Treatment status of extremely premature infants with gestational age<28 weeks in a Chinese perinatal center from 2010 to 2019

Background There is a paucity of studies conducted in China on the outcomes of all live-birth extremely premature infants(EPIs)and there is no unifed recommendation on the active treatment of the minimum gestational age in the feld of perinatal medicine in China.We aimed to investigate the current treatment situation of EPIs and to provide evidence for formulating reasonable treatment recommendations.Methods We established a real-world ambispective cohort study of all live births in delivery rooms with gestational age(GA)between 24+0 and 27+6 weeks from 2010 to 2019.Results Of the 1163 EPIs included in our study,241(20.7%)survived,while 849(73.0%)died in the delivery room and 73(6.3%)died in the neonatal intensive care unit.Among all included EPIs,862(74.1%)died from withholding or withdrawal of care.Regardless of stratifcation according to GA or birth weight,the proportion of total mortality attributable to withdrawal of care is high.For infants with the GA of 24 weeks,active treatment did not extend their survival time(P=0.224).The survival time without severe morbidity of the active treatment was signifcantly longer than that of withdrawing care for infants older than 25 weeks(P<0.001).Over time,the survival rate improved,and the withdrawal of care caused by socioeconomic factors and primary nonintervention were reduced signifcantly(P<0.001).Conclusions The mortality rate of EPIs is still high.Withdrawal of care is common for EPIs with smaller GA,especially in the delivery room.It is necessary to use a multi-center,large sample of real-world data to fnd the survival limit of active treatment based on our treatment capabilities.

Neurological consequences of systemic inflammation in the premature neonate

Despite substantial progress in neonatal care over the past two decades leading to improved survival of extremely premature infants, extreme prematurity continues to be associated with long term neurodevelopmental impairments. Cerebral white matter injury is the predominant form of insult in preterm brain leading to adverse neurological consequences. Such brain injury pattern and unfavorable neurologic sequelae is commonly encountered in premature infants exposed to systemic inflammatory states such as clinical or culture proven sepsis with or without evidence of meningitis, prolonged mechanical ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis and chorioamnionitis. Underlying mechanisms may include cytokine mediated processes without direct entry of pathogens into the brain, developmental differences in immune response and complex neurovascular barrier system that play a critical role in regulating the cerebral response to various systemic inflammatory insults in premature infants. Understanding of these pathologic mechanisms and clinical correlates of such injury based on serum biomarkers or brain imaging findings on magnetic resonance imaging will pave way for future research and translational therapeutic opportunities for the developing brain.

Improved survival at the cost of more chronic lung disease?Current management and outcomes in extremely preterm infants born in New South Wales and the Australian Capital Territory:2010-2020

Background Since 2010,most tertiary care hospitals in Australia have changed how they care for extremely premature infants.However,in-hospital and longer-term outcome data have suggested unchanged or even worse health outcomes in later epochs,especially respiratory outcomes.This study examined the trend in outcomes since these changes were introduced,particularly the prevalence of chronic neonatal lung disease(CLD).Methods This is a retrospective cross-sectional analysis of data from the Neonatal Intensive Care Units'(NICUS)database of all perinatal intensive care units in New South Wales and the Australian Capital Territory,including infants born at≥24 and≤28 weeks of gestational age in tertiary perinatal units between January 1,2010,and December 31,2020.Temporal trends and changes in primary outcome were examined by linear and adjusted multivariable logistic regression models.Results This study included 3258 infants.We saw significant changes in antenatal magnesium sulfate(75% increase),delayed cord clamping(66% increase),delivery room intubations(30% decrease),any time(20% decrease),duration on mechanical ventilation(100-hour decrease),and hours on noninvasive ventilation(200-hour increase).Mortality decreased from 17% to 6%.The incidence of CLD increased significantly even when adjusted for confounders(15% increase).Any time and mean hours spent on mechanical ventilation significantly increased the odds of CLD.This study could not find a significant association of any of the protective antenatal treatments on CLD.Conclusions The last decade saw a significant improvement in survival and survival to discharge without major morbidity.There was increased use of magnesium sulfate,delayed cord clamping,and less invasive respiratory management of extremely preterm infants.The avoidance of mechanical ventilation may impact the incidence of CLD.

Global variation in skin injures and skincare practices in extremely preterm infants

Background Globally,are skincare practices and skin injuries in extremely preterm infants comparable?This study describes skin injuries,variation in skincare practices and investigates any association between them.Methods A web-based survey was conducted between February 2019 and August 2021.Quantifying skin injuries and describing skincare practices in extremely preterm infants were the main outcomes.The association between skin injuries and skincare practices was established using binary multivariable logistic regression adjusted for regions.Results Responses from 848 neonatal intensive care units,representing all geographic regions and income status groups were received.Diaper dermatitis(331/840,39%)and medical adhesive-related skin injuries(319/838,38%)were the most common injuries.Following a local skincare guideline reduced skin injuries[medical adhesive-related injuries:adjusted odds ratios(aOR)=0.63,95%confidence interval(CI)=0.45–0.88;perineal injuries:aOR=0.66,95%CI=0.45–0.96;local skin infections:OR=0.41,95%CI=0.26–0.65;chemical burns:OR=0.46,95%CI=0.26–0.83;thermal burns:OR=0.51,95%CI=0.27–0.96].Performing skin assessments at least every four hours reduced skin injuries(abrasion:aOR=0.48,95%CI=0.33–0.67;pressure:aOR=0.51,95%CI=0.34–0.78;diaper dermatitis:aOR=0.71,95%CI=0.51–0.99;perineal:aOR=0.52,95%CI=0.36–0.75).Regional and resource settings-based variations in skin injuries and skincare practices were observed.Conclusions Skin injuries were common in extremely preterm infants.Consistency in practice and improved surveillance appears to reduce the occurrence of these injuries.Better evidence regarding optimal practices is needed to reduce skin injuries and minimize practice variations.

Predictive Value of Cranial Ultrasound for Neurodevelopmental Outcomes of Very Preterm Infants with Brain Injury

Background：Compared with full-term infants, very preterm infants are more vulnerable to injury and long-term disability and are at high risk of death. The predictive value of ultrasound and imaging on the neurodevelopment is one of the hot topics. This study aimed to investigate the relationship between cranial ultrasound （cUS） variables and neurodevelopmental outcomes of very preterm infants.Methods：Totally 129 very preterm infants （gestational age ≤28 weeks） in neonatal intensive care unit of Hunan Children’s Hospital between January 2012 and November 2014 were included in this retrospective study. Serial cUS （weekly before discharge and monthly after discharge） was performed on the infants until 6 months or older. Magnetic resonance imaging （MRI） was performed on the infants at approximately the term-equivalent age. The mental developmental index （MDI） and psychomotor developmental index （PDI） were followed up until the infants were 24 months or older. The relationship between brain injury and MDI/PDI scores was analyzed.Results：The consistency rate between cUS and MRI was 88%. At the first cUS, germinal matrix hemorrhage （GMH） Grades 3 and 4, hospitalization duration, and weight are significantly correlated with MDI/PDI and prognosis （MDI： odds ratio [OR] = 8.415, 0.982, and 0.042, P = 0.016, 0.000, and 0.004; PDI： OR = 7.149, 0.978, and 0.012, P = 0.025, 0.000, and 0.000, respectively）. At the last cUS, gestational age, extensive cystic periventricular leukomalacia （c-PVL）, and moderate and severe hydrocephaly are significantly correlated with MDI （OR = 0.292, 60.220, and 170.375, P = 0.004, 0.003, and 0.000, respectively）. Extensive c-PVL and moderate and severe hydrocephaly are significantly correlated with PDI （OR = 76.861 and 116.746, P = 0.003 and 0.000, respectively）.Conclusions：Very premature infants with GMH Grades 3 and 4, short hospitalization duration, and low weight have low survival rates and poorly developed brain nerves. Cerebral palsy can result from severe cerebral hemorrhage, moderate and severe hydrocephaly, and extensive c-PVL. The sustained, inhomogeneous echogenicity of white matter may suggest subtle brain injury.