Preterm Very Low Birth Weight Research Articles

First-year outcomes of very low birth weight preterm singleton infants with hypoxemic respiratory failure treated with milrinone and inhaled nitric oxide (iNO) compared to iNO alone: A nationwide retrospective study.

Inhaled nitric oxide (iNO) has a beneficial effect on hypoxemic respiratory failure. The increased use of concurrent iNO and milrinone was observed. We aimed to report the trends of iNO use in the past 15 years in Taiwan and compare the first-year outcomes of combining iNO and milrinone to the iNO alone in very low birth weight preterm (VLBWP) infants under mechanical ventilation. This nationwide cohort study enrolled preterm singleton infants with birth weight <1500g treated with iNO from 2004 to 2019. Infants were divided into two groups, with a combination of intravenous milrinone (Group 2, n = 166) and without milrinone (Group 1, n = 591). After propensity score matching (PSM), each group's sample size is 124. The primary outcomes were all-cause mortality and the respiratory condition, including ventilator use and duration. The secondary outcomes were preterm morbidities within one year after birth. After PSM, more infants in Group 2 needed inotropes. The mortality rate was significantly higher in Group 2 than in Group 1 from one month after birth till 1 year of age (55.1% vs. 13.5%) with the adjusted hazard ratio of 4.25 (95%CI = 2.42-7.47, p <0.001). For infants who died before 36 weeks of postmenstrual age (PMA), Group 2 had longer hospital stays compared to Group 1. For infants who survived after 36 weeks PMA, the incidence of moderate and severe bronchopulmonary dysplasia (BPD) was significantly higher in Group 2 than in Group 1. For infants who survived until one year of age, the incidence of pneumonia was significantly higher in Group 2 (28.30%) compared to Group 1 (12.62%) (p = 0.0153). Combined treatment of iNO and milrinone is increasingly applied in VLBWP infants in Taiwan. This retrospective study did not support the benefits of combining iNO and milrinone on one-year survival and BPD prevention. A future prospective study is warranted.

Sustaining the Continued Effectiveness of an Antimicrobial Stewardship Program in Preterm Infants.

There are wide variations in antibiotic use in neonatal intensive care units (NICUs). Limited data are available on antimicrobial stewardship (AS) programs and long-term maintenance of AS interventions in preterm very-low-birth-weight (VLBW) infants. We extended a single-centre observational study carried out in an Italian NICU. Three periods were compared: I. "baseline" (2011-2012), II. "intervention" (2016-2017), and III. "maintenance" (2020-2021). Intensive training of medical and nursing staff on AS occurred between periods I and II. AS protocols and algorithms were maintained and implemented between periods II and III. There were 111, 119, and 100 VLBW infants in periods I, II, and III, respectively. In the "intervention period", there was a reduction in antibiotic use, reported as days of antibiotic therapy per 1000 patient days (215 vs. 302, p < 0.01). In the "maintenance period", the number of culture-proven sepsis increased. Nevertheless, antibiotic exposure of uninfected VLBW infants was lower, while no sepsis-related deaths occurred. Our restriction was mostly directed at shortening antibiotic regimens with a policy of 48 h rule-out sepsis (median days of early empiric antibiotics: 6 vs. 3 vs. 2 in periods I, II, and III, respectively, p < 0.001). Moreover, antibiotics administered for so-called culture-negative sepsis were reduced (22% vs. 11% vs. 6%, p = 0.002), especially in infants with a birth weight between 1000 and 1499 g. AS is feasible in preterm VLBW infants, and antibiotic use can be safely reduced. AS interventions, namely, the shortening of antibiotic courses in uninfected infants, can be sustained over time with periodic clinical audits and daily discussion of antimicrobial therapies among staff members.

High protein intake can lead to serious hypophosphatemia and hypokalemia in growth restricted preterm newborns.

High protein parenteral nutrition (HPPN) in the early postnatal period is a recommended strategy for very low birth weight (VLBW) infants. However, limited data is available on electrolyte changes when HPPN strategy is utilized. We investigated the impact of HPPN on the development of hypophosphatemia and hypokalemia in preterm VLBW newborns. A retrospective, single-center study investigated the levels of phosphate and potassium in VLBW infants who received HPPN (amino acids intake up to 3.5 g/kg/day) during the first week of life. Preterm infants were divided into two subgroups: appropriate for gestational age (AGA) and small for gestational age (SGA) newborns. Clinical data were obtained from hospital database and medical records. Overall, 170 VLBW infants were included for the study analysis: 41 SGA (mean birth weight 752 ± 39 g) and 129 AGA infants (mean birth weight 994 ± 23 g). Phosphate and potassium levels were significantly lower in the SGA infants compared to AGA infants (Phosphate: 0.97 ± 0.07 mmol/l vs. 1.44 ± 0.04 mmol/l, p < 0.001; Potassium: 3.0 ± 0.1 mmol/l vs. 3.6 ± 0.1 mmol/l, p < 0.001). Repeated measurement of serum phosphate and potassium is recommended when HPPN strategy is utilized in preterm SGA infants where significant hypophosphatemia and hypokalemia might have serious clinical consequences.

Exploring Pregnant Women and Very Low Birth Weight Babies: A Study in a Tertiary Care Medical College Hospital

Low birth weight is a critical indicator of new-born health, particularly in developing countries where it is moreprevalent. However, data on low birth weight in these countries is often limited due to home or small healthfacility deliveries that go unreported. This study aimed to examine the characteristics of mothers and their verylow birth weight (VLBW) infants, who are at high risk for morbidity and mortality.Methods: The study included hospitalized mothers and their VLBW neonates. Pre- and perinatal data, includinghospitalization complications, were collected from case files using a pre-designed questionnaire and analysed.Results: The mean maternal age in the study group was 24.88 ± 2.92 years, with the majority falling between 21 and25 years. Gestational hypertension, alone or in combination with other risk factors, was the most significant riskfactor (18.36%). The caesarean section (C-section) rate was 58.7%. Among the study group, 49.81% of mothers hadone or more risk factors, with gestational hypertension (18.3%), leaking (12.6%), eclampsia (1.3%), and gestationaldiabetes mellitus (4.8%) being the most prevalent. Out of 7,288 neonates born in SMGS Hospital, 458 (4.3%) wereVLBW babies, with a mean gestational age of 32.19 ± 1.5 weeks and a mean birth weight of 1320 ± 0.21 grams. Themortality rate among VLBW neonates was 5.8%. The most common neonatal outcomes were sepsis (21.8%) andrespiratory distress syndrome (15.9%). The need for mechanical ventilation and surfactant therapy was 6.5% and9.1%, respectively.Conclusion: Delivering preterm VLBW babies from mothers with high-risk factors in hospitals equipped withtertiary care neonatal intensive care units is crucial to improving their outcomes and survival. These findingshighlight the importance of appropriate healthcare facilities for this vulnerable population.

Multimodal Sensory Stimulation among Very Low Birth Weight Preterm Newborns: A Quasi-experimental Study at a Tertiary Care Hospital in Agartala, Tripura, India

Introduction: There is a continuous search for an effective intervention to help preterm low birth weight neonates overcome their poor growth and developmental outcomes. Most researchers have examined the effect of Oromotor Stimulation (OMS) on feeding performance. Studies exploring Multimodal Sensory Stimulation (MSS) on various outcome parameters are sparse and reveal inconsistent results. Aim: To analyse the effectiveness of MSS in improving weight gain, length of hospitalisation, and feeding performance in preterm Very Low Birth Weight (VLBW) neonates. Materials and Methods: This quasi-experimental study was conducted between June 2021 and December 2022 in the Paediatrics Department of Agartala Government Medical College, Agartala, Tripura, India. A total of 104 hospitalised neonates with gestational age from 28 to less than 37 weeks and birth weight from 1000 to less than 1500 grams (VLBW) were included in the study. All neonates received standard care and Kangaroo Mother Care (KMC). On the advice of some faculties, several of them also received MSS. All neonates were divided into two groups: those who received MSS and those who did not, and they were monitored until discharge. Mean hospitalisation length, weight gain, and transition time were derived and statistically analysed using Chi-square and Mann-Whitney U tests. Results: In the present study, the mean gestational age was 32.04±1.75 and 32.679±1.19 weeks, and the M:F ratio was 1.43:1 and 1.30:1 in the MSS-given and MSS-not given groups, respectively. Mean weight gain was significantly higher in the MSS-given group (97.00±123.09 g versus- 23.42±43.96 g). Mean hospitalisation length was longer in the MSS-given group, but transition time did not differ significantly across the groups. Conclusion: Multimodal sensory stimulation is effective in promoting weight gain in preterm VLBW neonates.

9 The Correlation of IQ and Executive Function of VLBW and ELBW Preterm Children with Normal Early Development

AbstractObjective:Previous studies had shown that even with normal early development, preterm children at age six still have executive function deficits, including planning, cognitive flexibility, and nonverbal working memory. The present study aims to discuss further the correlation between IQ and EF of preterm children with different birthweight in order to clarify the potential influence of birthweight.Participants and Methods:The preterm children were recruited from the Regional Cohort Network for premature infants who were admitted to neonatal intensive care units. Inclusion criteria were their scores of Bayley Scales of Infant and Toddler Development, second or third edition at 12 and 24 months, and Wechsler Preschool and Primary Scale of Intelligence, Revised Edition at 5 years old were higher than 70. Meanwhile, their FSIQ of Wechsler Intelligence Scale for Children, Fourth Edition were higher than 85 at age 6. Exclusion criteria were visual impairment, hearing impairment, and cerebral palsy. There was a total of 251 preterm children recruited in the present study. Preterm children were then divided into very low birthweight (VLBW) and extremely low birth weight (ELBW) groups. The VLBW group included 183 preterm children, whose birthweight is between 1000-1500g, and gestational age is less than 37 weeks. The ELBW group included 68 preterm children, whose birthweight is less than 1000g and gestational age is less than 37 weeks. Four types of executive function were assessed. Inhibition was assessed through Comprehensive Nonverbal Attention Test Battery (CNAT), cognitive flexibility was assessed through Wisconsin Card Sorting Test (WCST), verbal working memory was assessed through the Longest Digit Span Forward (LDSB) index of Digit Span Subtest of Wechsler Intelligence Scale for Children-IV (WISC-IV), and nonverbal working memory was assessed through Knox's Cube Test (KCT), and planning ability was assessed through Tower of London (ToL). Data were analyzed with independent T-test and Pearson Correlation.Results:In VLBW preterm group, results showed that there were significant correlations (p&lt;.05) between FSIQ and EF indexes in five out of six indexes of WCST, LDSB of Digit Span of WISC-IV, Backward score of Knox's Cube Test, and three out of six indexes of ToL. As to the CNAT, there was no index of CNAT that was significantly correlated with FSIQ in the VLBW preterm group. In ELBW preterm group, results showed that there were significant correlations (p&lt;.05) between FSIQ and EF indexes in one out of five indexes of CNAT, one out of six indexes of WCST, Backward score of Knox's Cube Test, and two out of six indexes of ToL. And the LDSB of Digit Span of WISC-IV was not significantly correlated with FSIQ in ELBW preterm group.Conclusions:There were fewer EF indexes significantly correlated with FSIQ in ELBW preterm children with normal early development than VLBW preterm children with normal early development, suggesting that even with an IQ higher than 85, lower the birthweight, especially lower than 1000g, higher the EF performance should be concerned. Therefore, in the clinical setting, it is very important to assess the EF independently. And birthweight may be a crucial factor in preterm children's prefrontal cortex maturity.

Analysis of predictive parameters for extubation in very low birth weight preterm infants.

Mechanical ventilation is the primary treatment for preterm infants with respiratory failure. Prolonged intubation may lead to complications; thus, early extubation is desirable. No standard criteria exist for determining the appropriateness of extubating very-low-birth-weight (VLBW) infants. This study explored the predictors of successful extubation in preterm VLBW infants. This retrospective cohort study included 60 preterm VLBW infants who underwent their first extubation in the neonatal intensive care unit in a regional hospital in Hsinchu, Taiwan, between January 2017 and November 2020. Successful extubation was defined as having no requirement of reintubation within 3 days of extubation. Potentially predictive variables, including demographics, prenatal characteristics, and ventilator parameters were compared between a successful extubation group and failed extubation group. Of the 60 infants, 47 (78.33%) underwent successful extubation. The successful extubation group had higher Apgar scores at 1 (7 vs. 6, P=0.02) and 5min (9 vs. 7, P=0.007) than those of the failed extubation group. Ventilator inspiratory pressure and mean airway pressure were significantly lower at 24, 16, 8, and 1h before extubation and upon its completion in the successful extubation group. The areas under a number of the receiver operating characteristic curve curves in this study were moderate, specifically, 0.72, 0.74, and 0.69. Statistical analysis revealed an association between ventilator parameters before 1h extubation (IP>17.5cmH2O, MAP >7.5 cmH2O, RSS >1.82) and extubation failure (odds ratio 1.73, 2.27, 2.46 and 95% confidence interval:1.16-2.6, 1.26-4.08, 1.06-5.68, respectively). Higher Apgar scores at birth, lower ventilator inspiratory pressure, and mean airway pressure 24, 16, 8, and 1h and 1h RSS prior to extubation are associated with successful extubation in VLBW preterm infants.

Multidisciplinary and neuroimaging findings in preterm born very low birthweight individuals from birth to 28 years of age: A systematic review of a Norwegian prospective cohort study.

BackgroundChildren born preterm with very low birthweight (VLBW) face long‐lasting neurodevelopmental challenges, where multidisciplinary assessments are warranted. The International Classification of Functioning, Disability and Health (ICF) provides a framework for understanding and conceptualising these outcomes.ObjectivesWe aimed to review clinical and neuroimaging findings from birth to adulthood in a Norwegian cohort of individuals born preterm with VLBW (gestational age <37 weeks, birthweight ≤1500 g) within the framework of ICF.Data SourcesWe searched PubMed and Embase for articles reporting results of the Norwegian University of Science and Technology (NTNU) Low Birth Weight in a Lifetime Perspective study.Study Selection and Data ExtractionWe included original articles reporting proportions of adverse outcomes, mean group differences, risk factors or associations between outcomes. Data were extracted according to ICF's two‐level classification. Body functions and structures comprised outcomes of brain structures, cognition, mental health, vision, pain and physical health. Activities and participation comprised motor skills, general and social functioning, education, employment, and health‐related quality of life.SynthesisWe performed a qualitative synthesis of included articles. Where mean (SD) was reported, we calculated group differences in SD units.ResultsFifty‐eight publications were included. Within body functions and structures, increased prevalence of brain structure pathology, lower cognitive performance, mental health problems, visual and physical health impairments through childhood, adolescence and young adulthood were reported among preterm VLBW participants compared with controls. Within activities and participation, motor problems, lower general and social functioning, and lower academic attainment were found. Perinatal factors were associated with several outcomes, and longitudinal findings suggested persistent consequences of being born preterm with VLBW.ConclusionsBeing born preterm with VLBW has long‐term influences on body functions and structures, activities and participation. The ICF is appropriate for assessing general domains of functioning and guiding the management of individuals born preterm with VLBW.

Breastfeeding rates at discharge for very low birthweight neonates and their determinants: An observational study from a tertiary care neonatal intensive care unit in India.

Mother's milk is the best milk for neonates. Preterm very low birthweight (VLBW) neonates face many challenges leading to low rates of breastfeeding at discharge. (i) To determine the proportion of <32 weeks preterm VLBW neonates who are exclusively breastfed (EB) at discharge and (ii) determinants of exclusive breastfeeding (EBF) at discharge. An observational study was conducted for a duration of 1 year, from May 2019 to April 2020 in a tertiary care neonatal intensive care unit (NICU) in North India. Consecutive <32 weeks preterm VLBW neonates admitted within 72 h of birth and on full enteral feeds (FEF) within 10 days of birth were included in this study and followed up till discharge. Forty-four of 97 (45.4%) preterm VLBW neonates were exclusively breastfed and 31/97 (32%) received more than 80% mother's own milk (MOM) at discharge. Male sex (P=0.03), those whose first feed had any amount of MOM (P=0.038) or exclusive MOM in their first feed or when initiated on first FEF (P=0.002), and neonates with longer duration of hospital stay (P=0.035) had an increased chance of being exclusively breastfed at discharge. Preterm VLBW neonates who receive any amount of MOM in their first feed or first FEF, male infants and those who stay longer in hospital are more likely to be exclusively breastfed at discharge.

Fetal Reduction Could Improve but Not Completely Reverse the Pregnancy Outcomes of Multiple Pregnancies: Experience From a Single Center.

ObjectiveTo investigate the effectiveness and limitations of multifetal pregnancy reduction (MFPR) on the improvement of pregnancy outcomes of triplet or twin pregnancies conceived by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).MethodsWe performed a cohort study of women undergoing IVF or ICSI from 2002–2016 in reproductive center, women’s hospital, Zhejiang University School of Medicine. The cohort included 502 women who underwent MFPR and 9641 non-reduced women. Pregnancy outcomes were gestational age (GA) at delivery, pregnancy loss, preterm delivery, low birth weight (LBW), very low birth weight (VLBW), and small for gestational age (SGA). Multiple linear regression and logistic regression models were used to compare pregnancy outcomes between groups.ResultsTriplets reduced to singletons had a longer median GA (39.07 vs 37.00, P<0.001), and lower rates of LBW (8.9% vs 53.2%, P<0.001) and SGA (17.8% vs 44.7%, P=0.001) than triplets reduced to twins, with a similar pregnancy loss rate (6.7% vs 6.6%, P=0.701). Twins reduced to singletons had a comparable pregnancy loss rate (4.8% vs. 6.5%, P=0.40), a longer median GA (38.79 vs. 37.00, P<0.001), and lower rates of LBW (13.5% vs. 47.0%, P<0.001) and SGA (13.5% vs. 39.6%, P<0.001) than primary twins. Triplets reduced to twins had higher rates of LBW (53.2% vs. 47.0%, P=0.028) and SGA (44.7% vs. 39.6%, P=0.040) than primary twins, with a similar pregnancy loss rate (6.6% vs. 6.5%, P=0.877). Singletons reduced from triplets/twins had higher rates of preterm delivery (15.8% vs. 7.3%, P<0.001), LBW (12.3% vs. 4.32%, P<0.001), VLBW (2.3% vs. 0.4%, P=0.002), and SGA (14.6% vs.6.6%, P<0.001) than primary singletons, with a comparable pregnancy loss rate (5.3% vs. 5.4%, P=0.671).ConclusionsThis study suggests that the pregnancy loss rate is similar between reduction and non-reduction groups. MFPR improves pregnancy outcomes, including the risk of preterm delivery, LBW, and SGA, but still could not completely reverse the adverse pregnancy outcomes of multiple pregnancies.

Delivery Mode and Neurological Complications in Very Low Birth Weight Infants.

The risk of intraventricular hemorrhage (IVH) and periventricular leukomalacia is associated with low birth weight and gestational age. Caesarean section (CS) may reduce the risk of IVH, although it has been a matter of debate. The aim of this study was to evaluate the influence of the mode of delivery (MOD) on the development of IVH and cystic periventricular leukomalacia (cPVL). We analyzed an initial cohort of 11,023 very low birth weight (VLBW) infants born between January 2010 and December 2019. Infants with major malformations and gestational age <23 weeks and ≥32 weeks were excluded. A final cohort of 8,251 newborns was analyzed. Data was collected from Portuguese National very low birth weight registry. Cases were classified as vaginal delivery (VD) or CS. Outcome was assessed in univariate and logistic regression analyses. The median gestational age was 29 weeks (IQR 3.3) and the median weight was 1,100 g (IQR 555). The prevalence of IVH was significantly higher in the VD group versus the CS group, across all grading levels:1,144 newborns had grade I IVH (16% VD vs. 14% CS, p <0.01), 706 had grade II IVH (12% VD vs. 7.6% CS, p <0.01), and 777 had grade III IVH (14% VD vs. 7.9% CS, p <0.01). Post-hemorrhagic ventricular dilatation occurred in 457 newborns (8.3% VD vs. 4.6% CS, p <0.01) and 456 newborns had periventricular hemorrhagic infarction (8.4% VD vs. 4.5% CS, p <0.01). There was no association between MOD and cPVL. After applying a logistic regression analysis, including known risk factors for IVH and cPVL, VD was independently associated with an increased risk of IVH (odds ratio [OR] 1.600[1.423-1.799], p <0.001) and its complications (OR 1.440[1.195-1.735], p <0.001). MOD was not associated with an increased risk of cPVL. Our study suggests that CS is associated with a reduced risk of IVH and its complications in preterm VLBW infants < 32 weeks of gestational age. A CS should be considered in this group of infants to prevent the development of IVH and its complications. · IVH and cPVL are risk factors for neurological disabilities.. · CS may decrease the risk of IVH in preterms <32 weeks GA.. · There is no association between the MOD and cPVL..

Effect of Maternal Diet on Any Necrotizing Enterocolitis in Neonates: A Randomized Double-Blind Study.

Background: The etiology of necrotizing enterocolitis (NEC) is controversially discussed. One of the most recently proposed causes of NEC is an allergy to cow's milk protein. This study was designed to evaluate the effect of a maternal diet without bovine protein on the incidence of any NEC in very low birth weight (VLBW) infants. Materials and Methods: A pilot randomized controlled clinical trial was performed at Akbarabadi Hospital, Tehran, Iran, from December 2019 to July 2020, in women with VLBW infants. One hundred twenty mothers with VLBW neonates were randomly assigned to the intervention or the control group (60 in each). In the intervention group, mothers were given a dairy-free diet during the first 14 days after the newborn's onset of feeding. No special diet was given to the control group. The primary outcome of the study was the rate of any NEC in neonates, which was compared between groups. Any NEC was defined as Bell stage I or greater. Results: The minimum and maximum gestational ages were 26 and 33 weeks, respectively. The minimum birth weight of neonates was 700 g. The two groups did not differ significantly in terms of demographic and preinterventional clinical characteristics. Any NEC was reported in 0% and 10% (5/52) of neonates in the intervention and control groups, respectively; the difference was statistically significant (p = 0.028). The NEC symptoms began ∼34 days after birth. Four cases of NEC were classified as Bell stage I, and one was classified as Bell stage II. No statistical association was registered between sex, gestational age, birth weight, and the onset of feeding with the incidence of any NEC. Conclusion: The use of a cow's milk protein-free diet in mothers and exclusive breastfeeding in preterm VLBW infants may reduce the incidence of NEC. We recommend further studies with larger sample sizes in a multicenter setting. The study was registered at the Iranian Registry of Clinical Trials (IRCT20200415047086N1).

Risk Factors for Mortality From Late-Onset Sepsis Among Preterm Very-Low-Birthweight Infants: A Single-Center Cohort Study From Singapore.

ObjectiveTo determine the risk factors for mortality associated with late onset sepsis (LOS) among preterm very-low-birthweight (VLBW) infants.Study DesignWe performed a retrospective cohort study of infants born <32 weeks gestation and <1,500 gm admitted to a Singaporean tertiary-level neonatal intensive care unit. We determined the clinical, microbial, and laboratory risk factors associated with mortality due to culture-positive LOS in this cohort.ResultsA total of 1,740 infants were admitted, of which 169 (9.7%) developed LOS and 27 (16%) died. Compared to survivors, those who died had lower birth gestational age (median 24 vs. 25 weeks, p = 0.02) and earlier LOS occurrence (median 10 vs. 17 days, p = 0.007). There was no difference in the incidence of meningitis (11.1 vs. 16.9%, p = 0.3), NEC (18.5 vs. 14.8%, p = 0.6), or intestinal surgery (18.5 vs. 23.3%, p = 0.6) among infants who died compared to survivors. Gram-negative bacteria accounted for 21/27 (77.8%) LOS-associated deaths and almost all (13/14, 93%) fulminant episodes. The presence of multiorgan failure, as evidenced by the need for mechanical ventilation (100 vs. 79.0%, p = 0.008), elevated lactate (12.4 vs. 2.1 mmol/L, p < 0.001), and inotropic support (92.6 vs. 37.5%, p < 0.001), was significantly associated with mortality. Infants who died had significantly lower white blood cell (WBC) counts (median 4.2 × 109/L vs. 9.9 × 109/L, p = 0.001), lower platelet count (median 40 × 109/L vs. 62 × 109/L, p = 0.01), and higher immature to total neutrophil (I: T) ratio (0.2 vs. 0.1, p = 0.002). Inotrope requirement [AOR 22.4 (95%CI 2.9, 103.7)], WBC <4 × 109/L [AOR 4.7 (1.7, 13.2)], and I: T ratio >0.3 [AOR 3.6 (1.3, 9.7)] were independently associated with LOS mortality.ConclusionsIn a setting with predominantly Gram-negative bacterial infections, the need for inotropic support, leukopenia, and elevated I: T ratio were significantly associated with LOS mortality among preterm VLBW infants.

A quality improvement intervention to improve lactation in mothers of hospitalized extreme preterm and very low birth weight infants in the first 2 weeks of life at a tertiary hospital in South India

Objectives: Early establishment of human milk (HM) feeding significantly decreases neonatal morbidity. There are barriers in establishing and maintaining lactation in mothers of hospitalized extreme preterm and very low birth weight (VLBW) infants, particularly during the first 2 weeks of life. Infant feeding policy modification was done to improve lactation as a quality initiative project and the effect of this modification was studied. Material and Methods: This study was done at SRIHER by analyzing retrospective data from the period before infant feeding policy modification (April 1, 2017–June 30, 2017) and prospective data from post-policy modification (July 1, 2017–December 31, 2017). All extreme preterm babies and VLBW babies both inborn and outborn were included in the study. The policy was approved by the institutional quality control cell. Fishbone analysis and “why” question pattern were implemented to identify pitfalls in establishing and maintaining lactation in mothers of extreme preterm and VLBW mothers. Prior antenatal counseling (for inborn deliveries), immediate postnatal assessment, constant surveillance, internal audits, and regular interprofessional team meets were done to carry out the implementation of the quality control program. Results: Daily milk output improved after intervention from baseline value in the pre-policy modification group to nearly 3 times after policy modification. The total duration of the requirement of parenteral nutrition decreased from 11 days to 7 days and time to reach birth weight decreased from 17 days to 11 days after quality improvement initiative. Conclusion: A simple quality improvement initiative was able to achieve increased lactation in mothers of extreme preterm and VLBW neonates.

Effectiveness of Bedside Clinical Screening Tools in Predicting Short-Term Neurodevelopmental Delay Among Very-Low-Birth-Weight Pre-terms: A Prospective Observational Study.

Background: Pre-term births are associated with increased risk of various morbidities, especially neurological. Early detection and early intervention to prevent these morbidities will have immediate and long-term benefits to the individuals and society at large. However, the screening and assessment tools, including both clinical and radiological, are not uniformly available in resource-poor settings. The present study was carried out to evaluate the validity of the clinical screening tools for detecting neurodevelopmental delay among very-low-birth-weight (VLBW) pre-term babies.Methods: This prospective observational study was undertaken in the child development unit of a tertiary care hospital from July 2015 to October 2017. All pre-term VLBW neonates admitted in level III Neonatal Intensive Care within the first 24 hours of life were included in the study. They were subjected to Hammersmith Neonatal Neurological Examination (HNNE) and magnetic resonance imaging (MRI) of brain at term-equivalent age. Subsequently, the same group was followed up with Amiel-Tison (AT) angles, Child Development Centre (CDC) grading for sitting developed at Trivandrum, Kerala, India, and Denver Development Screening Test (DDST-II gross motor) at eight months corrected age, and their outcomes were analyzed.Results: 17.9% of the ex-preterm were abnormal as per HNNE evaluation at term-corrected age. At short-term follow-up screening, 13.8% were found to be abnormal based on AT angles, while 35.2% were found to be abnormal as per CDC grading and 30.4% were found to have risk for delay as per DDST-II (gross motor). A high level of sensitivity (93.6%) and positive predictive value (91.2%) was observed for HNNE at term equivalent with MRI brain assessment considered as gold standard. Among the follow-up screening tools, CDC grading for sitting, AT angles, and DDST-II had high sensitivity (>85%).Conclusion: The combination of HNNE along with radiological assessment at term-corrected age can be considered as appropriate for predicting long-term neurodevelopmental outcome in VLBW pre-term infants. During follow-up, simple tools like CDC grading for motor milestones, AT angles, and DDST-II may be utilized if facilities for standard assessment are not available as in resource-poor settings.

Screening for Neurodevelopmental Delay for Preterm Very Low Birth Weight Infants at Tertiary Care Center in Saudi Arabia.

BackgroundPreterm infants are more susceptible to death, short-term complications, and long-term complications such as neurodevelopmental impairments. However, definitive assessment tools are not available in a resource-limited setting. Hence a screening tool is needed the Arabic-speaking population.MethodInfants born at a gestational age of <32 weeks or a very low birth weight (VLBW) of less than 1500 g were recruited into a cross-sectional study. We identified infants (n = 61) admitted to the neonatal ICU at King Abdulaziz Medical City and reached 18 up to 24 months of corrected gestational age (CGA). The developmental assessment was done at 18, 20, 22, and 24 CGAs using the Ages and Stages Questionnaire third edition - Arabic version (ASQ3-A). The primary outcomes are early detection rate of neurodevelopmental delay (NDD), defined as a delay in one or more of the following: communication, gross motor, fine motor, problem-solving, and personal-social skills as per ASQ3-A.ResultsSixty-one out of 92 eligible infants (36 excluded) completed the sufficient assessment. Twenty-six infants (42.6%) had at least one NDD in one of the following domains: communication skills: (11.5%), gross motor: (11.5%), fine motor: (19.7%), problem-solving skills: twelve infants (19.7%), and personal-social skills: twenty infants (23%). Perinatal events and periventricular leukomalacia (PVL) were significant independent predictors for the NDD.ConclusionThis single-center study in Saudi Arabia screened preterm, VLBW infants based on ASQ3-A, twenty infants (42.6%) had an abnormal NDD at a corrected age of 18-24 months. Perinatal events and PVL were independent predictors of NDD. We recommend that all preterm VLBW infants in Saudi Arabia be evaluated by a neurodevelopmental screening tool, ASQ3-A, especially in resource-limited settings to start early intervention. Also, more extensive multicenter studies are to be carried out with definitive diagnostic tools to have a national benchmark for the long-term neurodevelopmental impairment.

Gut Dysbiosis, Bacterial Colonization and Translocation, and Neonatal Sepsis in Very-Low-Birth-Weight Preterm Infants.

Gut dysbiosis may precede neonatal sepsis, but the association is still not well-understood. The goal of this study is to investigate the association between gut microbiota and neonatal sepsis, and to seek the evidence of colonization of pathogenic bacteria in the gut before evolving into an invasive infection. A prospective cohort study examined fecal microbiota composition in preterm infants with and without sepsis. Thirty-two very-low-birth-weight (VLBW) preterm infants and 10 healthy term infants as controls were enrolled. The fecal samples collected from the participants at the first, fourth, and seventh weeks of life underwent 16S rRNA amplicon sequencing for measurement of the diversity and composition of the microbiota. The bacterial isolates causing neonatal sepsis were genome sequenced. PCR was performed to confirm the translocation of the bacteria from the gut to the blood. The results showed that VLBW preterm infants with sepsis had lower microbial diversity in the gut at birth compared to preterm infants without sepsis and term infants. The composition of gut microbiome in preterm infants was similar to healthy terms at birth but evolved toward dysbiosis with increasing Proteobacteria and decreasing Firmicutes weeks later. The strain-specific PCR confirmed the presence of causative pathogens in the gut in 4 (40%) out of 10 VLBW preterms with sepsis before or at onset of sepsis, and persistence of the colonization for weeks after antibiotic treatment. The same bacterial strain could horizontally spread to cause infection in other infants. Prolonged antibiotic exposure significantly reduced beneficial Bifidobacterium and Lactobacillus in the gut. In conclusion, preterm infants with gut dysbiosis are at risk for neonatal sepsis, and the causative pathogens may be from the gut and persist to spread horizontally. The association of increased Proteobacteria abundance and decrease in microbiome diversity suggests the need for interventions targeting the gut microbiome to prevent dysbiosis and sepsis in VLBW preterm infants.

Impact of mother-baby friendly initiative plus approach on improving human milk feeding for neonates in hospital: a quality improvement before-and-after uncontrolled study

Breastfeeding, use of pasteurised donor human milk when mother's own milk is unavailable and kangaroo mother care have independently proven benefits in improving survival of vulnerable sick babies. A triangulated approach called the Mother Baby Friendly Initiative Plus (MBFI+) model, bringing together the combined benefits of these proven interventions, was used to improve exclusive human milk feeding at health facilities through quality improvement and system strengthening approach. This quality improvement before-and-after uncontrolled study enrolled 5343 term and 278 very low birth weight (VLBW) mother-infant dyads. Pre- and post-intervention data were compared to evaluate effect on feeding-related healthcare processes and outcomes. Primary outcome which was incidence of exclusive human milk feeding during hospital stay, improved from 44 to 64.8% (RR 1.47, 95% CI: 1.40-1.55) among term and from 60.5 to 80.7% (RR: 1.33; 95% CI: 1.12-1.59) among VLBW neonates. Neonates receiving extended KMC improved from 43 to 71.1% (RR: 1.65; 95% CI: 1.30-2.10).Conclusion: MBFI+ approach improved exclusive human milk feeding among term and preterm VLBW neonates. What is Known: • Breastfeeding has immense health benefits to sick preterm neonates admitted in NICU. What is New: • Quality improvement approach can lead to system strengthening and can help overcome hindrances to achieve increased breastfeeding rates.

Late-onset sepsis in very low birth weight preterm infants: 7 years' experience at a tertiary hospital in China

Studies about the epidemiology and risk factors of late onset of sepsis (LOS) in preterm very low birth weight (PVLBW) infants of developing countries are limited and variable. The objective of this study was to explore the epidemiology, risk factors and pathogens of LOS in VLBW infants in a Chinese tertiary hospital. Data concerning demographies, pathogens, risk factors and outcomes of LOS were collected in a cohort of 710 VLBW infants discharged from January 2012 to December 2018. Chi-square, t-test and multivariable logistic regression analysis were used to identify risk factors. The overall incidence of LOS was 24.08% and blood culture-proven sepsis was 19.58%. Gram-negative bacteria accounted for 57.93%, and 32.41% of the isolates were Klebsiella pneumoniae. LOS led to a longer hospital stay, higher hospitalization cost and higher mortality compared to infants without LOS. Mortality in Gram-negative or fungi LOS was higher than in Gram-positive LOS. The factor of PVLBW infants with registered permanent residence (PR) was associated with 80% lower likelihood of LOS compared to those without registered PR (P=0.000, 95% CI 0.096-0.420). Infants with thrombocytopenia had 2.5 times LOS of control (P=0.014, CI 1.210-5.132). Duration of parenteral nutrition was a risk of LOS (P=0.009, CI 1.010-1.069). Gram-negative bacteria, especially Klebsiella pneumonia, were the dominant pathogens in this study. Social factors might be a risk of LOS in PVLBW infants in developing countries. Taking measures to reduce the duration of parenteral nutrition may be helpful in decreasing the incidence of LOS. Awareness of thrombocytopenia may help to recognized diagnosis of LOS.

Effects of Antenatal Magnesium Sulfate on the Gut Function of Preterm (

Antenatal magnesium sulfate (MgSO4) is found to have various adverse effects in newborn, but the effect on preterm gut is still unclear. This study aimed to evaluate the effects of antenatal MgSO4 on preterm gut function by assessing the clinical outcomes and mesenteric blood flow. This was a prospective cohort study on all preterm very low birth weight (VLBW) neonates born at a tertiary care center in South India from November 2016 to August 2017. Neonates with antenatal magnesium (Mg) exposure were compared with those with no exposure for various neonatal outcome variables like time to reach full feeds, feed intolerance, necrotizing enterocolitis (NEC) and other preterm complications, serial serum Mg levels and superior mesenteric artery (SMA) Doppler velocity measurements at two time points (24-48 h and 4-5 days after birth). Out of 84 neonates, 56 neonates were exposed to antenatal Mg with a median cumulative maternal dose of 28 g and the rest 28 neonates had no exposure. The mean time to reach full feeds was the same in both groups (10.5 days). Feed intolerance episodes were similar in the first week of life between the exposed and unexposed groups (48.2% vs. 46.4%; p = 0.88). Univariate analysis revealed no difference between groups concerning rates of NEC (p = 0.17) or mortality (p = 0.39). There was no significant difference in SMA Doppler parameters and hypermagnesemia between the two groups. Our study found no significant impact on postnatal feed tolerance and mesenteric blood flow among preterm VLBW neonates with antenatal MgSO4 exposure.