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Children
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Care and Outcome of the Extreme Preterm Infant
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Care and Outcome of the Extreme Preterm Infant

A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Pediatric Neonatology".

Deadline for manuscript submissions: closed (10 November 2024) | Viewed by 7792

Special Issue Editor

Dr. Elizabeth Asztalos

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Guest Editor
Department of Newborn & Developmental Medicine, Sunnybrook Health Sciences Centre, Department of Paediatrics, University of Toronto, Toronto, ON M5A 1B2, Canada
Interests: neonatal care; neurodevelopmental outcomes; clinical trials; feeding and nutritional support
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Over the last 10–20 years, there have been significant gains in the care of preterm infants at less than 30 weeks of gestation. We have been able to improve our skill set in the fields of respiratory and hemodynamic management so that neonatal morbidity is steadily declining in overall incidence for preterm infants, particularly in infants at 28–29 weeks of gestation. As we become more proficient in the care of these infants, we begin to translate these skill sets for the more extreme preterm infants, those at <26 weeks of gestation but most importantly the infants born below 24 weeks of gestation. These infants are not only preterm but are also physiologically immature, which adds a dimension in their care and ultimate survival. It is now important to share how we can optimize survival but also ensure that there are positive outcomes both in neonatal morbidities and neurodevelopmental outcomes. How these very extreme preterm infants traverse the neonatal pathways will play a significant role in how they are able to develop as a functioning child. The traditional outcomes of death, cerebral palsy, vision and hearing deficits, and cognitive deficits may not be adequate in evaluating how these extreme preterm infants present post-discharge. We need to go beyond theses traditional outcomes and look at functional outcomes as we explore our ongoing approaches in care. In addition, we need to explore how parents use coping skills in the 20–30 weeks of neonatal care their infants may have.

I hope that this Special Issue will be an opportunity to look at how we can optimize care for these infants and their parents.

Dr. Elizabeth Asztalos
Guest Editor

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Keywords

  • extreme prematurity
  • neonatal morbidities
  • ventilatory management
  • nutrition
  • developmental care
  • parental care
  • functional neurodevelopmental outcomes
  • family impact and stress

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Published Papers (6 papers)

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Research

12 pages, 3665 KiB  
Article
Enhancing Neurodevelopmental Outcomes in Preterm Infants Through the Sensory Development Care Map
by Lisa Sampson, Maureen Luther, Asaph Rolnitsky and Eugene Ng
Children 2025, 12(2), 192; https://doi.org/10.3390/children12020192 - 6 Feb 2025
Viewed by 925
Abstract
Background/Objectives: Preterm infants are at a high risk of neurodevelopmental impairments due to immature brain development and the stressors of the neonatal intensive care unit (NICU) environment. To improve outcomes, incorporating a neuropromotion strategy by promoting nurturing encounters (NEs) is essential. Methods: In [...] Read more.
Background/Objectives: Preterm infants are at a high risk of neurodevelopmental impairments due to immature brain development and the stressors of the neonatal intensive care unit (NICU) environment. To improve outcomes, incorporating a neuropromotion strategy by promoting nurturing encounters (NEs) is essential. Methods: In this 48-bed tertiary perinatal care center, an informal survey showed that staff lacked consistent knowledge about sensory neurodevelopment, while parents expressed a need for clearer guidance. This paper describes the development and implementation of the Sensory Developmental Care Map (SDCM) as part of a larger quality-improvement initiative. The SDCM is an educational tool designed to guide NICU staff and families in providing neuroprotective and neuropromotive care, based on the infant’s gestational age (GA). The SDCM was created by integrating evidence on sensory development across GAs and providing practical strategies to promote positive sensory input while protecting the developing brain. The map visually indicates when to protect or stimulate each sense, offering clear, developmentally appropriate guidance. Printed and digital versions of the map were made accessible to families and staff, with bedside copies and a poster displayed in the unit. Results: A post-implementation evaluation is ongoing, but preliminary feedback suggests that the SDCM improved the family understanding of sensory developmental care. The SDCM serves as a valuable resource for promoting appropriate sensory input for preterm infants and further enhancing developmentally supportive care within the NICU. Full article
(This article belongs to the Special Issue Care and Outcome of the Extreme Preterm Infant)
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14 pages, 2888 KiB  
Article
Implementation of Parenteral Nutrition Formulations with Increased Calcium and Phosphate Concentrations and Its Impact on Metabolic Bone Disease in Preterm Infants: A Retrospective Single-Centre Study
by Sushma Sureshchandra, Rajesh Maheshwari, Tamara Nowland, James Elhindi, Lily Rundjan, Daphne D'Cruz, Melissa Luig, Dharmesh Shah, Gemma Lowe, Jane Baird and Pranav R. Jani
Children 2025, 12(2), 172; https://doi.org/10.3390/children12020172 - 29 Jan 2025
Viewed by 828
Abstract
Background: Metabolic Bone Disease of Prematurity (MBDP) is common in extremely preterm infants (≤28 weeks gestation). Parenteral nutrition (PN) with higher calcium (Ca) and phosphorus (P) concentration started soon after birth may improve bone health in preterm infants. We compared the effect of [...] Read more.
Background: Metabolic Bone Disease of Prematurity (MBDP) is common in extremely preterm infants (≤28 weeks gestation). Parenteral nutrition (PN) with higher calcium (Ca) and phosphorus (P) concentration started soon after birth may improve bone health in preterm infants. We compared the effect of two standard PN formulations on the incidence of MBDP and explored the predictive ability of biochemical markers for diagnosing MBDP. Methods: This retrospective study included eligible preterm infants ≤ 28 weeks gestation. Infants in group 1 (January 2016–December 2017) received PN 1 formulation with lower Ca (1.6 mmol/kg/day) and P concentration (1.4 mmol/kg/day). Infants in group 2 (June 2018–May 2020) received PN 2 formulation with higher Ca (2.3 mmol/kg/day) and P concentration (1.8 mmol/kg/day). We reviewed the biochemical and radiological investigations performed for diagnosing MBDP. Results: The incidence of MBDP reduced from 82.8% (77/93) in group 1 to 47.3% (27/57) in group 2. Grade 2–3 MBDP reduced significantly from 14% in group 1 to none in group 2 (p < 0.01). Serum phosphate < 1.5 mmol/L had a sensitivity of 79% and specificity of 77%, and alkaline phosphatase > 500 U/L showed a sensitivity of 72% and specificity of 71% for diagnosing radiological MBDP. There was no increase in hypercalcemia, hypophosphatemia or nephrocalcinosis from PN 2 formulation. Conclusions: A higher Ca and P concentration in PN reduced MBDP and eliminated grade 2–3 MBDP in our cohort without an increase in adverse events. Low serum phosphate and high serum alkaline phosphatase were the best predictors for diagnosing MBDP. Full article
(This article belongs to the Special Issue Care and Outcome of the Extreme Preterm Infant)
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9 pages, 483 KiB  
Article
The Association Between Perinatal Pharmacologic Treatments and Spontaneous Intestinal Perforation in Extremely Preterm Infants: A Propensity Score Matching Study
by Wei-Hsin Cheng, Lo-Hsuan Tu, Ming-Chou Chiang, Yu-Ning Chen, Wei-Hung Wu and Kai-Hsiang Hsu
Children 2025, 12(2), 142; https://doi.org/10.3390/children12020142 - 27 Jan 2025
Viewed by 671
Abstract
Background: The impact of perinatal pharmacologic agents on spontaneous intestinal perforation (SIP) in extremely low-birthweight (ELBW, <1000 g) preterm infants remains inconclusive based on findings from retrospective cohort or case–control studies. This study aims to address this uncertainty by using propensity score [...] Read more.
Background: The impact of perinatal pharmacologic agents on spontaneous intestinal perforation (SIP) in extremely low-birthweight (ELBW, <1000 g) preterm infants remains inconclusive based on findings from retrospective cohort or case–control studies. This study aims to address this uncertainty by using propensity score matching (PSM) to reduce bias. Methods: We retrospectively reviewed ELBW infants in our unit between 2014 and 2023 to identify SIP cases. Confirmed through medical notes, surgical consultation, and author review, each SIP case was matched at a 1:3 ratio using propensity scores on factors including the gestational age (GA), birthweight, gender, and birth year. Pharmacologic agents commonly given antenatally and postnatally were analyzed. Only medications that were started 24 h before the onset of SIP or the corresponding age (PSM-controls) were included. Results: A total of 858 ELBW infants were reviewed, 28 SIP cases (GA 25.3 ± 2.1 weeks, BW 735 ± 167 g) were identified, and 84 PSM-controls were matched. The SIP cases received hydrocortisone (25% (7/28) vs. 9.5% (8/84), p = 0.037) and combined inotropic agents (17.9% (5/28) vs. 2.4% (2/84), p = 0.020) to a significantly greater extent. No differences were observed in the use of other medications. In logistic regression, the use of hydrocortisone and combined inotropes remained independent risks for SIP, with ORs (95% CIs) of 3.4 (1.1–10.9) and 2.1 (1.2–3.8), respectively. Conclusions: This first PSM-based study supported postnatal hydrocortisone and combined inotrope use as independent risks for SIP in ELBW infants. Clinicians should be aware of these risks and remain vigilant for SIP when administering hydrocortisone and inotropes. Full article
(This article belongs to the Special Issue Care and Outcome of the Extreme Preterm Infant)
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11 pages, 468 KiB  
Article
Longer Duration of Cord Clamping Improves Nicu Survival Without Major Morbidities in Very Preterm Infants
by Priya Jegatheesan, Esther Belogolovsky, Matthew Nudelman, Sudha Rani Narasimhan, Angela Huang, Balaji Govindaswami and Dongli Song
Children 2024, 11(12), 1546; https://doi.org/10.3390/children11121546 - 20 Dec 2024
Viewed by 986
Abstract
Background: Longer duration of deferred cord clamping (DCC), at least 120 s, is associated with the highest reduction in mortality compared to shorter durations of DCC or immediate cord clamping in preterm infants. We compared the neonatal outcomes of very preterm infants who [...] Read more.
Background: Longer duration of deferred cord clamping (DCC), at least 120 s, is associated with the highest reduction in mortality compared to shorter durations of DCC or immediate cord clamping in preterm infants. We compared the neonatal outcomes of very preterm infants who received at least 60 s to those who received at least 120 s of DCC. Methods: This is a retrospective single-center study including preterm infants born <33 weeks of gestational age (GA) between 2014 and 2019. The intended duration of DCC was 60 s in Period 1 (January 2014 to June 2016, n = 139) and 120 to 180 s in Period 2 (July 2016 to December 2019, n = 155). We compared the demographics, delivery room measures, and neonatal outcomes between the two periods as intent-to-treat analysis and per protocol analysis. Results: The intended duration of DCC was completed in 75% of infants in Period 1 (n = 106) and 76% of infants in Period 2 (n = 114). There was an increase in survival without major morbidities in the infants that received at least 120 s of DCC, which remained significant after adjusting for GA and erythropoietin use (Odds ratio 8.6, 95% CI 1.6 to 45.7). Conclusions: Longer duration of DCC is associated with improved survival without major morbidities in preterm infants <33 weeks GA. Full article
(This article belongs to the Special Issue Care and Outcome of the Extreme Preterm Infant)
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15 pages, 1806 KiB  
Article
Identification of Neonatal Factors Predicting Pre-Discharge Mortality in Extremely Preterm or Extremely Low Birth Weight Infants: A Historical Cohort Study
by Zhenyuan Dai, Xiaobing Zhong, Qian Chen, Yuming Chen, Sinian Pan, Huiqing Ye and Xinyi Tang
Children 2024, 11(12), 1453; https://doi.org/10.3390/children11121453 - 28 Nov 2024
Viewed by 740
Abstract
Background/Objectives: This study identified early neonatal factors predicting pre-discharge mortality among extremely preterm infants (EPIs) or extremely low birth weight infants (ELBWIs) in China, where data are scarce. Methods: We conducted a retrospective analysis of 211 (92 deaths) neonates born <28 weeks of [...] Read more.
Background/Objectives: This study identified early neonatal factors predicting pre-discharge mortality among extremely preterm infants (EPIs) or extremely low birth weight infants (ELBWIs) in China, where data are scarce. Methods: We conducted a retrospective analysis of 211 (92 deaths) neonates born <28 weeks of gestation or with a birth weight <1000 g, admitted to University Affiliated Hospitals from 2013 to 2024 in Guangzhou, China. Data on 26 neonatal factors before the first 24 h of life and pre-discharge mortality were collected. LASSO–Cox regression was employed to screen predictive factors, followed by stepwise Cox regression to develop the final mortality prediction model. The model’s performance was evaluated using the area under the curve (AUC) of the receiver operating characteristic, calibration curves, and decision curve analysis. Results: The LASSO–Cox model identified 13 predictors that showed strong predictive accuracy (AUC: 0.806/0.864 in the training/validation sets), with sensitivity and specificity rates above 70%. Among them, six predictors remained significant in the final stepwise Cox model and generated similar predictive accuracy (AUC: 0.830; 95% CI: 0.775–0.885). Besides the well-established predictors (e.g., gestational age, 5 min Apgar scores, and multiplicity), this study highlights the predictive value of the maximum FiO2. It emphasizes the significance of the early use of additional doses of surfactant and umbilical vein catheterization (UVC) in reducing mortality. Conclusions: We identified six significant predictors for pre-discharge mortality. The findings highlighted the modifiable factors (FiO2, surfactant, and UVC) as crucial neonatal factors for predicting mortality risk in EPIs or ELBWIs, and offer valuable guidance for early clinical management. Full article
(This article belongs to the Special Issue Care and Outcome of the Extreme Preterm Infant)
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15 pages, 3180 KiB  
Article
Growth and Neurodevelopmental Outcomes of Preterm Infants Born < 26 Weeks Gestation before and after Implementation of a Nutrition-Care Bundle
by Giulia Res, Rosine F. Bishara, Paige Terrien Church, Rena Rosenthal, Rita Maria Bishara, Annie Dupuis, Elizabeth Asztalos and Rudaina Banihani
Children 2024, 11(4), 475; https://doi.org/10.3390/children11040475 - 15 Apr 2024
Viewed by 2417
Abstract
Background: This study aimed to assess the impact of a nutrition-care bundle on growth and neurodevelopmental outcomes of micro-preterm infants born in a level III neonatal intensive care unit (NICU) by two years corrected age. Methods: A nutrition-care bundle emphasizing the prompt initiation [...] Read more.
Background: This study aimed to assess the impact of a nutrition-care bundle on growth and neurodevelopmental outcomes of micro-preterm infants born in a level III neonatal intensive care unit (NICU) by two years corrected age. Methods: A nutrition-care bundle emphasizing the prompt initiation of parenteral nutrition at birth, initiation of enteral feeds within 6 h after birth, and early addition of human milk fortifiers was implemented in 2015 for infants born < 26 weeks gestation. This before-and-after study evaluated growth and neurodevelopmental outcomes in infants born between 2012–2013 (before-nutrition-bundle, BNB) and 2016–2017 (after-nutrition-bundle, ANB). Results: A total of 145 infants were included in the study. Infants in the ANB group (n = 73) were smaller (birthweight and gestational age), and there were more male infants and multiples included compared to the BNB group (n = 72). Enteral feeds and fortifiers started earlier in the ANB group. Growth velocity and weight z-score changes were similar in both groups during NICU stay and post-discharge. Systemic steroid use, but not cohort, was linked to lower Bayley scores across all domains. Conclusions: Implementing a nutrition-care bundle was not consistently associated with improved weight gain and neurodevelopmental outcomes in the micro-preterm infant population, possibly due to ongoing high-quality nutritional care by the clinical team. Full article
(This article belongs to the Special Issue Care and Outcome of the Extreme Preterm Infant)
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