizing enterocolitis (stage 3 or 4), umbilical artery pH<7.1, umbilical artery base excess>12, and neonatal mortality. The components of these composites, neonatal intensive care unit length of stay, and Kaiser early-onset sepsis score were also measured. Neonates with acute funisitis on pathology were compared with those without acute funisitis using bivariate statistics. Regression was used to estimate the relative risk of outcomes. Of 184 neonates with deliveries complicated by intraamniotic infection, acute funisitis was present in 109 (59%) placental specimens. Composite neonatal sepsis was significantly higher among neonates with acute funisitis (relative risk, 1.85; 95% confidence interval, 1.13-3.03) than in those without acute funisitis. As a marker for sepsis, acute funisitis has a sensitivity of 39.4%, negative predictive value of 47.2%, specificity of 78.7%, and positive predictive value of 72.9%. An immature-to-total neutrophil ratio>0.2 (relative risk, 1.83; 95% confidence interval, 1.09-3.08) was also significantly associated with acute funisitis. Neonatal morbidity composite, intraventricular hemorrhage, necrotizing enterocolitis, neonatal intensive care unit admission, higher Kaiser early-onset sepsis scores, and other examined outcomes were not statistically associated with acute funisitis. In term deliveries complicated by intraamniotic infection, acute funisitis was associated with increased neonatal sepsis. Current approaches for estimating neonatal sepsis risk are limited by their reliance on indirect maternal factors such as maximum maternal temperature and intrapartum antibiotic use. This study suggests that acute funisitis may serve as a marker that could be utilized to augment risk stratification at birth if a protocol for evaluating the umbilical cord in real-time were widely adopted.

Preterm cesarean delivery for nonreassuring fetal heart rate tracing: Risk factors and predictability of adverse outcomes

ObjectiveTo compare adverse outcomes among preterm births that underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) versus those that did not. Study designConsortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton at 23.0 to 36.6 weeks who labored for at least 2 h. Composite adverse neonatal outcomes included any of the following intraventricular hemorrhage grade III or IV, seizures, mechanical ventilation, sepsis, necrotizing enterocolitis 2 or 3, or neonatal death. Composite adverse maternal outcomes included any of the following postpartum hemorrhage, endometritis, blood transfusion, chorioamnionitis, admission to intensive care unit, thromboembolism, or death. ResultsOf 228,438 births, 29,592 (13.0%) delivered preterm, and 16,679 (56.4%) labored for at least 2 hrs. CD for NR FHRT was done in 1,220 (7.3%). The rate of composite adverse neonatal outcome was different among those that had CD for NR FHRT (26.7%) versus those that did not (16.6%; aRR 1.59, 95% CI 1.43–1.76). Composite adverse maternal outcomes did not differ between the groups. The area under the curve for risk factors to identify composite adverse neonatal outcome was 0.81, and for composite adverse maternal outcomes, 0.64. ConclusionsSubsequent to CD for NR FHRT, composite adverse neonatal outcome is 59% higher among preterm births when compared to delivery with reassuring tracing; composite adverse maternal outcomes did not differ between the groups.

The prognosis of refractory hypotension and severe intraventricular hemorrhage in very low birth weight infants.

Background:The increased survival rate among very low birth weight infants has resulted in a higher risk for developing neuro-complications such as intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), and adverse neurodevelopmental outcomes.Purpose:We examined refractory hypotension experienced within a week of life in association with severe IVH (grades 3–4) among very low birth weight infants (VLBWIs).Method:Between Jan 2014 and Dec 2017, the clinical data of 191 VLBWIs were retrospectively chart reviewed. Of a total of 191 VLBWIs, 71.2% (136/191) had IVH, and 28.7% (55/191) had severe IVH.Results:The VLBWI with severe IVH group (grade 3–4) presented with a significantly lower gestational age along with higher use of postnatal hydrocortisone for refractory hypotension within a week of life. Resuscitation at delivery, pulmonary hemorrhage, neonatal seizure, and PVL were significantly more frequent in the severe IVH group (P < .05). Higher mortality occurred in the VLBWI with severe IVH group (P < .001). The multivariable logistic regression analysis consistently showed that refractory hypotension within a week of life and neonatal seizures were significantly associated with severe IVH. Those in the severe IVH and refractory hypotension groups had significantly lower composite cognitive, language, motor scores in Bayley Scales of Infant and Toddler Development III scores at corrected 18–24 months.Conclusion:Refractory hypotension within a week of life and seizures were consistently associated with severe IVH and developmental delay at corrected 18–24 months. VLBWI who experienced refractory hypotension within a week of life may indicate a more vulnerable clinical setting with a higher risk for developmental delay.

The Incidence of Intraventricular Hemorrhage in Low-Birth-Weight Infants: Assessment by Magnetic Resonance Imaging.

Intraventricular hemorrhage (IVH) is common in infants with a low-birth-weight (LBW) and has been suggested to cause major impairment not only of future motor development but also of cognitive function and learning ability. The purpose of the present study is to assess the frequency of IVH using magnetic resonance imaging (MRI) in LBW infants and its clinical neurodevelopmental outcomes. We enrolled a consecutive series of 247 neonates with an LBW of < 1,500 g hospitalized in the newborn intensive care unit between 2010 and 2015. The presence of IVH was examined using T2* MRI at term-equivalent age (TEA). We then investigated the clinical outcome at ≥3 years of age and its correlation with the IVH grade. The overall incidence of IVH among LBW infants was 16.2%. The proportion of infants with IVH showing a favorable outcome did not differ significantly from that of infants without IVH. The proportion of neonates showing a poor outcome was 6.7% for those with IVH and 1.9% for those without IVH and 2.7% for those with and without IVH combined. We were able to clarify the frequency of IVH in LBW infants using MRI at TEA. We demonstrated the lower incidence of mortality and IVH, the higher incidence of a favorable outcome, and the lower incidence of poor outcome.

Prevention of severe brain injury in very preterm neonates: A quality improvement initiative.

To determine the impact of neuroprotection interventions bundle on the incidence of severe brain injury or early death (intraventricular hemorrhage grade 3/4 or death by 7 days or ventriculomegaly or cystic periventricular leukomalacia on 1-month head ultrasound, primary composite outcome) in very preterm (270/7 to ≤ 296/7 weeks gestational age) infants. Prospective quality improvement initiative, from April 2017-September 2019, with neuroprotection interventions bundle including cerebral NIRS, TcCO2, and HeRO monitoring-based management algorithm, indomethacin prophylaxis, protocolized bicarbonate and inotropes use, noise reduction, and neutral positioning. There was a decrease in the incidence of the primary composite outcome in the intervention period on unadjusted (N = 11/99, pre-intervention to N = 0/127, intervention period, p < 0.001) and adjusted analysis (adjusted for birthweight and Apgar score <5 at 5 min, aOR = 0.042, 95% CI = 0.003-0.670, p = 0.024). Neuroprotection interventions bundle was associated with significant decrease in severe brain injury or early death in very preterm infants.

Impact of Changes in Early Respiratory Support Management on Respiratory Outcomes of Preterm Infants.

In the period immediately after birth, preterm infants are highly susceptible to lung injury. Ventilator-induced lung injury has been recognized as a major contributing factor for bronchopulmonary dysplasia (BPD) in preterm infants. Noninvasive respiratory support (NIRS) could decrease lung injury, and early respiratory support management might affect pulmonary outcomes. We conducted a study to evaluate the changes in early respiratory support management and their impact on respiratory outcome and complications of preterm infants in 3 different time periods over the last 13 years. This study was a retrospective, single-center cohort study. We retrospectively reviewed the medical records of preterm infants < 32 weeks of gestational age born in our hospital from 2007-2020. The study period was divided into three 3-y discrete periods: 2007-2009 (period A), 2013-2015 (period B), and 2018-2020 (period C). Changes in early respiratory support management were assessed in the 3 periods. The outcomes measured included mortality, BPD, other major neonatal complications, initial respiratory support, and duration of mechanical ventilation. In all, 1,880 clinical records were assessed in our study, with 358 in period A, 825 in period B, and 697 in period C. The use of antenatal corticosteroids increased over time (56.1% in period A, 56.7% in period B, and 74.0% in period C (P < .001). The need for surfactant decreased from 65.6% in period A to 40.7% in period B and 45.9% in period C. Increased utilization of NIRS was associated with decreased invasive mechanical ventilation within 24 h after birth. NIRS only during the hospital stay increased from 22.9% in period A to 36.8% and 45.1% in the latter 2 periods (P < .001). Oxygen therapy duration decreased from 24.3 d in period A to 14.4 d in period B and 17.2 d in period C (P < .001). The overall incidence of BPD was 32.4% in the first period, 23.9% in the second period, and 25.4% in the third period (P < .001). The moderate-to-severe forms of BPD decreased from 12.8% in period A to 7.9% in period B and 7.6% in period C (P = .009). Other neonatal complications, such as pneumothorax, pulmonary hemorrhage, persistent pulmonary hypertension of the newborn, surgical necrotizing enterocolitis, intraventricular hemorrhage grade III/IV, and periventricular leukomalacia, were unchanged among the 3 periods. From 2007-2020, respiratory management was characterized by a marked reduction in invasive mechanical ventilation and an increase in the use of NIRS. Changes in early respiratory support management resulted in improved respiratory outcomes with a decrease in the overall incidence of BPD. It is likely that our aim to reduce lung injury by improving our respiratory management has contributed to a favorable outcome.

The clinical burden of extremely preterm birth in a large medical records database in the United States: Mortality and survival associated with selected complications

BackgroundPreterm birth is a leading cause of infant mortality, particularly for those born extremely prematurely (EP; <28 weeks' gestational age [GA]). Survivors are predisposed to complications such as bronchopulmonary dysplasia (BPD), chronic lung disease (CLD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). AimsTo examine the epidemiology, complications, and mortality/survival among EP infants. Study designRetrospective analysis of electronic medical records from the Kaiser Permanente Northern California database. SubjectsEP infants live-born between 22 and <28 weeks' GA from 1997 to 2016. Outcome measuresCumulative all-cause mortality/survival were analyzed and stratified by GA (22 to <24, 24 to <26, 26 to <28 weeks), complications (BPD/CLD, IVH, ROP), and birth period (1997 to 2003, 2004 to 2009, 2010 to 2016). Cox proportional hazard models were constructed to assess the mortality risk associated with BPD/CLD or IVH. Results2154 EP infants were identified; of these, 916 deaths were recorded. Mortality was highest during the first 3 months (41.7 % cumulative mortality), and few were reported after 2 years (42.5 % cumulative mortality). Mortality decreased with higher GA and over more recent birth periods. BPD/CLD and IVH grade 3/4 were associated with increased mortality risk versus no complications (adjusted hazard ratios 1.41 and 1.78, respectively). ConclusionsThe risk of mortality is high during the first few months of life for EP infants, and is even higher for those with BPD and IVH. Despite an overall trend toward increased survival for EP infants, strategies targeting survival of EP infants with these complications are needed.

Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants.

AimThe aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants.MethodsWe used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case–control study. For every infant with severe IVH (grade 3 or peri‐ventricular haemorrhagic infarction), one IVH‐free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case–control pairs).ResultsTotal sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH.ConclusionOur results suggest a relationship between sodium‐rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion‐related factor.

Risk factors and outcomes of neonates with acute kidney injury needing peritoneal dialysis: Results from the prospective TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) study.

Acute kidney injury (AKI) is common in neonates admitted to neonatal intensive care units (NICUs). There is a need to have prospective data on the risk factors and outcomes of acute peritoneal dialysis (PD) in neonates. The use of kidney replacement therapy in this population compared to older populations has been associated with worse outcomes (mortality rates 17-24%) along with a longer stay in the NICU and/or hospital. The following multicentre, prospective study was derived from the TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) database, assessing all admitted neonates ≤28 days who received intravenous fluids for at least 48 h. The following neonates were excluded: death within 48 h, presence of any lethal chromosomal anomaly, requirement of congenital heart surgery within the first 7 days of life and those receiving only routine care in nursery. Demographic data (maternal and neonatal) and daily clinical and laboratory parameters were recorded. AKI was defined according to the Neonatal Kidney Disease: Improving Global Outcomes criteria. Of the included 1600 neonates, a total of 491 (30.7%) had AKI. Of these 491 neonates with AKI, 44 (9%) required PD. Among neonates with AKI, the odds of needing PD was significantly higher among those with significant cardiac disease (odds ratio (95% confidence interval): 4.95 (2.39-10.27); p < 0.001), inotropes usage (4.77 (1.98-11.51); p < 0.001), severe peripartum event (4.37 (1.31-14.57); p = 0.02), requirement of respiratory support in NICU (4.17 (1.00-17.59); p = 0.04), necrotising enterocolitis (3.96 (1.21-13.02); p = 0.03), any grade of intraventricular haemorrhage (3.71 (1.63-8.45); p = 0.001), evidence of fluid overload during the first 12 h in NICU (3.69 (1.27-10.70); p = 0.02) and requirement of resuscitation in the delivery room (2.72 (1.45-5.12); p = 0.001). AKI neonates with PD as compared to those without PD had a significantly lower median (interquartile range) duration of stay in NICU (7 (4-14) vs. 11 (6-21) days; p = 0.004), but significantly higher mortality (31 (70.5%) vs. 50 (3.2%); p < 0.001). This discrepancy is likely attributable to the critical state of the neonates with AKI. This is the largest prospective, multicentre study specifically looking at neonatal AKI and need for dialysis in neonates. AKI was seen in 30.7% of neonates (with the need for acute PD in 9% of the AKI group). The odds of needing acute PD were significantly higher among those with significant cardiac disease, inotropes usage, severe peripartum event, requirement of respiratory support in NICU, necrotising enterocolitis, any grade of intraventricular haemorrhage, evidence of fluid overload more than 10% during the first 12 h in NICU and requirement of resuscitation in the delivery room. AKI neonates with PD as compared to AKI neonates without PD had a significantly higher mortality. There is a need to keep a vigilant watch in neonates with risk factors for the development of AKI and need for PD.

Ventricular Volume in Infants Born Very Preterm: Relationship with Brain Maturation and Neurodevelopment at Age 4.5 Years

To evaluate the relationship of quantitative ventricular volume with brain maturation and neurodevelopmental outcomes at age 4.5years in children born very preterm. T1-weighted imaging, diffusion tensor imaging, and magnetic resonance spectroscopy were performed shortly after birth (n=212) and at term-equivalent age (TEA) (n=194). Intraventricular hemorrhage (IVH) grade and white matter injury (WMI) volume were measured on early T1-weighted magnetic resonance imaging (MRI) scans. Total cerebral volume and ventricular volume were quantified using the Multiple Automatically Generated Templates-Brain pipeline. At age 4.5years, 178 children (84%) underwent cognitive and motor assessments. Multivariable linear regression was used to examine the relationships between ventricular volume and neurodevelopmental outcomes. Generalized estimating equations were used to account for repeated measures when analyzing neonatal MRI data. All models accounted for sex, postmenstrual age at scan, WMI volume, IVH grade, and total cerebral volume and were corrected for multiple comparisons. On early MRI, 97 infants had IVH (grade 1, n=22; grade 2, n=66; grade 3, n=9), and 68 had WMI (median, 44mm3; IQR, 21-296mm3). IQ at 4.5years was associated with MRI ventricular volume at the early (β=-0.64; P<.001) and TEA (β=-0.44, P<.001) time points. Motor outcomes were associated with ventricular volume at TEA (β=-0.84, P=.01). Greater ventricular volume independently predicted lower fractional anisotropy in corpus callosum (genu: β=-0.0008, P=.002; splenium: β=-0.003, P<.001) and optic radiations (β=-0.001, P=.004); ventricular volume did not predict the N-acetylaspartate/choline ratio. In children born very preterm, neonatal ventricular size was associated with 4.5-year neurodevelopmental outcomes. Our findings suggest that white matter maturation may be abnormal in the setting of enlarged ventricular size beyond that expected from concurrent brain injuries.