Very Low Birth Weight Infants Research Articles

Association between Ureaplasma colonization and bronchopulmonary dysplasia defined by different criteria in very low birth weight infants: A retrospective cohort study.

To study the association between Ureaplasma colonization and bronchopulmonary dysplasia (BPD) with different definitions in very low birth weight (VLBW) infants. A retrospective cohort study was performed with VLBW infants admitted from January 2019 to October 2021. Neonates with a positive respiratory tract Ureaplasma culture were included in the study group. Control group infants, matched for gestational age (±1 week), birth weight (±100 g), and birth year, had a negative respiratory tract Ureaplasma culture during the same period. The primary outcomes included the incidence and severity of BPD, defined by various criteria. The study included 302 neonates (151 in the study group and 151 in the control group). After adjusting for confounders, Ureaplasma colonization was not associated with BPD as defined by the National Institutes of Health (NIH) in 2001 (adjusted odds ratio [aOR]: 0.820, 95% confidence interval [CI]: 0.362-1.860, p = .635). However, it was associated with BPD as defined by the NIH in 2018 (aOR: 2.490, 95% CI: 1.128-5.497, p = .024) and the Neonatal Research Network (NRN) in 2019 (aOR: 2.352, 95% CI: 1.077-5.134, p = .032). Additionally, VLBW infants with Ureaplasma colonization had a higher risk of moderate-severe BPD according to the NIH 2001 (aOR: 2.352, 95% CI: 1.077-5.134, p = .032), NIH 2018 (aOR: 6.339, 95% CI: 1.686-23.836, p = .006), and NRN 2019 definitions (aOR: 3.542, 95% CI: 1.267-9.904, p = .016). Ureaplasma colonization is not associated with BPD by the NIH 2001 definition, but is associated with an increased incidence by the NIH 2018 or NRN 2019 definitions.

A budget impact analysis of exclusive human milk diet in very low birth weight infants in United Arab Emirates

Introduction Very low birth weight (VLBW) infants have the highest rate of neonatal intensive care unit (NICU) admissions owing to the higher comorbidities associated with premature birth and long hospital stays. VLBW infants fed a bovine (BOV)-based diet have higher mortality rates, necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and other comorbidities than those fed 100% human milk-based products. This study aims to evaluate the budgetary impact of adopting an exclusive human milk diet (EHMD) instead of a BOV-based diet in VLBW infants from Al-Ain Hospital, Sheikh Shakhbout Medical City, and Dubai Health Authority (DHA) in the United Arab Emirates (UAE). Methods We use a decision tree model to estimate the budget impact of adopting EHMD versus the current local practice (BOV) over five years. Patients enter the tree model and have a probability of transitioning to one of the following mutually exclusive health states: NEC, which may be treated medically or surgically; LOS, NEC, and LOS; or neither NEC nor LOS. Depending on the feeding strategy, infants in the aforementioned health states are likely to develop any of the following complications: retinopathy of prematurity, bronchopulmonary dysplasia, or short bowel syndrome. The model accounts for the costs associated with diet, management of health states and complications, and the follow-up period. Results Al-Ain Hospital saved United Arab Emirates Dirham (AED) 3.3 million ($1.4million) in the first year of the EHMD feeding arm and AED 16.6 million ($7.1million) over the course of five years. In comparison to Sheikh Shabout Medical City and DHA, AED 36.7 million ($15.8million) and AED 24 million ($10.3million) were saved over five years, respectively, with AED 7.3 million ($3.1million) and 4.8 million ($2million) saved in the first year. The estimated pooled results across the three institutions were AED 5.1 million ($2.2million) and AED 25.7 million ($11million) savings in the first year and over five years, respectively. Conclusion Implementing the EHMD feeding scheme in VLBWs that has significant clinical benefits has resulted in substantial budget savings from the payer’s perspective in the UAE owing to fewer comorbidities associated with premature birth and shorter hospital stays. It is highly recommended for the Emirati health care settings to evaluate the real-world neonatal complication rates.

Risk factors for refractory respiratory distress syndrome among very-low-birth-weight infants

BackgroundThe objective was to evaluate refractory respiratory distress syndrome (RDS) risk factors among very-low-birth-weight infants (VLBWIs).MethodThe data of VLBWIs born between January 2013 and December 2020 registered in the Korean Neonatal Network (KNN) were analyzed. Infants who died within 5 postnatal days or who were not given surfactant were excluded. Infants were divided into a well-responding RDS group, which received surfactant replacement therapy (SRT) only once, and a refractory RDS group, which received SRT twice or more. The associations between perinatal characteristics and refractory RDS were investigated via multivariate logistic regression analysis.ResultsMultivariate logistic regression analysis revealed that low gestational age (adjusted odds ratio [aOR] = 1.26, 95% confidence interval (CI) [1.23, 1.26], male sex (aOR = 1.17, 95% CI [1.06, 1.29]), cesarean section (aOR = 1.59, 95% CI [1.38, 1.80]), maternal hypertensive disorder (aOR = 1.54, 95% CI[1.35, 1.75]), and low 5-minute Apgar scores (aOR = 1.24, 95% CI [1.12, 1.37]) were significantly associated with refractory RDS. Antenatal corticosteroid use (aOR = 0.81, 95% CI [0.73, 0.89]) and maternal chorioamnionitis (aOR = 0.79, 95% CI [0.71, 0.88]) were significantly inversely associated with refractory RDS. Compared with well-responding RDS, refractory RDS was significantly associated with increased major neonatal morbidity and mortality risk at 5 postnatal days.ConclusionMaternal hypertensive disorder is a significant risk factor for refractory RDS. Refractory RDS was associated with unfavorable neonatal outcomes.

Association of different types of abortions with neonatal outcomes in subsequent pregnancy.

Abortion is an important issue that concerns all women. It holds great significance to investigate the correlation between various types of abortion histories and the neonatal outcomes of subsequent pregnancies. This retrospective cohort study included pregnant women who gave birth to singleton live-born in Shanghai First Maternity and Infant Hospital from 2016 to 2020 (n = 75 773). Women with a history of abortion, including spontaneous abortion (SAB) and induced abortion (IA), were included in the exposed group, and the remaining were included in the unexposed group. The main outcomes were birthweight and preterm birth in the subsequent pregnancy. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for the association of maternal abortion history with birthweight and risk of preterm birth in subsequent pregnancy. Women who have experienced SAB history had an increased risk of delivering very low birth weight (VLBW) and preterm birth children, with (OR = 1.63, 95% CI = 1.15-2.32; OR = 1.38, 95% CI = 1.07-1.79). However, women with a history of IA were at greater risk of macrosomia (OR = 1.16; 95% CI = 1.06-1.27). We also observed that the likelihood of delivering a VLBW baby was heightened by the number of SAB occurrences (OR = 0.87, 95% CI = 0.54-1.38; OR = 1.84, 95% CI = 1.01-3.36, OR = 5.71, 95% CI = 3.21-10.15). Our study indicates that pregnant women with a history of SAB are at an increased risk of delivering VLBW infants and experiencing preterm labour. The risk is positively associated with the number of SABs. Conversely, women with a history of IA are more likely to deliver macrosomic infants.

Recommendations for antibiotic use in hospitalized preterm infants with late-onset sepsis in the neonatal intensive care unit

Late-onset sepsis (LOS) is commonly seen in neonates who are hospitalized for extended periods, particularly in very low birth weight infants (VLBWI) and extremely low birth weight infants (ELBWI). Currently, the management of LOS in preterm infants faces dual challenges of delayed diagnosis and treatment, as well as antibiotic overtreatment. To address these issues, the Hunan Neonatal Medical Quality Control Center and the Neonatology Group of Perinatal Medical Committee of Hunan Medical Association organized a group of neonatal experts from Hunan Province to formulate recommendations based on published literature and statistical data from the Hunan Neonatal Medical Quality Control Center, as well as real-world practices in most neonatal intensive care units in Hunan Province. The group of neonatal experts proposed 15 recommendations for the diagnosis and antibiotic treatment of LOS in hospitalized preterm infants in the neonatal intensive care unit.

A randomized-controlled trial of parent-administered interventions to improve short-term motor outcomes in hospitalized very low birthweight infants.

Premature infants are at increased risk for cerebral palsy (CP). Early interventions with a motor focus and administered by parents may improve motor outcomes. Secondary study evaluating the short-term motor outcomes and risk for CP in very low birthweight (VLBW) infants randomized to multimodal interventions with a motor focus provided by parents versus usual care. Randomized controlled trial (intervention vs. usual care (control group)). Infants (<32 weeks' gestational age (GA) and/or <1500 grams birthweight) born between March 2019 and October 2020. Short-term motor outcomes and risk for CP was evaluated using the Hammersmith Infant Neurological Evaluation (HINE, primary motor outcome), the General Movement Assessment (GMA) and the Test of Infant Motor Performance (TIMP) at 3 months' postmenstrual age (PMA). 70 participants were enrolled (GA 28.3±2.7 weeks, birthweight 1139.2±376.6 grams, 64.3% male). The in-person follow-up rate was 73%, lower than expected, in part due to COVID-19 restrictions, resulting in 25 infants (intervention) and 26 infants (control) with outcome data available for analysis. There was not a significant difference in the HINE, GMA or TIMP at 3 months' PMA between groups. Multimodal interventions with a motor focus and provided by parents need further investigation to determine if they can improve short-term motor outcomes in VLBW infants. These interventions are evidence-based and the evaluation of broader implementation into routine care is also needed.

Macronutrient Intake during Complementary Feeding in Very Low Birth Weight Infants Comparing Early and Late Introduction of Solid Foods: A Secondary Outcome Analysis.

Background/Objectives: Very low birth weight (VLBW) infants may require enhanced nutrition, even during complementary feeding. However, there are limited data on macronutrient intake during this period, particularly concerning the individual timing of the introduction of solid foods in a representative VLBW infant population. Methods: This prospective observational study analyzed macronutrient intake in VLBW infants with a gestational age < 32 weeks based on whether solid foods were introduced early (<17 weeks corrected age (CA)) or late (≥17 weeks corrected age) Nutritional intake was analyzed using a 24 h recall at 6 weeks CA and 3-day dietary records at 12 weeks, 6, 9, and 12 months CA. Results: In total, 115 infants were assigned to the early and 82 to the late group. The timing of solid food introduction did not affect macronutrient intake, except for a lower fat and higher carbohydrate intake (% of energy) in the early group at 12 weeks and 6 months CA: early vs. late, fat-12 weeks: 47.0% vs. 49.0%, 6 months: 39.2% vs. 43.3%; carbohydrates-12 weeks: 44.9% vs. 43.2%, 6 months: 51.3% vs. 48.0%. Apart from docosahexaenoic acid (DHA) and arachidonic acid (AA), dietary intake recommendations were met in both groups. While nutrient intakes varied significantly between breastfed and formula-fed infants, those with comorbidities exhibited similar nutrient intake levels compared to those without. Conclusions: Our findings suggest adequate macronutrient intakes in VLBW infants irrespective of the timing of solid introduction. However, there is a notable need to enhance dietary intakes of DHA and AA. Future research is crucial to assess whether current nutrient intakes are sufficient for VLBW infants with comorbidities.

Early-onset preeclampsia/gestational hypertension may be associated with a low incidence of cerebral palsy at 3 years old in singleton very low-birth-weight infants born at 28-31 weeks of gestation (EOPE-DQ study): a multi-center retrospective cohort study in 2013-2016.

Our aim was to evaluate the effects of any types of hypertensive disorders of pregnancy (HDP) on the development of either cerebral palsy (CP) or developmental delay (DD) at 3 years old in singleton very low-birth-weight (VLBW) infants born at 24-31 weeks of gestation. This was a retrospective cohort study of VLBW infants born at 24-31 weeks in 2013-2016 in Japan, using a nationwide obstetrical database, and Neonatal Research Network Japan (NRNJ) Database, accompanied by a secondary survey of women complicated with HDP (EOPE-DQ study). In 529 candidates for long-term follow-up in 7 tertiary centers, the percentage undergoing follow-up for CP at 3 years old was 56.1%, and the percentage receiving follow-up for DD at 3 years old was 54.1%. The percentage of PE/SPE/GH was significantly lower in infants with CP than in controls (1/22 [4.5%] vs. 66/274 [24.1%], p = 0.034); especially, in infants born at 28-31 weeks, the percentage of PE/SPE/GH was significantly lower in infants with CP than in controls (0/13 [0%] vs. 44/151 [29.1%], p = 0.021). The percentage of PE/SPE/GH was not different between infants with DD and controls (9/49 [18.4%] vs. 54/237 [22.8%], p = 0.574). The percentage of composite risk factors (either bronchopulmonary dysplasia at a postmenstrual age of 36 weeks, intraventricular hemorrhage, hypoxic ischemic encephalopathy, sepsis, necrotizing enterocolitis, or periventricular leukomalacia) was significantly higher in infants with DD than in controls. In conclusion, PE/SPE/GH around 30 weeks may be associated with a low incidence of CP.

Perinatal risk factors for late neonatal severe acute kidney injury in very low birth weight infants: a retrospective study.

This study aimed to identify the perinatal risk factors of severe acute kidney injury (AKI) occurring after the first week of birth in very low birth weight (VLBW) infants who survived up to the first week. We conducted a single-center, retrospective cohort study on VLBW infants (birth weight, <1,500 g) delivered at <32 weeks of gestational age (GA) from January 2012 to December 2022. We classified AKI based on changes in serum creatinine and urine output based on the modified The Kidney Disease: improving Global Outcomes (KDIGO) neonatal AKI criteria. Stage 2-3 AKI were considered as severe AKI (sAKI). We performed logistic regression analysis to evaluate risk factors for late neonatal severe AKI identified in the second week after birth. We included 274 VLBW infants. The prevalence of late neonatal severe AKI (sAKI) was 27.4%, with the diagnosis rate of sAKI being higher early after birth. Logistic regression analysis revealed that the factors associated with late neonatal sAKI were small for gestational age (SGA) (OR, 3.02; P = 0.032), endotracheal intubation in the delivery room (OR, 2.79; P = 0.022), necrotizing enterocolitis (NEC) (OR, 12.41; P = 0.029), and decreased minimum weekly fluid balance <0 (OR, 2.97; P = 0.012). SGA, intubation in the delivery room, and NEC were associated factors for late neonatal sAKI in VLBW infants. The association of no weekly weight gain with increased late neonatal sAKI risk indicates its use in guiding fluid therapy and aids in biomarker research.

Risk factors associated with anemia of prematurity requiring red blood cell transfusion in very low birth weight infants: a retrospective study

BackgroundAnemia of prematurity (AOP) is prevalent among very low birth weight infants (VLBWIs). Red blood cell (RBC) transfusions, while necessary for managing AOP, have been linked to adverse neonatal outcomes.MethodsThis retrospective study analyzed the medical records of 98 VLBWIs (24–31 weeks gestation) admitted to the Chungbuk National University Hospital neonatal intensive care unit. Infants were categorized based on RBC transfusion status and birth weight (< 1000 g and 1000–1499 g). Clinical outcomes between the groups were compared.ResultsOf the 98 infants, 35 (35.7%) received RBC transfusions. The RBC transfusion group exhibited significantly higher incidence of bronchopulmonary dysplasia (\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\:\\ge\\:\\:$$\\end{document}moderate), prolonged invasive mechanical ventilation, intraventricular hemorrhage (grades 1–2), extended time to full enteral feeding, and extended total parenteral nutrition (TPN) compared to the non-RBC transfusion group. Birth weight was inversely correlated with the number of RBC transfusions (p = 0.004). The duration of invasive mechanical ventilation and TPN administration were positively associated with the number of RBC transfusions (p < 0.001 and p = 0.025, respectively).ConclusionsThe RBC transfusion group experienced more comorbidities than the non-transfusion group. Birth weight, duration of invasive ventilation, and duration of TPN were associated with the number of RBC transfusions. Strategies to reduce the duration of invasive ventilation and early discontinuation of TPN may mitigate the need for RBC transfusions in AOP.

Micronutrient Intake during Complementary Feeding in Very Low Birth Weight Infants Comparing Early and Late Introduction of Solid Foods: A Secondary Outcome Analysis.

Background/Objectives: The complementary feeding period is crucial for addressing micronutrient imbalances, particularly in very low birth weight (VLBW) infants. However, the impact of the timing of solid food introduction on micronutrient intake in a representative VLBW population remains unclear. Methods: This prospective, observational study investigated micronutrient intake during complementary feeding in VLBW infants categorized based on whether solids were introduced early (<17 weeks corrected age (CA)) or late (≥17 weeks CA). Nutritional intake was assessed using a 24 h recall at 6 weeks CA and with 3-day dietary records at 12 weeks and at 6, 9, and 12 months CA. Results: Among 218 infants, 115 were assigned to the early group and 82 to the late group. In total, 114-170 dietary records were valid for the final analysis at each timepoint. The timepoint of solid introduction did not affect micronutrient intake, except for a higher iron and phosphorus intake at 6 months CA in the early group (early vs. late: iron 0.71 vs. 0.58 mg/kg/d, adjusted p-value (p-adj.) = 0.04; phosphorus 341 vs. 286 mg/d, p-adj. = 0.04). Total vitamin D, calcium, zinc, and phosphorus greatly met intake recommendations; however, dietary iron intake was insufficient to equalize the iron quantity from supplements during the second half year CA. While nutrient intakes were similar between infants with and without comorbidities, breastfed infants had lower micronutrient intakes compared with formula-fed infants. Conclusions: This study suggests that micronutrient intakes were sufficient during complementary feeding in VLBW infants. However, prolonged iron supplementation may be necessary beyond the introduction of iron-rich solids. Further research is essential to determine micronutrient requirements for infants with comorbidities.

Improved Outcomes following a Conservative Approach to Hemodynamically Significant Patent Ductus Arteriosus: A Comparison across Two Periods

Introduction: Patent ductus arteriosus (PDA) is a commonly encountered morbidity that occurs inversely with gestational age. In response to the growing trend of avoiding PDA ligation and prophylactic interventions, our center adopted a conservative approach starting in September 2020. This approach involves more precise fluid restriction for hemodynamically significant (hs) PDA. This study aimed to evaluate whether a conservative approach to hsPDA has led to a reduction in adverse clinical outcomes for very low birth weight infants (VLBWIs) during the period of conservative treatment. Methods: Since more conservative approach to hsPDA was adopted since September 2020, the two periods were divided into period 1 (January 2015 to August 2020) and period 2 (September 2020 to June 2023). Fluid therapy was carefully monitored and advanced from day 1 in all VLBWI, and a more conservative approach as fluid restriction was attempted in hsPDA during period 2. Results: Of the 540 VLBWI with hsPDA, 348 infants were born and diagnosed with hsPDA. Period 2 demonstrated a significantly higher rate of medical treatment (79.17% vs. 19.51%) and lower PDA ligation (54.17% vs. 78.05%). Period 2 showed a greater adherence to conservative fluid restriction compared to period 1. Bronchopulmonary dysplasia (BPD) and BPD ≥ moderate, sepsis, necrotizing enterocolitis (≥ grade 2), IVH (grade ≥3) were notably lower in period 2 with lower mortality. In regard to PDA-related treatment, primary PDA ligation was significantly higher in period 1. The secondary PDA ligation after medical failure and more conservative fluid restriction were significantly higher in period 2. At corrected age of 18–24 months, cognitive score was significantly lower in VLBWI born in period 1 compared to those born in period 2. Conclusion: Our study demonstrated that a conservative approach to hsPDA led to better clinical outcomes and improved cognitive scores at a corrected age of 18–24 months compared to the period of active PDA ligation. This conservative strategy, involving more precise fluid restriction and the judicious use of appropriate diuretics, has shown to improve clinical outcomes with minimal intervention.

Clinical correlates of a high cardiorespiratory risk score for very low birth weight infants

Abstract Background A pulse oximetry warning system (POWS) to analyze heart rate and oxygen saturation data and predict risk of sepsis was developed for very low birth weight (VLBW) infants. Methods We determined the clinical correlates and positive predictive value (PPV) of a high POWS score in VLBW infants. In a two-NICU retrospective study, we identified times when POWS increased above 6 (POWS spike). We selected an equal number of control times, matched for gestational and chronologic age. We reviewed records for infection and non-infection events around POWS spikes and control times. We calculated the frequencies and PPV of a POWS spike for infection or another significant event. Results We reviewed 111 POWS spike times and 111 control times. Days near POWS spikes were more likely to have clinical events than control days (77% vs 50%). A POWS spike had 52% PPV for suspected or confirmed infection and 77% for any clinically significant event. Respiratory deterioration occurred near more POWS spike times than control times (34% vs 18%). Conclusions In a retrospective cohort, infection and respiratory deterioration were common clinical correlations of a POWS spike. POWS had a high PPV for significant clinical events with or without infection. Impact There are significant gaps in understanding the best approach to implementing continuous sepsis prediction models so that clinicians can best respond to early signals of deterioration. Infection and respiratory deterioration were common clinical events identified at the time of a high predictive model score. Understanding the clinical correlates of a high-risk early warning score will inform future implementation efforts.

Effects of synbiotics on necrotizing enterocolitis and full enteral feeding in very low birth weight infants: A double-blind, randomized controlled trial.

Necrotizing enterocolitis (NEC) is a multifactorial disease primarily affecting infants with very low birth weight (VLBW). Research has shown that the pathogenesis of NEC is associated with abnormal bacterial colonization. Synbiotics, dietary supplements containing probiotics (beneficial bacteria) and prebiotics (non-digestible food), can alter the gut microbiome. A double-blind, randomized controlled trial was conducted to assess the efficacy of PediLact®, an oral drop multi-strain synbiotic containing Lactobacillus rhamnosus, Lactobacillus reuteri, and Bifidobacterium infantis, on nutritional parameters and the occurrence of NEC in VLBW neonates. In this study, 118 VLBW neonates from neonatal intensive care units were randomly allocated in a 1:1 ratio to receive either a synbiotic or a placebo. The synbiotic administration continued until the infant was fully fed. The primary outcomes were the occurrence of NEC and the number of days required to achieve full enteral feeding. Log-binomial regression and ANOVA/ANCOVA models were used for analysis. In the group that received the synbiotic, the incidence of NEC decreased significantly (adjusted RR = 0.22, 95% CI: 0.07-0.72, P value = .01; adjusted RD = -0.22, 95% CI: -0.33 to -0.12, P value < .001; NNT = 5). Additionally, feeding intolerance was less frequent in this group (adjusted RR = 0.27, 95% CI: 0.14-0.51, P value < .001; NNT = 3). Furthermore, consumption of the synbiotic was associated with significant weight gain (approximately 40 g) in infants (adjusted SMD = 0.63; 95% CI: 0.26-1.00, P value < .001). The duration of hospitalization and the time required to reach full enteral feeding were also significantly shorter in the synbiotic group (by approximately 3 days). No serious side effects were reported. Prescribing multi-strain synbiotics reduces the incidence of NEC in VLBW infants and has beneficial effects on breastfeeding tolerance and weight gain velocity. Therefore, physicians may consider prescribing synbiotics to VLBW neonates.

Mortality of very low birth weight infants by neonatal intensive care unit workload and regional group status.

Very low birth weight infants (VLBWIs) continue to face high mortality risk influenced by the care quality of neonatal intensive care units (NICUs). Understanding the impact of workload and regional differences on these rates is crucial for improving outcomes. This study aimed to assess how the structural and staffing attributes of NICUs influence the mortality rates of VLBWIs, emphasizing the significance of the availability of medical personnel and the regional distribution of care facilities. Data from 69 Korean NICUs collected by the Korean Neonatal Network between January 2015 and December 2016 were retrospectively analyzed. The NICUs were classified by various parameters: capacity (small, medium, large), nurse-to-bed ratio (1-4), and regional location (A, B, C). Pediatrician staffing was also analyzed and NICUs categorized by beds per pediatrician into low (≤10), medium (11-15), and high (≥16). The NICUs were classified by mortality rates into high-performance (1st and 2nd quartiles) and low-performance (3rd and 4th quartiles). Demographic, perinatal, and neonatal outcomes were analyzed using multivariate logistic regression to explore the association between NICU characteristics and mortality rates. This study included 4,745 VLBWIs (mean gestational age, 28.4 weeks; mean birth weight, 1,088 g; 55.4% male) and found significant variations in survival rates across NICUs linked to performance and staffing levels. High-performing NICUs, often with lower bed-to-staff ratios and advanced care levels, had higher survival rates. Notably, NICUs with two rather than one neonatologist were associated with reduced mortality rates. The study also underscored regional disparities, with NICUs in certain areas showing less favorable survival rates. Adequate NICU staffing and proper facility location are key to lowering the number of VLBWI deaths. Enhancing staffing and regional healthcare equity is crucial for improving the survival of this population.

Change in the prevalence of extra-uterine growth restriction in very low birthweight infants, following the introduction of a written nutrition protocol, in a tertiary neonatal unit

Background: Advances in neonatal medicine, resulting in improved survival, have brought the concept of extra-uterine growth restriction (EUGR), defined as postnatal growth failure secondary to protein and energy deficits, to the forefront as an important cause of morbidity, particularly in very low birthweight (VLBW) neonates. Objectives: This study’s main objective was to determine the prevalence of EUGR in Steve Biko Academic Hospital in VLBW infants. Methods: This was a pre- (epoch 1) and post- (epoch 2) intervention study. The intervention was the introduction of a written nutritional protocol in the neonatal unit in mid-November 2017. Three definitions were used to identify EUGR, namely: (1) discharge weight < 10th percentile, (2) a change by −1.28 z-score in weight at discharge, and (3) the discharge weight percentile below the nadir percentile. Results: The prevalence of EUGR in epoch 1 was 85.7%, 63.5%, and 88.0% using the above definitions, respectively. The prevalence of EUGR in epoch 2 was 73.9%, 65.8%, and 89.4% using the above definitions, respectively. EUGR using the three definitions combined was present in 95.2% and 92.8% of infants in epochs 1 and 2, respectively. None of the differences in EUGR prevalence between the two epochs were significant. Conclusion: The prevalence of EUGR was not significantly different between the two epochs, although it had been proposed that the introduction of a written nutritional protocol would have decreased the prevalence of EUGR in epoch 2. One of the reasons proposed for this finding was poor adherence to the nutritional protocol during epoch 2.

Neonatologist staffing is related to the inter-hospital variation of risk-adjusted mortality of very low birth weight infants in Korea

This study investigated whether hospital factors, including patient volume, unit level, and neonatologist staffing, were associated with variations in standardized mortality ratios (SMR) adjusted for patient factors in very-low-birth-weight infants (VLBWIs). A total of 15,766 VLBWIs born in 63 hospitals between 2013 and 2020 were analyzed using data from the Korean Neonatal Network cohort. SMRs were evaluated after adjusting for patient factors. High and low SMR groups were defined as hospitals outside the 95% confidence limits on the SMR funnel plot. The mortality rate of VLBWIs was 12.7%. The average case-mix SMR was 1.1; calculated by adjusting for six significant patient factors: antenatal steroid, gestational age, birth weight, sex, 5-min Apgar score, and congenital anomalies. Hospital factors of the low SMR group (N = 10) had higher unit levels, more annual volumes of VLBWIs, more number of neonatologists, and fewer neonatal intensive care beds per neonatologist than the high SMR group (N = 13). Multi-level risk adjustment revealed that only the number of neonatologists showed a significant fixed-effect on mortality besides fixed patient risk effect and a random hospital effect. Adjusting for the number of neonatologists decreased the variance partition coefficient and random-effects variance between hospitals by 11.36%. The number of neonatologists was independently associated with center-to-center differences in VLBWI mortality in Korea after adjustment for patient risks and hospital factors.

Cord blood utilization as a blood conservation measure in the neonatal intensive care unit

Extremely low birth weight (ELBW) and very low birth weight (VLBW) infants are often exposed to several laboratory blood draws throughout their neonatal intensive care unit (NICU) stay, particularly at admission. Required routine admission labs place patients at risk for iatrogenic blood loss and need for treatment. Studies have demonstrated that blood collected from an umbilical cord segment may be used to obtain admission labs rather than drawing blood directly from the patient. The purpose of the quality improvement (QI) project was to determine if the utilization of umbilical cord blood for routine admission labs compared to the standard practice of infant phlebotamization result in fewer cases of iatrogenic anemia and the need for treatment in ELBW and VLBW infants. The following outcomes were monitored pre/post-implementation: number of blood transfusions, intra-ventricular hemorrhage (IVH) diagnosis, IVH severity, and vasopressor use. Despite a small sample size, statistically significant results were obtained.

Machine-learning-based evaluation of the usefulness of lactate for predicting neonatal mortality in preterm infants

BackgroundUnlike in adult and pediatric patients, the usefulness of lactate in preterm infants has not been thoroughly discussed. This study aimed to evaluate whether the lactate level in the first hours of life is an important factor associated with neonatal death in very-low-birth-weight (VLBW) preterm infants. MethodsElectronic medical records from a level 4 neonatal intensive care unit in South Korea were reviewed to obtain perinatal and neonatal outcomes. Data on lactate levels of preterm infants in the first 12 h of life were collected. Neonatal mortality and morbidities were compared based on lactate levels. Subsequently, machine-learning models incorporating 20 independent variables, both with and without lactate, were compared for model performances and feature importance of lactate for predicting in-hospital mortality in the applicable models. ResultsOne hundred and sixty-eight preterm infants were included. Death rates on days 7 and 30 of life (D30-mortality) were significantly higher in infants with high lactate levels (≥3rd interquartile range) than in those with lower levels (<3rd interquartile range). Though statistically insignificant, the overall in-hospital mortality was more than twice as high in the high lactate level group than in the lower lactate level group. Based on the machine learning results, Random Forest, Gradient Boosting, and LightGBM models all showed greater area under the curves when lactate was included. Lactate consistently ranked in the variables of top five feature importance, particularly showing the greatest value in the Gradient Boosting model. ConclusionLactate levels during the early hours of life may be an important factor associated with in-hospital death of preterm VLBW infants. Based on the enhanced performance of the above-mentioned machine learning models, lactate levels in the early postnatal period may add to assessing the clinical status and predicting the hospital course in this population.

Biomarker screening for pulmonary hypertension in VLBW infants at risk for bronchopulmonary dysplasia.

Very low birth weight (VLBW) infants demonstrate altered alveolar and pulmonary vascular development and carry an increased risk of developing bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH). Risk stratification for BPD-associated PH (BPD-PH) in at-risk infants may help tailor management, improve outcomes, and optimize resource utilization. VLBW infants were screened for PH with blood gas measurements, serum NT-proBNP and bicarbonate (HCO3) levels, and echocardiograms if they remained on respiratory support at 34 weeks corrected gestational age. We then tested 11 models using different cutoffs for NT-proBNP and HCO3 to predict infants at low risk of BPD-PH. We identified PH in 34 of 192 (17.6%) VLBW infants. The median NT-proBNP in VLBWs with PH was 2769 pg/mL versus 917 pg/mL in those without PH (p < 0.0001). A model with NT-proBNP < 950 pg/mL and HCO3 < 32 mmol/L had a sensitivity of 100%, specificity of 34.2%, and negative predictive value of 100%. Using this model, 54 of 192 (28%) of the patients in this study would have been categorized as low risk for PH and could have avoided a screening echocardiogram. NT-proBNP and HCO3 together may serve as sensitive and cost-effective screening tools for BPD-PH in VLBW infants. NT-proBNP and HCO3 concentrations obtained together may help identify very low birth weight infants at risk for bronchopulmonary dysplasia who should undergo screening for pulmonary hypertension with echocardiography. This large dataset demonstrates that NT-proBNP and HCO3 levels together are more sensitive than NT-proBNP alone in identifying VLBW infants to undergo echocardiography. The combination of NT-proBNP and HCO3 levels may identify VLBW infants at low risk for pulmonary hypertension and thus those who may be able to avoid screening echocardiography.