Peritoneal dialysis in very low and extremely low birthweight infants: A pooled analysis

Background: Peritoneal dialysis (PD) represents an important therapeutic option in neonatal acute kidney injury (AKI), although evidence regarding its effects in preterm neonates remains unclear. The present study aims to evaluate the feasibility of PD in very low birthweight (VLBW) and extremely low birthweight (ELBW) infants and clarify the association of catheter choice with clinical outcomes. Methods: Medline, Scopus, Web of Science, Clinicaltrials.gov and CENTRAL databases were systematically searched from inception to 15 January 2021. Studies reporting individual participant data of VLBW and ELBW infants treated with PD were selected. Results: Overall, 20 studies were included comprising 101 patients. Catheter-related complications were significantly more frequent among ELBW infants (odds ratio: 5.18, 95% confidence intervals (CI): 1.23–29.09). After inverse probability treatment weighting, compared to drainage catheters, death risk was significantly lower with the use of PD (hazard ratio: 0.42, 95% CI: 0.19–0.90) but not vascular catheters (hazard ratio: 0.58, 95% CI: 0.28–1.20). Similarly, kidney function loss was significantly lower only with the implementation of PD catheters (hazard ratio: 0.44, 95% CI: 0.21–0.94). Conclusions: PD is a feasible kidney replacement therapy modality in VLBW and ELBW infants with AKI. The use of drainage catheters may be linked to significantly worse kidney recovery and overall survival rates, compared to PD catheters. Future cohorts should confirm the most appropriate catheter type and contribute to the standardisation of PD procedures.

Case Report: Treatment of Extremely Preterm Infants With Birthweight Below 300 g: Case Series

Reports on the birth of infants weighing <300 g are quite rare and little is known about the best practices in treating such micropreemies. Therefore, we report here on three cases of low birthweight infants weighing <300 g, of whom two infants survived. The birthweights and gestational ages were ranging 279–293 g and 22 + 6/7 – 23 + 6/7 weeks, respectively. All the infants had severe fetal growth restriction and prematurity. The infant in case 1 died of hepatic rupture, perhaps due to birth trauma, which emphasized the need for less invasive obstetric procedures including en caul delivery. The infant in case 2 managed to survive through severe prematurity secondary to hydrops fetalis. However, complications followed soon as tracheal granulation tissue was formed with neurodevelopmental impairment. The infant in case 3 was born recently and her clinical course was less remarkable without severe complications, despite having the least gestational age and birthweight among the three patients. The improved care protocols for extremely low birthweight infants over these years through experiential learning including that with cases 1 and 2 may have ensured the better outcome of case 3. Accumulating evidence and recording the experience of such cases with continuous constructive discussion can contribute to better outcomes and appropriate parental counseling for extremely small babies in the future.

Perinatal Outcomes of Fetuses and Infants Diagnosed with Trisomy 13 or Trisomy 18

Objectives: To identify factors associated with adverse prenatal, perinatal and postnatal outcomes, and determine the utilization medical care for fetuses & infants with trisomy 13 (T13) and trisomy (T18). Study Design: This population-based retrospective cohort study included all prenatal and postnatal diagnoses of T13 or T18 in the Greater Cincinnati area from 1/1/12-12/31/18. Overall survival, survival to hospital discharge, approach to medical management, and maternal, fetal and neonatal characteristics are analyzed. Results: 124 pregnancies (125 fetuses) were identified, which resulted in 72 liveborn infants. Male fetal sex and hydrops were associated with a higher rate of spontaneous loss. The median length of survival was 7 days (95% CI, 0-18 days) and 29 days (95% CI, 2-115 days), for infants with T13 and T18, respectively. Of the 27 infants who were alive at 1 month of age, 14 (52%) were alive at 1 year of age. Only the trisomy type, chosen goals of care (comfort care), and extremely low birthweight were associated with overall length of survival. A high degree of variability existed in the use of medical services, with 28% of infants undergoing at least one surgical procedure and some children requiring repeated (up to 29) or prolonged hospitalization (> 1 year). Conclusions: Although many infants with T13 or T18 did not survive past the first week of life, up to 25% of infants lived for more than one year. Length of survival for an individual infant cannot be easily predicted, and surviving infants have high health care utilization throughout their lifespan.

Vascular Endothelial Function Assessed by Flow-Mediated Vasodilatation in Young Adults Born Very Preterm or With Extremely Low Birthweight: A Regional Cohort Study

Background: Preterm birth and low birthweight have been associated with increased risk of cardiovascular disease in young adults. Endothelial dysfunction is established as an early marker for development of atherosclerotic cardiovascular disease. Previous studies of endothelial function in young adults born very preterm or with extremely low birthweight have, however, shown diverging results.Objective: We aimed to evaluate the risk of cardiovascular disease as measured by vascular endothelial function in young adults born very preterm (<29 weeks of gestation) or with extremely low birthweight (<1,000 g), compared with term-born controls.Methods: This study included 50 young adults born very preterm or with extremely low birthweight and 49 term-born controls born in Norway in the periods 1982–1985, 1991–1992, and 1999–2000 at mean age 28 (±6) years. The endothelial function was assessed by ultrasound measured flow-mediated dilatation (FMD) of the right brachial artery. The arterial diameter was measured at baseline, after release of 5 min of occlusion, and after sublingual administration of nitroglycerine. FMD was reported as absolute and percentage diameter change from baseline and relative to nitroglycerine-induced dilatation.Results: The participants were mainly normal weight non-smokers, without hypertension, diabetes, or established cardiovascular disease. The cases and controls had mean blood pressure 112/71 (SD 12/9) and 112/69 (SD 11/8) mmHg, body mass index 24.0 (SD 4.2) and 24.4 (SD 4.5) kg/m2, and HbA1c 32.7 (SD 2.5) and 33.0 (SD 2.6) mmol/mol, respectively. For both groups, 4 (8%) were smokers. Mean FMD for the adults born very preterm or with extremely low birthweight was 0.17 mm (95% CI 0.14, 0.21) vs. 0.24 mm (95% CI 0.20, 0.28) for the controls (p = 0.01), corresponding to a percentage increase of 5.4% (95% CI 4.2, 6.6) and 7.6% (95% CI 6.2, 8.9), respectively (p = 0.02). The FMD relative to maximal nitroglycerine-induced dilatation was 20% and 31%, respectively (p = 0.001).Conclusions: Young adults born very preterm or with extremely low birthweight have significantly lower FMD compared with the term-born controls suggesting an increased risk of cardiovascular disease.

Association between blood carboxyhemoglobin level and bronchopulmonary dysplasia in extremely low birthweight infants

Carboxyhemoglobin (CO-Hb) can be endogenously formed in the presence of oxidative stress and may be elevated in inflammatory lung disease. There is lack of evidence of its relationship with the development of bronchopulmonary dysplasia (BPD) in extremely low birthweight (ELBW) infants. The objective of the study is to evaluate the relationship between blood CO-Hb levels in the first 14 days of life (DOL) in ELBW infants and the development of BPD at 36 weeks postmenstrual age (PMA). This is a retrospective cohort study of 58 ELBW infants born at LAC-USC Medical Center between June 2015 and and June 2019 who survived to 36 weeks PMA. CO-Hb values were collected daily from DOL 1 to DOL 14. BPD definition using the recent 2019 NICHD criteria was used. Multivariate logistic regression was performed to determine the association between blood CO-Hb levels and BPD. Receiver operator curve was used to evaluate the ability of the median fraction of inspired oxygen (FiO2) level used at DOL 11–14 in discriminating absent to mild BPD versus moderate to severe BPD. 58 ELBW infants were included in the study. 24 (41%) were diagnosed with moderate to severe BPD, while 34 (59%) were diagnosed with no to mild BPD. Severity of BPD was fairly discriminated by FiO2 at DOL 11–14, but not with CO-Hb levels at any point within the first 14 DOL. The role and mechanism of CO-Hb production in this population need to be further studied.

Necrotising enterocolitis, late-onset sepsis and mortality after routine probiotic introduction in the UK

ObjectiveTo compare necrotising enterocolitis (NEC), late-onset sepsis (LOS), focal intestinal perforation (FIP) and mortality in infants from a single neonatal unit before and after probiotic introduction.DesignRetrospective review of infants <32 weeks admitted January 2009–December 2012 (no probiotic) and January 2013–December 2017 (routine probiotics). Infants included were admitted before day 3, and not transferred out before day 3. NEC, LOS and FIP were defined with standard definitions.Patients1061 infants were included, 509 preprobiotic and 552 postprobiotic. Median gestation, birth weight and antenatal steroid use did not differ, and proportions of extremely low birthweight infants were similar (37% and 41%).ResultsOverall unadjusted risk of NEC (9.2% (95% CI 7.1 to 12.1) vs 10.6% (95% CI 8.2 to 13.4), p=0.48), LOS (16.3% (95% CI 13.2 to 19.6) vs 14.1% (95% CI 11.5 to 17.4), p=0.37) and mortality (9.2% (95% CI 7.1 to 12.1) vs 9.7% (95% CI 7.6 to 12.6), p=0.76) did not differ, nor proportion of surgical NEC. In multiple logistic regression, accounting for gestation, birth weight, antenatal steroid, maternal milk, chorioamnionitis and sex, probiotic receipt was not significantly associated with NEC (adjusted OR (aOR) 1.08 (95% CI 0.71 to 1.68), p=0.73), LOS or mortality. In subgroup (645 infants) >28 weeks, aOR for NEC in the probiotic cohort was 0.42 (95% CI 0.2 to 0.99, p=0.047). FIP was more common in the probiotic cohort (OR 2.3 (95% CI 1.0 to 5.4), p=0.04), not significant in regression analysis (2.11 (95% CI 0.97 to 4.95), p=0.05).ConclusionsProbiotic use in this centre did not reduce overall mortality or rates of NEC, LOS or FIP but subgroup analysis identified NEC risk reduction in infants >28 weeks, and LOS reduction <28 weeks.