Predicting neurosensory disabilities at two years of age in a national cohort of extremely premature infants

Background

Extreme prematurity carries a high risk of neurosensory disability.

Aims

Examine which information obtained pre-, peri- and postnatally may be predictive of neurosensory disabilities at 2 years of age.

Study design

Prospective observational study of all infants born in Norway in 1999 and 2000 with gestational age (GA) 22-27 completed weeks or birth weight (BW) of 500-999 g.

Outcome measures

Incidence of neurosensory disabilities.

Results

Of 373 surviving children, 30 (8%) had major neurosensory disabilities (26 CP, 6 blind, 3 deaf), and a further 46 (12%) had minor visual or hearing disabilities. The rate of major neurosensory disabilities was 19 of 99 (19%) for children with GA 23-25 vs. 8 of 189 (4%) for GA 26-27 weeks (p < 0.001). In a multivariable model, only morbidities detected in the neonatal intensive care unit (NICU) were associated with major neurosensory disabilities; adjusted odds ratios (95% confidence intervals) were 68.6 (18.7, 252.2) for major abnormalities on cerebral ultrasound, 6.8 (1.7, 27.4) for retinopathy of prematurity (ROP) grade > 2, 3.2 (1.0, 9.7) for ROP grade 1-2, 6.5 (1.9, 22.3) for prolonged use (≥ 21 days) of steroid treatment for lung disease and 3.1 (1.0, 9.4) for clinical chorioamnionitis. The visual outcome was strongly related to the degree of ROP (p < 0.001), and all who had a normal hearing screen in the NICU had normal hearing at 2 years.

Conclusion

NICU morbidities, rather than GA or intrauterine growth are the significant predictors of major neurosensory disabilities among extreme prematurity surviving to discharge from the NICU.     

Breast milk feeding in very low birthweight infants

ABSTRACT. The infant feeding practices of 77 very low birthweight (VLBW) survivors with birthweights under 1500 g were studied. 58 (75%) infants received fresh expressed breast milk (EBM) from their own mothers, of whom 42 were successfully breastfed at a medium postconceptual age of 36 weeks. Overall incidence of breastfeeding in the VLBW population was 44% at 3 months and 23% at 6 months. The postnatal ages at which breastfeeding stopped ranged from 2 months to 28 months (median 4 months). No significant differences in perinatal factors were found between the breast milk and milk formula groups. There were significantly more mothers in the breast milk group who were given advice and encouragement during their pregnancy on breastfeeding and who had planned in the antenatal period to breastfeed their infants. The most common reasons given for deciding against providing breast milk were related to extreme prematurity of the infant. Nursery weight gain of infants fed breast milk and milk formula were similar. Necrotizing enterocolitis occurred significantly less frequently in the breast milk group. The study suggested that the special attention and positve encouragement given to parents of VLBW infants had contributed to the successful establishment and continuation of a feeding regime utilizing fresh breast milk from the infant's own mother, which we believe has immunological, psychological and nutritional benefits in this high-risk infant population.     

Increased epidermal growth factor levels in human milk of mothers with extremely premature infants

Maternal milk is the major source of nutrients and growth-promoting substances in the first weeks of life for the majority of neonates. Epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) are trophic peptides present in human milk with significant healing effects on injured gastrointestinal mucosa. Decreasing gestational age of neonates is associated with higher risk of developing gastrointestinal disorders, and human milk provides better protection against these diseases compared with formula. The aim of this study was to evaluate the concentrations of EGF and TGF-alpha in human milk collected from mothers with infants born: extremely preterm, preterm, and full term. Milk samples were collected at the end of first, second, and fourth week postpartum from each mother of infants born in one of the three gestational age groups: extremely preterm (23-27 wk, n = 16), preterm (32-36 wk, n = 16), and full term (38-42 wk, n = 15). Milk concentrations of EGF and TGF-alpha were quantified with a homologous RIA in the milk aqueous fraction. Concentrations of EGF in human milk from the extremely preterm group (23-27 wk) were significantly higher compared with values from the preterm and full-term groups throughout the first month of lactation. A similar pattern was observed with human milk TGF-alpha; however, milk TGF-alpha levels were lower than EGF. In conclusion, we have found higher concentrations of EGF and TGF-alpha in human milk of mothers with extremely preterm babies. These data may indicate the potential importance of milk-borne EGF and TGF-alpha for the development of extremely premature infants.     

Bronchopulmonary dysplasia – prevalence,severity and predictive factors in a national cohort of extremely premature infants

Aim: To study prevalence and predictive factors of bronchopulmonary dysplasia (BPD) in a cohort of preterm infants with a high incidence of prenatal steroid and surfactant treatment. Methods: BPD was analysed in a national cohort of infants with gestational age (GA) of 22–27 completed weeks (wks) or birth weight (BW) of 500–999 g. Of 464 infants who were transferred to a NICU, 377 infants with GA ≤ 30 wks and survived beyond 28 days were included in the study. Results: Moderate or severe BPD was strongly related to GA. Of infants with GA 22–25 wks, 67.3% developed BPD compared to 36.6% at GA 26–30 wks. Overall, moderate and severe BPD was significantly more common in boys (63.3%) than in girls (36.6%) (p = 0.0004), but female gender was not a protective factor in infants with GA 22–25 wks. In multivariate analyses, BPD was significantly associated with gender, surfactant treatment and treatment for PDA. Conclusions: BPD remains a severe complication of extreme prematurity in spite of prenatal steroids and surfactant treatment. Whether associations with surfactant and PDA treatment simply reflect severity of early lung disease or have causal relationships should probably be studied in randomized controlled trials.     

Oral feeding in premature infants: advantage of a self-paced milk flow

An earlier study demonstrated that oral feeding of premature infants (<30 wk gestation) was enhanced when milk was delivered through a self-paced flow system. The aims of this study were to identify the principle(s) by which this occurred and to develop a practical method to implement the self-paced system in neonatal nurseries. Feeding performance, measured by overall transfer, duration of oral feedings, efficiency, and percentage of successful feedings, was assessed at three time periods, when infants were taking 1-2, 3-5, and 6-8 oral feedings/day. At each time period, infants were fed, sequentially and in a random order, with a self-paced system, a standard bottle, and a test bottle, the shape of which allowed the elimination of the internal hydrostatic pressure. In a second study, infants were similarly fed with the self-paced system and a vacuum-free bottle which eliminated both hydrostatic pressure and vacuum within the bottle. The duration of oral feedings, efficiency, and percentage of successful feedings were improved with the self-paced system as compared to the standard and test bottles. The results were similar in the comparison between the self-paced system and the vacuum-free bottle. Elimination of the vacuum build-up naturally occurring in bottles enhances the feeding performance of infants born <30 wk gestation as they are transitioned from tube to oral feeding. The vacuum-free bottle is a tool which caretakers can readily use in neonatal nurseries.     

Milk curd obstruction in premature infants receiving fortified expressed breast milk

Aim:   Milk curd obstruction is one of the less common causes of neonatal bowel obstruction. It has been described in premature infants who received high caloric formula feeds. We report presentation, management and outcome of premature neonates who developed milk curd obstruction while being fed fortified expressed breast milk.
Methods:   A retrospective case note review of babies who were treated for milk curd obstruction in Royal Children's Hospital and Mater Children's Hospital in Brisbane between 2001 and 2007 was performed.
Results:   Nine preterm neonates developed milk curd obstruction (mean gestational age 27 weeks). All babies received ortified expressed breast milk. Symptoms presented were those of bowel obstruction in the majority of cases. Laparotomy was required in eight babies, one had a pre-existing ileostomy that was washed out. Two babies died shortly after surgery, while two followed several months later.
Conclusion:   The diagnosis of milk curd obstruction should be considered in all premature babies with signs of bowel obstruction who are fed expressed breast milk with caloric fortification.     

Early cessation of breast milk feeding in very low birthweight infants

This investigation was carried out to comparatively assess the duration of breast milk feeding and to analyze risk factors for early cessation of breast milk feeding in term and very preterm infants. A cohort study was performed in 89 consecutive very low birthweight (VLBW) infants (<1500 g) who survived for at least for one week, and 177 term infants with birthweights >2500 g born in the same hospital matched for gender and multiplicity. Median duration of breast milk feeding, as determined from charts and questionnaires mailed to the mothers at 6 and 12 months corrected age, was 36 days in VLBW infants, compared to 112 days in control infants (P<0.0001). In both VLBW and control infants, smoking during pregnancy, low maternal and low paternal school education were each significantly associated with short duration of breast milk feeding. In VLBW infants, multiple pregnancy and gestational age <29 weeks were each associated with prolonged breast milk feeding, as were maternal age >35 years and spontaneous pregnancy (as opposed to pregnancy following infertility treatment) in term infants. Multivariate analysis revealed that VLBW, smoking and low parental school education were independent negative predictors of breast milk feeding. While these results emphasize the need for special support of VLBW infant mothers promoting lactation, the relationships between smoking, school education and breast milk feeding in both strata show that efforts to increase breast milk feeding require a public health perspective.     

捐献母乳喂养对极低出生体重儿院内感染发生的影响

目的 探讨捐献母乳在预防极低出生体重儿院内感染中的作用。方法 将105例极低出生体重住院早产儿纳入研究,根据其所接受的喂养方式分为亲母母乳、捐献母乳、早产儿配方奶喂养组,每组各35例。比较3组院内感染发生率、坏死性小肠结肠炎发生率、喂养不耐受发生率以及达到全肠道喂养时间、早期生长指标。结果 与配方奶组比较,捐献母乳组和亲母母乳组患儿院内感染及坏死性小肠结肠发生率明显降低,且捐献母乳组和亲母母乳组达到全肠道喂养的时间短于配方奶组,差异均有统计学意义（P < 0.05）。3组患儿头围、身长、体重增长速率比较差异无统计学意义。结论 极低出生体重儿在亲母母乳不足时可以采用捐献母乳替代喂养,有助于降低院内感染的发生。     

胎膜早破对超早产儿早期预后的影响

目的 探讨胎膜早破（PROM）对超早产儿早期预后的影响,为超早产儿管理、产前咨询提供依据。方法 收集2017~2019年单胎超早产儿179例为研究对象,按是否存在PROM分为PROM组（69例）和非PROM组（110例）,对孕母情况及患儿早期预后指标进行统计分析。结果 PROM组早发型败血症和坏死性小肠结肠炎发生率高于非PROM组（P < 0.05）,肺表面活性物质使用率及血流动力学显著的动脉导管未闭发生率低于非PROM组（P < 0.05）。多因素logistic回归分析显示绒毛膜羊膜炎是早发型败血症、坏死性小肠结肠炎的独立危险因素（分别OR=11.062、9.437,P < 0.05）,PROM是使用肺表面活性物质的独立保护因素（OR=0.363,P < 0.05）。结论 PROM增加了超早产儿早发型败血症及坏死性小肠结肠炎的发生率,未增加其他不良结局发生率。对有超早产风险的PROM孕妇,建议积极保胎、预防绒毛膜羊膜炎以延长孕周、降低感染发生率,从而改善超早产儿结局。     

Serial serum 25-hydroxyvitamin D and mineral homeostasis in very premature infants fed preterm human milk

Fourteen very low birthweight infants (mean +/- SD 1,070 +/- 180 g and 29.3 +/- 1.9 weeks gestation) fed their own mother's milk were clinically followed until 3-4 months of age with frequent measurements of serum calcium, phosphorus, magnesium, 25-hydroxyvitamin D (25-OHD), parathyroid hormone, alkaline phosphatase, and albumin, and urine calcium, phosphorus, and magnesium. These infants were matched for birthweight and gestation with 14 infants (1,075 +/- 152 g and 29.0 +/- 1.7 weeks) who had been similarly followed during concomitant studies of infants fed standard formula (Similac 20 cal/oz). Urine phosphorus was markedly lower in the breast milk-fed group from initiation of feedings, and serum phosphorus became significantly lower at and after 6 weeks of age. The fall in serum phosphorus was accompanied by a marked calciuria. Parathyroid hormone was suppressed in the breast milk-fed group, although serum calcium was not elevated and did not differ from formula-fed infants. A high incidence of moderate-severe hypomineralization on radiographs was seen in both breast milk- and formula-fed groups. Six of 14 breast-fed infants required phosphorus supplementation at 8-10 weeks of age because of significant hypophosphatemia, hypercalciuria, and hypomineralization. These infants differed from those not requiring phosphorus supplements by being smaller at birth but not of lower gestation, and having persistently low serum 25-OHD at and after 6 weeks of age.