Life events and low birthweight--analysis by infants preterm and small for gestational age

Social stress was assessed in 92 women with low-birthweight babies and 92 controls using the detailed LEDS measure of life events and severe chronic difficulties. The low-birthweight group was divided into preterm delivery (n = 40), small for gestational age (SGA) (n = 40) and mixed groups. Multivariate analysis was performed using a binomial-logit model to examine whether social factors were independently and significantly associated with low birthweight once the effect of demographic factors, obstetric factors and smoking/drinking were taken into account. Comparison of preterm births with controls indicated that three factors were significantly associated: a previous low-birthweight baby, severe life event/difficulty and bleeding during pregnancy. For SGA babies the factors were: previous low-birthweight baby, low social support and smoking. By using a reliable measure of life events and adequate numbers of low-birthweight babies, this study overcame the potential inaccuracies of previous studies and indicates a more specific relation between social stress and low birthweight.     

Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth

OBJECTIVE: To determine the association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth. DESIGN: Multicentre prospective cohort study. SETTING: Ten European centres offering prenatal screening for toxoplasmosis. POPULATION: Deliveries after 23 weeks of gestation in 386 women with singleton pregnancies who seroconverted to toxoplasma infection before 20 weeks of gestation. Deliveries after 36 weeks in 234 women who seroconverted at 20 weeks or later, and tested positive before 37 weeks. METHODS: Comparison of infected and uninfected births, adjusted for parity and country of birth. MAIN OUTCOME MEASURES: Differences in gestational age at birth, birthweight and birthweight centile. RESULTS: Infected babies were born or delivered earlier than uninfected babies: the mean difference for seroconverters before 20 weeks was -5.4 days (95% CI: -1.4, -9.4), and at 20 weeks or more, -2.6 days (95% CI: -0.5, -4.7). Congenital infection was associated with an increased risk of preterm delivery when seroconversion occurred before 20 weeks (OR 4.71; 95% CI: 2.03, 10.9). No significant differences were detected for birthweight or birthweight centile. CONCLUSION: Babies with congenital toxoplasmosis were born earlier than uninfected babies but the mechanism leading to shorter length of gestation is unknown. Congenital infection could precipitate early delivery or prompt caesarean section or induction of delivery. We found no evidence for a significant association between congenital toxoplasmosis and reduced birthweight or small for gestational age birth.     

Clinical outcome of small for gestational age preterm infants

Data from 55 preterm SGA infants and 55 preterm AGA infants matched for gestational age and sex were reviewed retrospectively. An increased incidence of perinatal hypoxia (30 vs. 18), gastrointestinal problems, minor infections (27 vs. 9), hematological problems and increased mortality (21.8% vs. 7.2%) was observed in the SGA infants. The incidence of HMD was higher in the AGA group (not significant), but the HMD was much more severe in the SGA group. Mortality as a result of HMD was significantly higher in the SGA group. The percentage of handicapped children is 19% in the SGA group and 9% in the AGA group. The percentages of severely handicapped children are 4.8% and 2.3% respectively. The combination of prematurity and severe intrauterine growth retardation in the SGA group caused a higher mortality and morbidity than was seen in their AGA controls. This clinical performance of SGA preterm infants is important especially for those who have to decide at what moment such a child should be delivered by caesarean section.     

Outcome of very preterm small for gestational age infants: the first nine years of life

Objective To determine the influence of intrauterine growth retardation of preterm infants on mortality and cognitive development.
Design A nationwide study cohort of very preterm and/or small for gestational age infants (< 32 weeks and/or < 1500 g) born alive in 1983 in the Netherlands. Assessment on neuromotor and cognitive development at five years, and a parental questionnaire on school performance at nine years. Cognitive outcome is defined as handicap for mental and speech-language development, and need for special education.
Sample 134 small for gestational age infants (< 10th centile) and 410 appropriate for gestational age infants (between 25th and 75th centile) of all infants between 25 and 32 weeks of gestational age were identified; infants with congenital malformations and not of Caucasian race were excluded.
Main outcome measures Neonatal mortality, in-hospital and five years mortality; Cognitive outcome at five years; School performance at nine years.
Results The mortality risk for small for gestational age compared with appropriate for gestational age infants was significantly higher, after adjustment for gestational age, sex, multiple pregnancy and mode of delivery (OR 2–56,95% CI 1.26–5.26). Small for gestational age infants showed more often gross motor and minor neurological dysfunction, but less cerebral palsy than appropriate for gestational age infants. Cognitive outcome at five years in small for gestational age infants was significantly worse than appropriate for gestational age infants stratified for mode of delivery OR 2.44 (95% CI 1.05–5.55). At nine years of age significantly more small for gestational age infants (1 6.4%) needed special education than appropriate for gestational age infants (11.9%).
Conclusion Intrauterine growth retardation increases the risk of mortality and of cognitive disorders.     

Cardiopulmonary resuscitation in very low birthweight infants.

Of 191 patients with birthweight less than 1500 gm admitted to our neonatal intensive care unit in a 2-year period, 41 underwent cardiopulmonary resuscitation (CPR). Eleven of 41 very low birthweight (VLBW) (27%) survived to be discharged. None of the infants who received CPR after 72 hours of life survived. Also, all infants who underwent CPR, both in the delivery room and neonatal intensive care unit (NICU), died. The most significant factor distinguishing survivors from nonsurvivors was the demonstration of vasopressor unresponsive hypotension 20 hours prior to CPR in the latter group. This study confirmed the very poor survival rate after CPR in VLBW infants. We conclude that performance of CPR in patients with vasopressor unresponsive hypotension or previous delivery room resuscitation should be considered a rescue or experimental treatment and parents should be given the option of no resuscitation. Future research efforts should be directed to better the understanding and treatment of cardiovascular dysfunction prior to cardiac arrest.     

Rapid biometric assessment of gestational age in very low birth weight infants.

Foot length and intermamillary distance were compared to gestational age assessment using obstetrical dates, physical criteria of Ballard score and the evaluation of the anterior vascular capsule of the lens (IPM). Thirty-eight healthy and appropriate for gestational age preterm infants (30 +/- 2.4 weeks) with a birth weight of 1280 +/- 410 g were studied. Internipple distance (IM) and foot length (FL) were measured with a sliding caliper graduated in millimeters. Results were analyzed using the linear regression analysis. Obstetrical dates, physical Ballard score and IMP correlated significantly with both biometric measurements. Mean IM was 58.5 +/- 8.5 mm (range: 45 mm-89 mm) and mean FL was 60.6 +/- 7.9 mm (range: 45 mm-75 mm). The data indicate that the appropriate use of biometric parameters in the early postnatal period can be used to improve assessment of gestational age in VLBW infants.     

Evaluation of carnitine deficit in very low birth weight preterm newborns small for their gestational age

Objective: To verify whether small-for-gestational-age (SGA) preterm newborns represent a special risk group for carnitine deficiency. Secondary outcome includes assessment of longitudinal differences of total carnitine (TC), free carnitine (FC) and acylcarnitines between SGA and appropriate-for-gestational-age (AGA).

Methods: A retrospective study to evaluate carnitine and acylcarnitines profile on 144 very-low-birth weight newborns (VLBW), classified as AGA (n?=?73) and SGA (n?=?71), was performed by tandem mass spectrometry, during their first 5 weeks of life. Carnitine deficiency was defined as FC <40?µmol/L and FC/TC <0.7.

Results: Carnitine deficiency was observed in the two study groups throughout the monitoring period (maximum FC: 36.05?µmol/L in AGA and 32.24?µmol/L in SGA). FC/TC remains under 0.7 in both with progressive improvement. Unlike expected, a comparatively higher value of TC, FC and total acylcarnitines (tAC) was found in SGA during the first 2 weeks, with significant relevance on day 3–5, especially for tAC (p?<?0.001). The only acylcarnitine with persistently lower value in SGA is C5 (p?<?0.05 in first 2 weeks).

Conclusions: A carnitine deficiency was demonstrated in all VLBW. Although birth weight restriction has been suggested as a risk factor for impaired carnitine status, in our study, SGA was not related with higher carnitine deficiency.     

Increased risk of bronchopulmonary dysplasia and increased mortality in very preterm infants being small for gestational age

OBJECTIVE. The objective was to evaluate the impact of being born small for gestational age (SGA) on neonatal mortality and neonatal pulmonary morbidity in preterm infants <32 weeks of gestation. METHODS. We reviewed the data reported prospectively to the quality assurance program of the Federal State of Hesse, Germany, from 1990 to 1996 of infants <32 weeks of gestation. SGA was defined as birth weight below the 10th percentile. Mann Whitney U tests were used to compare continuous variables and Fisher's exact tests to analyze differences in dichotomous variables between preterm SGA neonates and preterms born appropriate for gestational age (AGA). The effect of SGA and other potential risk factors for neonatal death and bronchopulmonary dysplasia, i.e., requiring a fraction of inspired oxygen >0.21 at day 28, was tested by multivariable analyses. RESULTS. Data from 1,365 infants were analyzed. One hundred and eighty-three neonates were SGA (mean [SD] birth weight 789 [179] g; mean [SD] gestational age 28.9 [1.7] weeks) and 1,182 were AGA (mean [SD] birth weight 1,260 [348] g; mean [SD] gestational age 28.8 [2.1] weeks). Neonatal mortality and the rate of bronchopulmonary dysplasia were significantly higher in SGA neonates (23 vs. 11% and 28 vs. 14%, respectively). There was a statistically significant association of SGA with neonatal death (odds ratio [OR] = 4.54, 95% confidence interval [CI] 2.56, 8.04) and bronchopulmonary dysplasia (OR=3.80, 95% CI 2.11, 6.84). CONCLUSION. SGA neonates below 32 weeks gestation are a high-risk group regarding neonatal mortality and neonatal pulmonary morbidity.     

Life events and low birthweight—analysis by infants preterm and small for gestational age

Summary. Social stress was assessed in 92 women with low-birthweight babies and 92 controls using the detailed LEDS measure of life events and severe chronic difficulties. The low-birthweight group was divided into preterm delivery (  n = 40  ), small for gestational age (SGA) (  n = 40  ) and mixed groups. Multivariate analysis was performed using a bino-mial-logit model to examine whether social factors were independently and significantly associated with low birthweight once the effect of demographic factors, obstetric factors and smoking/drinking were taken into account. Comparison of preterm births with controls indicated that three factors were significantly associated: a previous low-birthweight baby, severe life event/difficulty and bleeding during pregnancy. For SGA babies the factors were: previous low-birthweight baby, low social support and smoking. By using a reliable measure of life events and adequate numbers of low-birthweight babies, this study overcame the potential inaccuracies of previous studies and indicates a more specific relation between social stress and low birthweight.     

Caesarean delivery and outcome in very low birthweight infants

OBJECTIVE: To determine the relationship between mode of delivery, intraventricular haemorrhage (IVH), and mortality in very low birthweight (VLBW) infants. STUDY DESIGN: A historical cohort study of infants admitted to a single level III neonatal intensive care unit during a five-year period. Infants < 1500 g born by caesarean delivery (n = 400) were compared to those born by vaginal delivery (n = 305). RESULTS: After controlling for potential confounding variables including: gestational age, fetal presentation, and multiple birth, caesarean delivery was not associated with a decreased odds of IVH (odds ratio 1.2, 95% CI 0.7-2.0), severe IVH (1.9, 0.9-4.0), or mortality (1.2, 0.6-2.4). CONCLUSIONS: In our population of very low birthweight infants, caesarean delivery is not associated with a decreased risk for mortality or intraventricular haemorrhage.     

Validity of postnatal assessments of gestational age in low birthweight infants from a Caribbean community.

The Dubowitz assessment of gestational maturity was compared with the best obstetric estimate of gestational age based on date of last menstrual period (LMP) or ultrasonography performed early in the pregnancy or both. This study involved 384 low birthweight infants admitted to the neonatal tertiary center in Guadeloupe, French West Indies, during the period 1986 through 1988. The Dubowitz assessment exceeded the best obstetric estimation by an average of nearly 5 days. This overestimation by the Dubowitz method was observed at every gestational age and was greatest at gestational ages of less than 35 weeks. The physical characteristics of the postnatal assessment were in closer agreement with the best obstetric estimate than the neurological characteristics. These findings concur with other investigations that indicate that the Dubowitz postnatal assessment of gestational age overestimates the gestational age interval from date of LMP in low birthweight and preterm infants.     

Neonatal outcomes of small for gestational age preterm infants in Canada

To compare the effect of small for gestational age (SGA) on mortality, major morbidity and resource utilization among singleton very preterm infants (<33 weeks gestation) admitted to neonatal intensive care units (NICUs) across Canada. Infants admitted to participating NICUs from 2003 to 2008 were divided into SGA (defined as birth weight <10th percentile for gestational age and sex) and non-small gestational age (non-SGA) groups. The risk-adjusted effects of SGA on neonatal outcomes and resource utilization were examined using multivariable analyses. SGA infants (n = 1249 from a cohort of 11,909) had a higher odds of mortality (adjusted odds ratio [AOR] 2.46; 95% confidence interval [CI], 1.93-3.14), necrotizing enterocolitis (AOR 1.57; 95% CI, 1.22-2.03), bronchopulmonary dysplasia (AOR 1.78; 95% CI, 1.48-2.13), and severe retinopathy of prematurity (AOR 2.34; 95% CI, 1.71-3.19). These infants also had lower odds of survival free of major morbidity (AOR 0.50; 95% CI, 0.43-0.58) and respiratory distress syndrome (AOR 0.79; 95% CI, 0.68-0.93). In addition, SGA infants had a more prolonged stay in the NICU, and longer use of ventilation continuous positive airway pressure, and supplemental oxygen (p < 0.01 for all). SGA infants had a higher risk of mortality, major morbidities, and higher resource utilization compared with non-SGA infants.     

Renal function in early childhood in very low birthweight infants

We evaluated renal function in early childhood in 48 very low birthweight (VLBW) ex-preterms and correlated the perinatal risk factors for acute renal failure (ARF) and postnatal growth course to abnormal renal findings at children-age. Nineteen boys and 29 girls (6.3 to 8.2 years of age) had a physical examination, exploration of renal function, and ultrasound. Cases were compared with age-matched controls that were born full term. All patients had normal blood pressure, renal ultrasound, and kidney length to body height. Plasma creatinine and clearance were normal, and no differences were observed with controls. No correlation was found between childhood renal parameters and perinatal variables. Versus controls, 8.3% had pathological microalbuminuria (ACR > 20 mg/g; P = 0.19). Analysis of risk factors for ARF showed that hypotension during neonatal life had a significant independent association with ACR > 20 mg/g at children-age ( P = 0.009). Microalbumin excretion and ACR > 20 mg/g strongly correlated with weight z score at 12 months (R, 0.48; 0.21 < R < 0.68) and weight catch-up growth at 6 months (R, 0.38; 0.09 < R < 0.61) and 12 months (R, 0.56; 0.32 < R < 0.74) of corrected age. In conclusion, in VLBW infants, acute conditions such as hypotension and early catch-up growth correlate in childhood to subtle changes in renal function, which can provide early information about the risk of kidney disease in this population.