Neurodevelopmental outcomes of extremely preterm infants: theoretical and epidemiological perspectives to guide shared-care decision-making

Although births below 28 completed weeks' of gestation contribute to less than 1% of all preterm births globally, the impact of extreme prematurity (EPT) on neurodevelopmental outcomes across the life-course is disproportionately large. Higher rates and increased severity of neurodevelopmental impairments (NDIs) are reported among extremely preterm infants (EPIs). Cognitive skills, motor skills (manifesting as cerebral palsy) and vision are most commonly affected, with effects pervasive throughout school, adolescence and early adulthood. In addition, poorer academic outcomes and higher rates of psychiatric morbidity are seen among EPTs. Consistent improvements in EPI survival in recent years has not been matched with improvements in neurodevelopmental outcomes, especially for those born at less than 25 gestational weeks. However, over the last 20 years, several national and cross-national cohort studies have helped advance our understanding of extreme prematurity's developmental and life-course consequences. Here we provide an overview of the key findings from 13 multi-centre cohorts measuring neurodevelopmental outcomes and discuss the theoretical and epidemiological perspectives of NDIs in the context of extreme prematurity to guide communication with families and shared care decision-making.     

玻璃体腔内注射抗血管内皮生长因子治疗早产儿视网膜病复发的危险因素分析

目的 探讨玻璃体腔内注射抗血管内皮生长因子（vascular endothelial growth factor，VEGF）治疗早产儿视网膜病（retinopathy of prematurity，ROP）的效果及复发的危险因素。 方法 回顾性收集2016年1月—2021年12月在郑州大学第一附属医院出生行抗VEGF治疗的ROP患儿159例的临床资料，根据首次抗VEGF治疗后随访周期内ROP复发与否分为复发组（24例）和非复发组（135例），比较分析2组临床资料，采用多因素logistic回归分析探讨抗VEGF治疗ROP复发的危险因素。 结果 经单次抗VEGF治疗后，所有159例患儿均显示附加病变消退。24例（15.1%）抗VEGF治疗后复发，复发平均时间为治疗后（8.4±2.6）周。多因素logistic回归分析显示，术前眼底出血、总用氧时间较长是ROP复发的危险因素（P<0.05），而妊娠高血压是保护因素（P<0.05）。 结论 玻璃体腔内注射抗VEGF治疗ROP是有效的。术前眼底出血和氧疗时间较长可增加ROP复发的风险，而对于妊娠高血压对ROP复发的影响，还需进一步研究证实。     

Bleeding during pregnancy is associated with familial preterm birth

Purpose: the purpose of this study is to identify risk factors for familial, likely genetically-determined, preterm birth.

Materials and methods: We performed a case–control study, enrolling 211 patients (103 cases and 108 controls). Cases delivered between 20 and 35 weeks gestation, with a prior preterm birth or first-degree relative born prematurely. Controls delivered between 37–42 weeks. Groups were compared using a comprehensive questionnaire validated by medical record. Multivariate logistic regression assessed risk factor associations.

Results: Of cases, 30% reported bleeding during pregnancy compared with 5% of controls, adjusted odds ratio (adjOR) 9.0, 95%CI 3.31–24.47. Of cases that delivered at 20–28 weeks, 44.8% reported bleeding during pregnancy compared with 24.6% at 29–35 weeks, p?=?.04. Other associations were prior first-trimester miscarriage adjOR 2.55 (CI 1.21–5.35) or second-trimester miscarriage, adjOR 6.3 (CI 1.76–22.56).

Conclusions: Bleeding during pregnancy and prior miscarriage were significantly associated with familial preterm birth. The magnitude of effect for bleeding in pregnancy was higher with earlier preterm births. These associations warrant further investigation.     

Propofol and fentanyl sedation for laser treatment of retinopathy of prematurity to avoid intubation

Background: Despite the optimization of neonatal assistance, severe retinopathy of prematurity (ROP, stage III–IV) remains a common condition among preterm infants. Laser photocoagulation usually requires general anesthesia and intubation, but extubation can be difficult and these infants often affected by chronic lung disease. We retrospectively evaluated the clinical charts of 13 neonates that were sedated with propofol in association with fentanyl for the laser treatment of ROP. This protocol was introduced in our unit to avoid intubation and minimize side effects of anesthesia and ventilation.

Methods: Propofol 5% followed by a bolus of fentanyl was administered as sedation during laser therapy to 13 preterm infants, affected by ROP stage III–IV. Propofol was initially infused as a slow bolus of 2–4?mg/kg and then continuously during the entire procedure, at 4?mg/kg/hour, increasing the dosage to 6?mg/kg/hour if sedation was not achieved. A laryngeal mask was placed and patients were ventilated with a flow-inflating resuscitation bag.

Results: Thirteen neonates were treated allowing to perform surgery without intubation. Only 4/13 (30.8%) of infants required minimal respiratory support during and/or after surgery. Heart rate after the intervention was higher than that at the beginning while remaining in the range of normal values. Blood pressures before, during and after surgery were similar. No episodes of bradycardia nor hypotension were recorded. Laser treatment was always successful.

Conclusion: The good level of anesthesia and analgesia achieved sustains the efficacy of sedation with propofol during laser photocoagulation to avoid intubation and mechanical ventilation during and after the procedure.