Outcomes and care practices of extremely preterm infants at 22-25 weeks' gestation age from the Chinese Neonatal Network / 中华儿科杂志

Objective: To describe the current status and trends in the outcomes and care practices of extremely preterm infants at 22-25 weeks' gestation age from the Chinese Neonatal Network (CHNN) from 2019 to 2021. Methods: This cross-sectional study used data from the CHNN cohort of very preterm infants. All 963 extremely preterm infants with gestational age between 22-25 weeks who were admitted to neonatal intensive care units (NICU) of the CHNN from 2019 to 2021 were included. Infants admitted after 24 hours of life or transferred to non-CHNN hospitals were excluded. Perinatal care practices, survival rates, incidences of major morbidities, and NICU treatments were described according to different gestational age groups and admission years. Comparison among gestational age groups was conducted using χ2 and Kruskal-Wallis tests. Trends by year were evaluated by Cochran-Armitage and Jonckheere-Terpstra tests for trend. Results: Of the 963 extremely preterm infants enrolled, 588 extremely preterm infants (61.1%) were male. The gestational age was 25.0 (24.4, 25.6) weeks, with 29 extremely preterm infants (3.0%), 88 extremely preterm infants (9.1%), 264 extremely preterm infants (27.4%), and 582 extremely preterm infants (60.4%) at 22, 23, 24, and 25 weeks of gestation age, respectively. The birth weight was 770 (680, 840) g. From 2019 to 2021, the number of extremely preterm infants increased each year (285, 312, and 366 extremely preterm infants, respectively). Antenatal steroids and magnesium sulfate were administered to 67.7% (615/908) and 51.1% (453/886) mothers of extremely preterm infants. In the delivery room, 20.8% (200/963) and 69.5% (669/963) extremely preterm infants received noninvasive positive end-expiratory pressure support and endotracheal intubation. Delayed cord clamping and cord milking were performed in 19.0% (149/784) and 30.4% (241/794) extremely preterm infants. From 2019 to 2021, there were significant increases in the usage of antenatal steroids, antenatal magnesium sulfate, and delivery room noninvasive positive-end expiratory pressure support (all P<0.05). Overall, 349 extremely preterm infants (36.2%) did not receive complete care, 392 extremely preterm infants (40.7%) received complete care and survived to discharge, and 222 extremely preterm infants (23.1%) received complete care but died in hospital. The survival rates for extremely preterm infants at 22, 23, 24 and 25 weeks of gestation age were 10.3% (3/29), 23.9% (21/88), 33.0% (87/264) and 48.3% (281/582), respectively. From 2019 to 2021, there were no statistically significant trends in complete care, survival, and mortality rates (all P>0.05). Only 11.5% (45/392) extremely preterm infants survived without major morbidities. Moderate to severe bronchopulmonary dysplasia (67.3% (264/392)) and severe retinopathy of prematurity (61.5% (241/392)) were the most common morbidities among survivors. The incidences of severe intraventricular hemorrhage or periventricular leukomalacia, necrotizing enterocolitis, and sepsis were 15.3% (60/392), 5.9% (23/392) and 19.1% (75/392), respectively. Overall, 83.7% (328/392) survivors received invasive ventilation during hospitalization, with a duration of 22 (10, 42) days. The hospital stay for survivors was 97 (86, 116) days. Conclusions: With the increasing number of extremely preterm infants at 22-25 weeks' gestation admitted to CHNN NICU, the survival rate remained low, especially the rate of survival without major morbidities. Further quality improvement initiatives are needed to facilitate the implementation of evidence-based care practices.

Tamaño del léxico en niños(as) muy prematuros y prematuros extremos de 24 meses: un estudio transversal / Vocabulary size in very preterm and extremely preterm infants: a cross-sectional study

Las investigaciones muestran que un número importante de niños nacidos prematuros (antes de las 37 semanas de gestación) presentan dificultades en su desarrollo, entre ellas el desarrollo lingüístico. Las investigaciones previas indican que algunas complicaciones biomédicas, como la hemorragia intraventricular (los grados III y IV), la leucomalacia periventricular y la displasia broncopulmonar, incrementan la probabilidad de presentar alteraciones en el desarrollo de la cognición y/o del lenguaje, por lo que se hace necesario realizar investigaciones que proporcionen más información y con ello poder anticiparse a posibles consecuencias en los aprendizajes futuros de estos niños nacidos bajo la condición de prematuridad. Es así, que los objetivos de este estudio fueron medir el tamaño del léxico temprano en niños muy prematuros y prematuros extremos (con y sin complicaciones biomédicas) a los 24 meses de edad corregida, así como también determinar la asociación entre número de complicaciones biomédicas presentes y el tamaño del léxico. Para ello, se trabajó con 108 niños divididos en tres grupos: 39 niños prematuros de alto riesgo (con complicaciones biomédicas), 36 niños prematuros de bajo riesgo (sin complicaciones biomédicas asociadas a alteraciones del lenguaje y /o cognición) y 33 niños nacidos de término. Todos fueron evaluados con el Inventario II de Desarrollo de Habilidades Comunicativas MacArthur-Bates. Los resultados muestran que los niños nacidos de término tienen significativamente mayor tamaño del léxico que los prematuros, no existiendo diferencias en los resultados entre prematuros de bajo riesgo y los prematuros de alto riesgo. Por otra parte, el tamaño del léxico no presenta correlación con las complicaciones biomédicas.

Research shows that a significant number of children born preterm (before 37 weeks of gestation) have developmental difficulties, among them disturbances in language development. Studies indicate that some biomedical complications such as intraventricular hemorrhage (grades III and IV), periventricular leukomalacia, and bronchopulmonary dysplasia increase the probability of cognitive and/or language development disorders. Therefore, there is a need to conduct more studies that provide information that allows anticipating possible consequences in the learning process of children born prematurely. The aims of this study were to measure the early vocabulary size in very preterm and extremely preterm children (with and without biomedical complications) at 24 months of corrected age and to determine the association between the number of biomedical complications and vocabulary size. To that effect, we worked with 108 children divided into three groups: 39 high-risk preterm children (with biomedical complications), 36 low-risk preterm children (without biomedical complications associated with language and/or cognitive disturbances), and 33 full-term children. All children were evaluated using the MacArthur-Bates Communicative Development Inventory II. The results show that the vocabulary size of full-term children is significantly larger than that of preterm children and that no differences exist between the group of high-risk versus low-risk preterm children. On the other hand, vocabulary size does not correlate withbiomedical complications.

Limite de viabilidade de prematuros extremos atendidos em um hospital universitário / Limit of viability of extremely preterm infants treated at a university hospital / Límite de viabilidad de prematuros extremos atendidos en un hospital universitario

Objetivo: descrever o perfil de recém-nascidos com prematuridade extrema e identificar fatores associados a mortalidade segundo idade gestacional e o limite de viabilidade destes. Método: estudo observacional retrospectivo, com abordagem quantitativa, realizado em um hospital universitário do estado de Minas Gerais, desenvolvido de agosto de 2021 a janeiro de 2022. A amostra foi composta por 39 prontuários de prematuros extremos nascidos vivos. Foi realizada a análise descritiva das variáveis quantitativas usando medidas como média, desvio-padrão e valores mínimo e máximo. As variáveis categóricas foram descritas a partir de suas distribuições de frequência absoluta e percentual. Resultados: a maioria das gestantes são mulheres adultos-jovens, realizaram pré-natal e parto cesárea. Dos prematuros prevalece sexo masculino, idade gestacional de 25 semanas, evoluíram para óbito a maioria destes com idade gestacional de 23 e 24 semanas. Conclusão: o limite de viabilidade nesse serviço situa-se em uma idade gestacional igual ou maior que 25 semanas.

Objective: to describe the profile of newborns with extreme prematurity and to identify factors associated with mortality according to gestational age and their limit of viability. Method: a retrospective observational study, with a quantitative approach, carried out in a university hospital in the state of Minas Gerais, developed from August 2021 to January 2022. The sample consisted of 39 records of live-born extreme preterm infants. Descriptive analysis of quantitative variables was performed using measures such as mean, standard deviation and minimum and maximum values. Categorical variables were described from their absolute and percentage frequency distributions. Results: most pregnant women are young-adult women, who underwent prenatal care and cesarean delivery. Of the preterm infants, the male sex prevails, with a gestational age of 25 weeks, most of whom died at a gestational age of 23 and 24 weeks. Conclusion: the limit of viability in this service is at a gestational age equal to or greater than 25 weeks.

Objetivo: describir el perfil de los recién nacidos con prematuridad extrema e identificar los factores asociados a la mortalidad según la edad gestacional y su límite de viabilidad. Método: estudio observacional retrospectivo, con abordaje cuantitativo, realizado en un hospital universitario del estado de Minas Gerais, desarrollado entre agosto de 2021 y enero de 2022. La muestra estuvo compuesta por 39 prontuarios de prematuros extremos nacidos vivos. El análisis descriptivo de las variables cuantitativas se realizó utilizando medidas como la media, la desviación estándar y los valores mínimo y máximo. Las variables categóricas se describieron a partir de sus distribuciones de frecuencia absoluta y porcentual. Resultados: la mayoría de las gestantes son mujeres adultas jóvenes, que realizaron control prenatal y parto por cesárea. De los prematuros prevalece el sexo masculino, con una edad gestacional de 25 semanas, la mayoría de los cuales fallecieron a las 23 y 24 semanas de edad gestacional. Conclusión: el límite de viabilidad en este servicio es a una edad gestacional igual o mayor a 25 semanas.

Recent research on the long-term neurodevelopmental outcomes of very preterm infants / 中国当代儿科杂志

With the increase in the survival rate of very preterm infants, the long-term neurodevelopmental outcomes of such infants have attracted more and more attention. Very preterm infants tend to develop movement disorders and psychological and behavioral problems, including cerebral palsy, developmental coordination disorders, autism spectrum disorders, attention deficit hyperactivity disorders, specific learning disorders, and intellectual developmental disorders. It is of vital importance to improve the long-term prognosis of very preterm infants, and early comprehensive intervention measures can minimize disability and achieve optimal parenting outcomes. This article provides a review of the research progress on the long-term neurodevelopmental outcomes in extremely preterm infants.

Risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants / 中国当代儿科杂志

OBJECTIVES@#To investigate the risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants.@*METHODS@#A retrospective analysis was conducted on clinical data of extremely preterm infants admitted to the Children's Hospital of Zhejiang University School of Medicine from January 2019 to April 2022. Based on the presence of hypotension within 72 hours after birth, the eligible infants were divided into a hypotension group (41 cases) and a normotension group (82 cases). The clinical characteristics, echocardiographic parameters within 72 hours after birth, and early complications were compared between the two groups. Multivariate logistic regression analysis was used to explore the risk factors for hypotension within 72 hours after birth, and receiver operating characteristic curve analysis was performed to evaluate the predictive value of relevant indicators for the occurrence of hypotension within 72 hours after birth in the preterm infants.@*RESULTS@#The proportion of infants who required medication or surgical closure of patent ductus arteriosus (PDA), the proportions of infants with intraventricular hemorrhage ≥ grade III and severe pulmonary hemorrhage, and the mortality rate within 7 days in the hypotension group were significantly higher than those in the normotension group (P<0.05). Multivariate logistic regression analysis showed that lower birth weight, larger PDA diameter, and hemodynamically significant PDA were risk factors for the occurrence of hypotension within 72 hours after birth in extremely preterm infants (P<0.05). The receiver operating characteristic curve analysis showed that the combination of birth weight, PDA diameter, and hemodynamically significant PDA had an area under the curve of 0.873 (95%CI: 0.802-0.944, P<0.05) for predicting hypotension within 72 hours after birth, with a sensitivity of 73.2% and specificity of 91.5%.@*CONCLUSIONS@#Hypotension within 72 hours after birth is closely related to birth weight and PDA, and increases the risk of early severe complications and mortality in extremely preterm infants.

Impact of the environmental layout of the neonatal intensive care unit on clinical outcomes and neurological development in very/extremely preterm infants / 中国当代儿科杂志

OBJECTIVES@#To investigate the impact of the environmental layout of the neonatal intensive care unit (NICU) on clinical outcomes and neurological development in very/extremely preterm infants.@*METHODS@#A total of 304 very/extremely preterm infants admitted to Children's Hospital of Chongqing Medical University between January 2021 and June 2022 within 24 hours after birth were included in this retrospective cohort study. Based on different environmental layouts in the NICU, the infants were divided into two groups: centralized layout group (n=157) and decentralized layout group (n=147). The clinical outcomes and Test of Infant Motor Performance (TIMP) scores at corrected gestational age between 34 to 51+6 weeks were compared between the two groups.@*RESULTS@#The decentralized layout group had lower incidence rates of bronchopulmonary dysplasia (44.9% vs 62.4%, P<0.05) and intracranial hemorrhage (17.7% vs 28.0%, P<0.05) than the centralized layout group. The cure rate was higher in the decentralized layout group compared to the centralized layout group (68.7% vs 56.7%, P<0.05). The decentralized layout group had higher TIMP scores than the centralized layout group at corrected gestational age between 34 to 51+6 weeks (P<0.05).@*CONCLUSIONS@#The decentralized layout of the NICU exhibits positive effects on the clinical outcomes and early neurological development compared to the centralized layout in very/extremely preterm infants.

A multicenter prospective cohort study of late-onset sepsis and its poor prognosis in very low birth weight infants / 中华儿科杂志

Objective: To investigate the prevalence and poor prognosis of late-onset sepsis (LOS) in very low birth weight infant (VLBWI). Methods: This prospective, multicenter observational cohort study was conducted based on the data from Sina-Northern Neonatal Network (SNN). The general data, perinatal information and poor prognosis of 6 639 VLBWI, who were admitted to the 35 neonatal intensive care units from 2018 to 2021, were collected and analyzed. According to the occurrence of LOS during hospitalization, the VLBWI were assigned to the LOS group and non-LOS group. The LOS group was further divided into 3 subgroups according to the occurrence of neonatal necrotizing enterocolitis (NEC) and purulent meningitis. The Chi-square test or Fisher exact probability method, independent sample t test, Mann-Whitney U test and multivariate Logistic regression model were used to analyze the relationship between LOS and poor prognosis in VLBWI. Results: A total of 6 639 eligible VLBWI were enrolled, including 3 402 cases (51.2%) of males and 1 511 cases (22.8%) with LOS. The incidences of LOS in extremely low birth weight infants (ELBWI) and extremely preterm infants were 33.3% (392/1 176) and 34.2% (378/1 105), respectively. There were 157 cases (10.4%) who died in the LOS group and 48 cases (24.9%) in the subgroup of LOS complicated with NEC. Multivariate Logistic regression analysis showed that LOS complicated with NEC was associated with increased mortality and incidence of grade Ⅲ-Ⅳ intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), moderate or severe bronchopulmonary dysplasia (BPD), and extrauterin growth retardation (EUGR) (ORadjust=5.27, 2.59, 3.04, 2.04; 95%CI 3.60-7.73, 1.49-4.50, 2.11-4.37, 1.50-2.79; all P<0.01); LOS complicated with purulent meningitis was also associated with increased mortality and incidence of grade Ⅲ-Ⅳ IVH or PVL, and moderate or severe BPD (ORadjust=2.22, 8.13, 3.69, 95%CI 1.30-3.37, 5.22-12.67, 2.49-5.48; all P<0.01); the infants without NEC or purulent meningitis in the LOS group was only associated with increased incidence of moderate or severe BPD (ORadjust=2.20, 95%CI 1.83-2.65, P<0.001). After ruling out contaminated bacteria, a total of 456 cases showed positive blood culture, including 265 cases (58.1%) of Gram-negative bacteria, 126 cases (27.6%) of Gram-positive bacteria, and 65 cases (14.3%) of fungi. The most common pathogenic bacteria was Klebsiella pneumoniae (n=147, 32.2%), followed by coagulase-negative Staphylococcus (n=72, 15.8%) and subsequently Escherichia coli (n=39, 8.6%). Conclusions: The incidence of LOS is high in VLBWI. Klebsiella pneumoniae is the most common pathogenic bacteria, followed by coagulase-negative Staphylococcus and Escherichia coli. LOS is associated with a poor prognosis for moderate to severe BPD. The prognosis of LOS complicated with NEC is poor with the highest mortality, and the risk of brain damage is significantly increased when LOS complicated with purulent meningitis.

Management and prognosis of extremely preterm infants with gestational age ≤25+6 weeks / 中华儿科杂志

Objective: To investigate the outcomes including major complications and prognosis of extremely preterm infants with gestational age ≤25+6 weeks. Methods: The cross-sectional study enrolled 233 extremely preterm infants with gestational age ≤25+6 weeks who were admitted to the Department of Neonatology of Shenzhen Maternity and Child Healthcare Hospital from January 2015 to December 2021. The clinical data including perinatal factors, treatments, complications, and prognosis were extracted and analyzed. These extremely preterm infants were also grouped according to gestational age and year of admission to further analyze their survival rate, major complications, causes of death, and long-term outcomes. The comparisons between the groups were performed with Chi-square test and Kruskal-Wallis. Results: Among these 233 extremely preterm infants, 134 (57.5%) were males and 99 (42.5%) females. The gestational age was (24.6±0.9) weeks, the birth weight was 710.0 (605.0,784.5) g, and the overall survival rate was 61.8% (144/233). Among the surviving extremely preterm infants, the earliest gestational age was 22+2 weeks and the lowest birth weight was 390 g. There were 17.6% (41/233) of extremely preterm infants had treatment withdrawn and were discharged in line with the will of guardians. Among the rest 192 extremely preterm infants managed with aggressive treatments, 14 (7.3%) died in hospital and 34 (17.7%) had treatment withdrawn later due to severe complications. Of the 192 extremely preterm infants, 144 (75.0%) survived, and the survival rate increased year by year (χ2=26.28, P<0.001) while the mortality decreased year by year (χ2=14.09, P=0.027). Among the survivors, 20.8%(30/144) had no major complications, and the incidence of complications was also negatively related with the gestational age (χ2=7.24, P=0.044), and the length of invasive ventilation was negatively related to the gestational age (χ2=29.14, P<0.001). In the group of less than 23+6 weeks, all extremely preterm infants had one or more major complications. The follow-up were completed in 122 infants and revealed that delayed motor development, language retardation, and hearing and vision impairment accounted for 17.2% (21/122), 8.2% (10/122) and 17.2% (21/122), respectively. Conclusions: Extremely preterm infants with gestational age ≤25+6 weeks are difficult to treat, but the survival rate of infants undergoing aggressive treatments increases year by year. Although the prevalence of major complications is still high, most extremely preterm infants have acceptable prognosis during follow-up.

Status of fungal sepsis among preterm infants in 25 neonatal intensive care units of tertiary hospitals in China / 中华儿科杂志

Objective: To analyze the prevalence and the risk factors of fungal sepsis in 25 neonatal intensive care units (NICU) among preterm infants in China, and to provide a basis for preventive strategies of fungal sepsis. Methods: This was a second-analysis of the data from the "reduction of infection in neonatal intensive care units using the evidence-based practice for improving quality" study. The current status of fungal sepsis of the 24 731 preterm infants with the gestational age of <34+0 weeks, who were admitted to 25 participating NICU within 7 days of birth between May 2015 and April 2018 were retrospectively analyzed. These preterm infants were divided into the fungal sepsis group and the without fungal sepsis group according to whether they developed fungal sepsis to analyze the incidences and the microbiology of fungal sepsis. Chi-square test was used to compare the incidences of fungal sepsis in preterm infants with different gestational ages and birth weights and in different NICU. Multivariate Logistic regression analysis was used to study the outcomes of preterm infants with fungal sepsis, which were further compared with those of preterm infants without fungal sepsis. The 144 preterm infants in the fungal sepsis group were matched with 288 preterm infants in the non-fungal sepsis group by propensity score-matched method. Univariate and multivariate Logistic regression analysis were used to analyze the risk factors of fungal sepsis. Results: In all, 166 (0.7%) of the 24 731 preterm infants developed fungal sepsis, with the gestational age of (29.7±2.0) weeks and the birth weight of (1 300±293) g. The incidence of fungal sepsis increased with decreasing gestational age and birth weight (both P<0.001). The preterm infants with gestational age of <32 weeks accounted for 87.3% (145/166). The incidence of fungal sepsis was 1.0% (117/11 438) in very preterm infants and 2.0% (28/1 401) in extremely preterm infants, and was 1.3% (103/8 060) in very low birth weight infants and 1.7% (21/1 211) in extremely low birth weight infants, respectively. There was no fungal sepsis in 3 NICU, and the incidences in the other 22 NICU ranged from 0.7% (10/1 397) to 2.9% (21/724), with significant statistical difference (P<0.001). The pathogens were mainly Candida (150/166, 90.4%), including 59 cases of Candida albicans and 91 cases of non-Candida albicans, of which Candida parapsilosis was the most common (41 cases). Fungal sepsis was independently associated with increased risk of moderate to severe bronchopulmonary dysplasia (BPD) (adjusted OR 1.52, 95%CI 1.04-2.22, P=0.030) and severe retinopathy of prematurity (ROP) (adjusted OR 2.55, 95%CI 1.12-5.80, P=0.025). Previous broad spectrum antibiotics exposure (adjusted OR=2.50, 95%CI 1.50-4.17, P<0.001), prolonged use of central line (adjusted OR=1.05, 95%CI 1.03-1.08, P<0.001) and previous total parenteral nutrition (TPN) duration (adjusted OR=1.04, 95%CI 1.02-1.06, P<0.001) were all independently associated with increasing risk of fungal sepsis. Conclusions: Candida albicans and Candida parapsilosis are the main pathogens of fungal sepsis among preterm infants in Chinese NICU. Preterm infants with fungal sepsis are at increased risk of moderate to severe BPD and severe ROP. Previous broad spectrum antibiotics exposure, prolonged use of central line and prolonged duration of TPN will increase the risk of fungal sepsis. Ongoing initiatives are needed to reduce fungal sepsis based on these risk factors.

Función pulmonar: función pulmonar en pacientes con displasia broncopulmonar / Pulmonary function: pulmonary function in patients with bronchopulmonary dysplasia

La displasia broncopulmonar (DBP) es una complicación frecuente en los prematuros extremos. La detención de la alveolarización determina menor volumen pulmonar total, el cual se recupera al menos parcialmente en el trayecto de la vida. La vía aérea se ve afectada en su crecimiento en mayor proporción que los alvéolos, y en los pacientes con displasia severa va a existir hasta la etapa adulta una limitación al flujo aéreo debido a su menor calibre. En este artículo, se describirá el origen, hallazgos característicos y evolución de las alteraciones en la función pulmonar, especialmente, en los pacientes con la nueva DBP.

Bronchopulmonary dysplasia (BPD) is a frequent complication in extremely premature infants. The arrest of alveolarization determines a lower total lung volume, which recovers at least partially during life. The airway is affected in its growth to a greater extent than the alveoli, and in patients with severe dysplasia there will be airflow limitation until adulthood due to its smaller caliber. In this article, the origin, characteristic findings, and evolution of changes in lung function will be described, especially in patients with the new BPD.

Evidence-based standardized nutrition protocol can shorten the time to full enteral feeding in very preterm/very low birth weight infants / 中国当代儿科杂志

OBJECTIVES@#To investigate whether evidence-based standardized nutrition protocol can facilitate the establishment of full enteral nutrition and its effect on short-term clinical outcomes in very preterm/very low birth weight infants.@*METHODS@#A retrospective analysis was performed on the medical data of 312 preterm infants with a gestational age of ≤32 weeks or a birth weight of <1 500 g. The standardized nutrition protocol for preterm infants was implemented in May 2020; 160 infants who were treated from May 1, 2019 to April 30, 2020 were enrolled as the control group, and 152 infants who were treated from June 1, 2020 to May 31, 2021 were enrolled as the test group. The two groups were compared in terms of the time to full enteral feeding, the time to the start of enteral feeding, duration of parenteral nutrition, the time to recovery to birth weight, the duration of central venous catheterization, and the incidence rates of common complications in preterm infants.@*RESULTS@#Compared with the control group, the test group had significantly shorter time to full enteral feeding, time to the start of enteral feeding, duration of parenteral nutrition, and duration of central venous catheterization and a significantly lower incidence rate of catheter-related bloodstream infection (P<0.05). There were no significant differences between the two groups in the mortality rate and the incidence rate of common complications in preterm infants including grade II-III necrotizing enterocolitis (P>0.05).@*CONCLUSIONS@#Implementation of the standardized nutrition protocol can facilitate the establishment of full enteral feeding, shorten the duration of parenteral nutrition, and reduce catheter-related bloodstream infection in very preterm/very low birth weight infants, without increasing the risk of necrotizing enterocolitis.

Non-erythrocyte blood products transfusion in very preterm and extremely preterm infants in Chinese neonatal intensive care units / 中华儿科杂志

Objective: To describe the use of non-erythrocyte blood products transfusion in very preterm and extremely preterm infants in the neonatal intensive care units (NICU) of the Chinese Neonatal Network (CHNN) in 2019, to explore the disparity between different centers, and to further investigate the rationality and standardability of non-erythrocyte blood products transfusion. Methods: This was a cross-sectional study based on the CHNN cohort of very preterm and extremely preterm infants. All 6 598 infants with gestational age (GA)<32 weeks and admitted to the 57 NICU of CHNN within 24 h of life in 2019 were enrolled. Non-erythrocyte blood products included platelet, plasma, albumin, immunoglobulin, cryoprecipitate and prothrombin complex. Infants who received at least one type of non-erythrocyte blood products were defined in transfusion group. The comparison between infants with and without transfusion was done by t-test, rank-sum test or χ2 test as appropriate. Linear regression model was used to generate adjusted transfusion rate of each center, and to investigate the correlation between adjusted rate and center-level characteristics. Results: A total of 6 598 infants were enrolled in the study, with gestational age of 30.0 (28.7, 31.0) weeks and birth weight of (1 353±312) g, and 43.6 % (2 877) of them were female. Among them, 42.7% (2 816) infants were enrolled in transfusion group, with the times of transfusion as 3 (1, 6) times. Compared to the infants without any transfusion of non-erythrocyte blood products, those infants received transfusion had lower gestational age (Z=17.62, P<0.01), lower birth weight (t=18.64, P<0.01), higher proportion of small-for-gestation age (χ2=31.06, P<0.01), multiple birth (χ²=12.82, P<0.01) and intensive resuscitation in delivery room (χ²=287.52, P<0.01), as well as lower proportion of females (χ²=10.68, P<0.01) and even lower proportion of infants born in this hospital (χ²=78.23, P<0.01). Among the entire study population, albumin (25.4%, 1 674 cases), immunoglobulin (21.5%, 1 417 cases) and plasma (18.9%, 1 245 cases) were the most commonly used non-erythrocyte blood products. Overall, 60.4% (544/901) infants with gestational age <28 weeks received transfusion 4 (2, 8) times. A total of 39.9% (2 272/5 697) infants between 28-31weeks received non-erythrocyte blood products 3 (1, 6) times. The non-erythrocyte blood products transfusion rates of critically-ill and non-critically-ill infants were 62.2% (1 693/2 723) and 29.0% (1 123/3 875) respectively, and the transfusion times were 4 (2,7) and 2 (1,4) times. The transfusion rates varied significantly among different NICU, and the disparities remained obvious after adjustment (adjusted χ²=153.48, P<0.01). Conclusion: Near half of very preterm and extremely preterm infants admitted to Chinese NICU in 2019 receive non-erythrocyte blood products during hospitalization with significant disparities among different hospitals.

Sex differences in clinical outcomes of extremely preterm infants/extremely low birth weight infants: a propensity score matching study / 中国当代儿科杂志

OBJECTIVES@#To study the effect of sex on the clinical outcome of extremely preterm infants (EPIs)/extremely low birth weight infants (ELBWIs) by propensity score matching.@*METHODS@#A retrospective analysis was performed for the medical data of 731 EPIs or ELBWIs who were admitted from January 1, 2011 to December 31, 2020. These infants were divided into two groups: male and female. A propensity score matching analysis was performed at a ratio of 1:1. The matching variables included gestational age, birth weight, percentage of withdrawal from active treatment, percentage of small-for-gestational-age infant, percentage of use of pulmonary surfactant, percentage of 1-minute Apgar score ≤3, percentage of mechanical ventilation, duration of mechanical ventilation, percentage of antenatal use of inadequate glucocorticoids, and percentage of hypertensive disorders in pregnancy. The two groups were compared in the incidence rate of main complications during hospitalization and the rate of survival at discharge.@*RESULTS@#Before matching, compared with the female group, the male group had significantly higher incidence rates of neonatal respiratory distress syndrome, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, and patent ductus arteriosus (P<0.05), while after matching, the male group only had a significantly higher incidence rate of BPD than the female group (P<0.05). There was no significant difference in the rate of survival at discharge between the two groups before and after matching (P>0.05).@*CONCLUSIONS@#Male EPIs/ELBWIs have a higher risk of BPD than female EPIs/ELBWIs, but male and female EPIs/ELBWIs tend to have similar outcomes.

Clinical treatment outcomes and their changes in extremely preterm twins: a multicenter retrospective study in Guangdong Province, China / 中国当代儿科杂志

OBJECTIVES@#To investigate the clinical treatment outcomes and the changes of the outcomes over time in extremely preterm twins in Guangdong Province, China.@*METHODS@#A retrospective analysis was performed for 269 pairs of extremely preterm twins with a gestational age of <28 weeks who were admitted to the department of neonatology in 26 grade A tertiary hospitals in Guangdong Province from January 2008 to December 2017. According to the admission time, they were divided into two groups: 2008-2012 and 2013-2017. Besides, each pair of twins was divided into the heavier infant and the lighter infant subgroups according to birth weight. The perinatal data of mothers and hospitalization data of neonates were collected. The survival rate of twins and the incidence rate of complications were compared between the 2008-2012 and 2013-2017 groups.@*RESULTS@#Compared with the 2008-2012 group, the 2013-2017 group (both the heavier infant and lighter infant subgroups) had lower incidence rates of severe asphyxia and smaller head circumference at birth (P<0.05). The mortality rates of both of the twins, the heavier infant of the twins, and the lighter infant of the twins were lower in the 2013-2017 group compared with the 2008-2012 group (P<0.05). Compared with the 2008-2012 group, the 2013-2017 group (both the heavier infant and lighter infant subgroups) had lower incidence rates of pulmonary hemorrhage, patent ductus arteriosus (PDA), periventricular-intraventricular hemorrhage (P-IVH), and neonatal respiratory distress syndrome (NRDS) and a higher incidence rate of bronchopulmonary dysplasia (P<0.05).@*CONCLUSIONS@#There is a significant increase in the survival rate over time in extremely preterm twins with a gestational age of <28 weeks in the 26 grade A tertiary hospitals in Guangdong Province. The incidences of severe asphyxia, pulmonary hemorrhage, PDA, P-IVH, and NRDS decrease in both the heavier and lighter infants of the twins, but the incidence of bronchopulmonary dysplasia increases. With the improvement of diagnosis and treatment, the multidisciplinary collaboration between different fields of fetal medicine including prenatal diagnosis, obstetrics, and neonatology is needed in the future to jointly develop management strategies for twin pregnancy.

Staphylococcus coagulasa negativos como causantes de endocarditis en un recién nacido pretérmino / Neonatal coagulase negative Staphylococcus as a cause of endocarditis / Staphylococcus coagulase negativa como causa de endocardite em recém-nascido prematuro

Los estafilococos coagulasa negativos son microorganismos frecuentemente aislados cuya significancia clínica puede ser difícil de establecer por su carácter de comensales habituales de la piel. En la población neonatal estos patógenos han ido adquiriendo mayor protagonismo debido a la sobrevida de pacientes mas prematuros que en el pasado, así como sus necesidades de tratamiento, que determinan mayores tiempos de estadía hospitalaria. Estos elementos representan factores de riesgo también para el desarrollo de endocarditis en estos pacientes, particularmente debido a la utilización de catéteres intravasculares centrales por tiempo prolongado. En este caso clínico se presenta un paciente pretérmino severo que presentó una endocarditis a estafilococo coagulasa negativo a partir del cual discutiremos las características de las infecciones por estos microorganismos, las características de la endocarditis infecciosa en el recién nacido pretérmino y la utilización de antibióticos en estos pacientes, así como algunos elementos asociados a la vigilancia activa en el uso de antibióticos.

Coagulase negative staphylococcus (CoNS) are commonly isolated microorganisms whose clinical importance may be difficult to establish due to their role as part of our usual skin microbiota. These pathogens have gained relevance in neonatal population due to an improvement in neonatal care that determine longer survival rates and hospitals stays. Neonatal endocarditis is also affected by these microorganisms and particularly by the use of central intra vascular lines for long periods of time. In this clinical case we introduce a severe preterm patient who developed a CoNS endocarditis and discuss the characteristics of CoNS infections and endocarditis in preterm newborns as well as some antibiotic vigilance principles.

Os estafilococos coagulase negativos são microrganismos frequentemente isolados, cujo significado clínico pode ser difícil de estabelecer devido ao seu caráter de comensais cutâneos comuns. Na população neonatal, esses patógenos vêm adquirindo maior destaque devido à sobrevida de pacientes mais prematuros do que no passado, bem como suas necessidades de tratamento, as quais determinam tempos de internação mais longos. Esses elementos também representam fatores de risco para o desenvolvimento de endocardite nesses pacientes, principalmente pelo uso prolongado de cateter intravascular central. Neste caso clínico apresentaremos um paciente pré-termo grave que apresentou endocardite estafilocócica coagulase-negativa a partir do qual discutiremos as características das infecções por esses microrganismos, as características da endocardite infecciosa no recém-nascido pré-termo e o uso de antibióticos nesses pacientes bem como alguns elementos associados à vigilância ativa no uso de antibióticos.

Intervención con probióticos para la prevención de enterocolitis necrotizante en prematuros extremos menores de 1500 gramos o de 32 semanas / Probiotic intervention to prevent necrotizing enterocolitis in extremely preterm infants born before 32 weeks of gestation or with a birth weight of less than 1500 g

Introducción. Existe evidencia del beneficio de los probióticos en prevenir enterocolitis necrotizante en prematuros extremos. Desde 2015, se usa probiótico preventivo en el Servicio de Neonatología, Hospital Hernán Henríquez Aravena, Temuco, Chile.Objetivo. Evaluar el impacto de este probiótico en la incidencia, gravedad, necesidad de terapia quirúrgica y letalidad por enterocolitis necrotizante en prematuros extremos. Pacientes y método. Estudio retrospectivo de cohortes. Datos analizados con Stata. Se aplicó la prueba exacta de Fisher para comparar porcentajes y, para los promedios, la prueba t para varianzas distintas. Los egresados entre 2015 y 2017 recibieron Lactobacillus reuteri Protectis (LRP), dosis única (1 x 108 unidades formadora de colonias) desde los primeros días de vida hasta cumplir las 36 semanas de edad gestacional corregida. Los controles egresados entre 2012 y 2014 no recibieron LRP.Resultados. El 3,45 % de los casos tuvo algún grado de enterocolitis: grado i (el 64 %), ii (el 18 %), iii (el 18 %); requirió cirugía el 18 % y no hubo letalidad. El 3,75 % de los controles históricos presentaron enterocolitis: grado i (el 12 %), ii (el 35 %), iii (el 53 %); el 64,7 % requirió cirugía, y el 47 % falleció. El grupo intervenido presentó grado ii o iii en un 36 %; en el grupo control, la sumatoria de estos estadios fue del 88 %.Conclusión.LRP administrado en dosis única diaria al prematuro extremo no modificó la incidencia de enterocolitis, pero disminuyó su gravedad, la letalidad y necesidad de tratamiento quirúrgico.

Introduction. There is evidence of the beneficial effects of probiotics to prevent necrotizing enterocolitis in extremely preterm infants. Probiotic prevention has been used since 2015 in the Division of Neonatology of Hospital Hernán Henríquez Aravena, Temuco, Chile.Objective. To assess the impact of this probiotic on the incidence, severity, surgical treatment requirement, and fatality rate of necrotizing enterocolitis in extremely preterm infants.Patients and methods. Retrospective, cohort study. Data were analyzed using Stata. Fisher's exact test was used to compare percentages, and the unequal variances t-test, for averages. Infants discharged between 2015 and 2017 received Lactobacillus reuteri Protectis (LRP), in a single dose (1 x 108 colony forming units), since the first days of life until 36 weeks of corrected gestational age. Controls discharged between 2012 and 2014 did not receive LRP.Results. Some degree of enterocolitis was observed in 3.45 % of cases: stage I (64 %), stage II (18 %), stage III (18 %); 18 % required surgery, and there were no deaths. Among historical controls, 3.75 % had enterocolitis: stage I (12 %), stage II (35 %), stage III (53 %); 64.7 % required surgery, and 47 % died. In the intervention group, stage II or III accounted for 36 % of cases, whereas in the control group, for 88 %.Conclusion. Administering a single daily dose of LRP to extremely preterm infants did not affect the incidence of enterocolitis, but reduced its severity, fatality rate, and surgical treatment requiremen

Association between ventilatory settings and pneumothorax in extremely preterm neonates

OBJECTIVES: Pneumothorax is a catastrophic event associated with high morbidity and mortality, and it is relatively common in neonates. This study aimed to investigate the association between ventilatory parameters and the risk of developing pneumothorax in extremely low birth weight neonates. METHODS: This single-center retrospective cohort study analyzed 257 extremely low birth weight neonates admitted to a neonatal intensive care unit between January 2012 and December 2017. A comparison was carried out to evaluate the highest value of positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), and driving pressure (DP) in the first 7 days of life between neonates who developed pneumothorax and those who did not. The primary outcome was pneumothorax with chest drainage necessity in the first 7 days of life. A matched control group was created in order to adjust for cofounders associated with pneumothorax (CRIB II score, birth weight, and gestational age). RESULTS: There was no statistically significant difference in PEEP, PIP, and DP values in the first 7 days of life between extremely low birth weight neonates who had pneumothorax with chest drainage necessity and those who did not have pneumothorax, even after adjusting for potential cofounders. CONCLUSIONS: Pressure-related ventilatory settings in mechanically ventilated extremely low birth weight neonates are not associated with a higher risk of pneumothorax in the first 7 days of life.

Association between time of birth and resuscitation outcomes in extremely preterm infants / 中国当代儿科杂志

OBJECTIVE@#To study whether there are differences in the resuscitation process and early outcomes between the extremely preterm infants delivered on off-hours (6 pm to 8 am of working days, weekends, and national holidays) and those delivered on working hours.@*METHODS@#A retrospective analysis was performed on the medical data of extremely preterm infants who were born in the Peking University Third Hospital from January 1, 2010 to December 31, 2020 and transferred to the neonatal intensive care unit (NICU). According to the time of birth, they were divided into two groups:working hours (@*RESULTS@#Compared with the working hours group, the off-hours group had a significantly lower proportion of infants with the use of full-dose dexamethasone before delivery (@*CONCLUSIONS@#Extremely preterm infants delivered on off-hours tend to have a low Apgar score at 1 minute after birth, with a higher proportion of infants requiring positive pressure ventilation or tracheal intubation during resuscitation than those delivered on working hours, and they tend to develop neonatal respiratory distress syndrome and intrauterine pneumonia. This suggests that it is important to make adequate preparations in terms of personnel and supplies for resuscitation of extremely preterm infants after birth and that NICUs should develop a detailed management plan for extremely preterm infants at each period of time before, during, and after birth.

Delivery room resuscitation and short-term outcomes of extremely preterm and extremely low birth weight infants: a multicenter survey in North China / 中华医学杂志(英文版)

BACKGROUND@#Delivery room resuscitation assists preterm infants, especially extremely preterm infants (EPI) and extremely low birth weight infants (ELBWI), in breathing support, while it potentially exerts a negative impact on the lungs and outcomes of preterm infants. This study aimed to assess delivery room resuscitation and discharge outcomes of EPI and ELBWI in China.@*METHODS@#The clinical data of EPI (gestational age [GA] <28 weeks) and ELBWI (birth weight [BW] <1000 g), admitted within 72 h of birth in 33 neonatal intensive care units from five provinces and cities in North China between 2017 and 2018, were analyzed. The primary outcomes were delivery room resuscitation and risk factors for delivery room intubation (DRI). The secondary outcomes were survival rates, incidence of bronchopulmonary dysplasia (BPD), and risk factors for BPD.@*RESULTS@#A cohort of 952 preterm infants were enrolled. The incidence of DRI, chest compressions, and administration of epinephrine was 55.9% (532/952), 12.5% (119/952), and 7.0% (67/952), respectively. Multivariate analysis revealed that the risk factors for DRI were GA <28 weeks (odds ratio [OR], 3.147; 95% confidence interval [CI], 2.082-4.755), BW <1000 g (OR, 2.240; 95% CI, 1.606-3.125), and antepartum infection (OR, 1.429; 95% CI, 1.044-1.956). The survival rate was 65.9% (627/952) and was dependent on GA. The rate of BPD was 29.3% (181/627). Multivariate analysis showed that the risk factors for BPD were male (OR, 1.603; 95% CI, 1.061-2.424), DRI (OR, 2.094; 95% CI, 1.328-3.303), respiratory distress syndrome exposed to ≥2 doses of pulmonary surfactants (PS; OR, 2.700; 95% CI, 1.679-4.343), and mechanical ventilation ≥7 days (OR, 4.358; 95% CI, 2.777-6.837). However, a larger BW (OR, 0.998; 95% CI, 0.996-0.999), antenatal steroid (OR, 0.577; 95% CI, 0.379-0.880), and PS use in the delivery room (OR, 0.273; 95% CI, 0.160-0.467) were preventive factors for BPD (all P < 0.05).@*CONCLUSION@#Improving delivery room resuscitation and management of respiratory complications are imperative during early management of the health of EPI and ELBWI.

Clinical features of very preterm small-for-gestational-age infants born due to severe preeclampsia / 中国当代儿科杂志

OBJECTIVE@#To study the clinical features of very preterm small-for-gestational-age infants born by cesarean section due to severe preeclampsia.@*METHODS@#Forty-two small-for-gestational-age infants who were admitted from August 2017 to July 2018 and were born due to severe preeclampsia were enrolled as the observation group. Forty very preterm infants who were born to healthy mothers since uterine contractions could not be suppressed were enrolled as the control group. Perinatal features, clinical manifestations of infection, complications, and clinical outcomes were analyzed for the two groups.@*RESULTS@#Within 6 hours and 2-3 days after birth, the observation group had significantly lower white blood cell count (WBC), absolute neutrophil count (ANC), and platelet count (PLT) than the control group (@*CONCLUSIONS@#Very preterm small-for-gestational-age infants born due to severe preeclampsia have a high incidence rate of infection and severe conditions. Early manifestations include reductions in the infection indicators WBC, ANC, and PLT, and CRP does not increase significantly in the early stage and gradually increases at 2-3 days after birth. Most of these infants require invasive ventilation after birth, with bronchopulmonary dysplasia as the main complication. Clinical changes should be closely observed and inflammatory indicators should be monitored for early identification of infection, timely diagnosis, and timely adjustment of antibiotic treatment, so as to improve the outcome.