Health Care in Premature Infants

A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Global and Public Health".

Deadline for manuscript submissions: closed (15 November 2021) | Viewed by 48273

Special Issue Editor

Department of Newborn & Developmental Medicine, Sunnybrook Health Sciences Centre, Department of Paediatrics, University of Toronto, Toronto, ON M5A 1B2, Canada
Interests: neonatal care and neurodevelopmental outcomes; clinical trials; breastfeeding in the preterm population; breast milk enhancement
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Special Issue Information

Dear Colleagues,

This Special Issue’s primary focus is on the spectrum of care for the extreme preterm infant, with a special focus on the most current management approaches for these vulnerable infants.

This Special Issue will highlight the current approaches in (1) resuscitative measures; (2) the respiratory management of these small infants to minimize chronic lung disorders; (3) the management of patent ductus arteriosus; and (4) brain protection to minimize severe intracranial disorders. It will also highlight the current developmental challenges faced by these most vulnerable infants.

Preterm birth remains a major health problem worldwide. At least 15 million infants are born preterm, with a significant number of those born extremely preterm, i.e., at 28 weeks gestation and under. Preterm birth is associated with a significant cost to health care systems, and families with a preterm infant can experience considerable psychological and financial hardship.

For these reasons, it is important for us to continue to study and provide the best care possible so that the smallest of infants can become functional members of today’s society.

Dr. Elizabeth Asztalos
Guest Editor

Manuscript Submission Information

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Keywords

  • extreme preterm
  • respiratory management
  • patent ductus arteriosus
  • brain protection
  • developmental morbidities
  • ethics of care

Published Papers (13 papers)

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Editorial

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2 pages, 143 KiB  
Editorial
Optimizing Care for the Preterm Infant
Children 2022, 9(6), 778; https://doi.org/10.3390/children9060778 - 25 May 2022
Cited by 1 | Viewed by 1070
Abstract
Preterm birth remains an ongoing global health issue with over 15 million infants born preterm annually [...] Full article
(This article belongs to the Special Issue Health Care in Premature Infants)

Research

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13 pages, 918 KiB  
Article
Association of Weight Changes by Three Days after Birth and Mortality and/or Severe Neurological Injury in Preterm Infants < 29 Weeks Gestational Age: A Multicenter Cohort Study
Children 2022, 9(2), 276; https://doi.org/10.3390/children9020276 - 17 Feb 2022
Cited by 4 | Viewed by 1331
Abstract
Objective: This study aimed to determine the range of weight loss, at 3 days postnatal age, associated with the lowest risk of mortality/short-term morbidity in preterm infants <29 weeks gestational age (GA). Study design: This multicenter retrospective cohort study employed data from the [...] Read more.
Objective: This study aimed to determine the range of weight loss, at 3 days postnatal age, associated with the lowest risk of mortality/short-term morbidity in preterm infants <29 weeks gestational age (GA). Study design: This multicenter retrospective cohort study employed data from the Canadian Neonatal Network database. The primary outcome was a composite of mortality and/or severe neurological injury. Multivariable quadratic and linear regression models which adjusted for potential confounders were built. Results: A total of 9275 preterm infants (median GA 26, IQR 25, 28 weeks) were included. The optimal weight change range at day three, after adjustment for potential confounders for the primary outcomes, was −15 to −8.9%. Conclusions: There is a ‘U’-shaped relationship between weight change from birth to day three and mortality and/or severe neurological injury. Interventional studies, which target weight loss within the range found in this study and evaluate the impact on neonatal outcomes, are needed to corroborate our findings. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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15 pages, 1117 KiB  
Article
Consequences of Prematurity on Cortisol Regulation and Adjustment Difficulties: A 9-Year Longitudinal Study
Children 2022, 9(1), 9; https://doi.org/10.3390/children9010009 - 24 Dec 2021
Cited by 2 | Viewed by 2600
Abstract
A preterm birth represents a stressful event having potentially negative long-term consequences. Thirty-three children born preterm (<33 weeks gestational age) and eleven full-term children participated in a nine-year longitudinal study. Perinatal Risk Inventory (PERI) was used at birth to assess the perinatal stress. [...] Read more.
A preterm birth represents a stressful event having potentially negative long-term consequences. Thirty-three children born preterm (<33 weeks gestational age) and eleven full-term children participated in a nine-year longitudinal study. Perinatal Risk Inventory (PERI) was used at birth to assess the perinatal stress. Salivary cortisol, collected four times a day over two consecutive days, was measured with radioimmunoassay technique at six months and nine years to assess the hypothalamic-pituitary-adrenal (HPA) axis. Mothers reported post-traumatic symptoms on a self-report questionnaire 12 months after their child’s birth and children’s adjustment problems at 9 years of child age on the Child Behavior Checklist. Results showed a significant difference in cortisol regulation at nine years between preterm and full-term children but no differences in adjustment problems. Whereas biological factors (i.e., PERI, cortisol regulation at six months) explained cortisol at nine years, maternal post-traumatic symptoms were predictive of adjustment problems in their child. In conclusion, very preterm birth has some long-term consequences on the HPA-axis regulation at nine years. Although cortisol regulation is mostly influenced by biological factors, the presence of maternal post-traumatic symptoms predicts the manifestation of adjustment problems in both groups. This shows the importance of maternal psychological well-being for child development. Further research is needed to understand the exact consequences of premature birth on cortisol regulation and the implication for the child’s development and health. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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13 pages, 597 KiB  
Article
Impact of a “Brain Protection Bundle” in Reducing Severe Intraventricular Hemorrhage in Preterm Infants <30 Weeks GA: A Retrospective Single Centre Study
Children 2021, 8(11), 983; https://doi.org/10.3390/children8110983 - 31 Oct 2021
Cited by 6 | Viewed by 2627
Abstract
Background: despite advances in perinatal care, periventricular/intraventricular hemorrhage (IVH) continues to remain high in neonatal intensive care units (NICUs) worldwide. Studies have demonstrated the benefits of implementing interventions during the antenatal period, stabilization after birth (golden hour management) and postnatally in the first [...] Read more.
Background: despite advances in perinatal care, periventricular/intraventricular hemorrhage (IVH) continues to remain high in neonatal intensive care units (NICUs) worldwide. Studies have demonstrated the benefits of implementing interventions during the antenatal period, stabilization after birth (golden hour management) and postnatally in the first 72 h to reduce the incidence of IVH. Objective: to compare the incidence of severe intraventricular hemorrhage (IVH ≥ Grade III) before and after implementation of a “brain protection bundle” in preterm infants <30 weeks GA. Study design: a pre- and post-implementation retrospective cohort study to compare the incidence of severe IVH following execution of a “brain protection bundle for the first 72 h from 2015 to 2018. Demographics, management practices at birth and in the NICU, cranial ultrasound results and short-term morbidities were compared. Results: a total of 189 and 215 infants were included in the pre- and post-implementation phase, respectively. No difference in the incidence of severe IVH (6.9% vs. 9.8%, p = 0.37) was observed on the first cranial scan performed after 72 h of age. Conclusion: the implementation of a “brain protection bundle” was not effective in reducing the incidence of severe IVH within the first 72 h of life in our centre. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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13 pages, 1116 KiB  
Article
Risk Factors of Growth Retardation and Developmental Deficits in Very Preterm Infants in a German Tertiary Neonatal Unit
Children 2021, 8(5), 394; https://doi.org/10.3390/children8050394 - 14 May 2021
Cited by 3 | Viewed by 2019
Abstract
Over the last two decades, improvements in perinatology have led to increased survival rates of preterm infants. A large number of studies and meta-analyses have investigated of preterm infants and/or the influence of developmental care. However, the combined influence of the most frequent [...] Read more.
Over the last two decades, improvements in perinatology have led to increased survival rates of preterm infants. A large number of studies and meta-analyses have investigated of preterm infants and/or the influence of developmental care. However, the combined influence of the most frequent risk factors and developmental care on the long-term somatic, motor, and cognitive outcome of preterm infants remains unclear. This retrospective, single-center cohort study includes 256 children treated in a tertiary neonatal intensive care unit in Rostock, Germany, between 2008 and 2013. Follow-up examinations (somatic, psychomotor, and mental development) were performed at (corrected) 24 months using Bayley Scales of Infant Development II (BSID-II). Developmental care was carried out according to the legal framework and national guidelines (physiotherapy and/or early education). Bronchopulmonary dysplasia (BPD) and an exclusive formula feeding showed a 2.8–4.6-fold higher risk (95% Confidence Interval: Mental Developmental Index 1.73–7.58; Psychomotor Developmental Index 1.44–14.54; body length 1.20–6.41) for developmental deficits (mental and psychomotor developmental index; body length). Developmental care after discharge according to national guidelines did not prevent this. Since this is a retrospective pilot study, no recommendations can be made based on this analysis. Therefore, future research should evaluate whether standard developmental care should be extended by tailored measures depending on individual risk factors. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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11 pages, 463 KiB  
Article
Evaluating the Effect of a Neonatal Care Bundle for the Prevention of Intraventricular Hemorrhage in Preterm Infants
Children 2021, 8(4), 257; https://doi.org/10.3390/children8040257 - 25 Mar 2021
Cited by 10 | Viewed by 5774
Abstract
Germinal matrix intraventricular hemorrhage (IVH) remains a severe and common complication in preterm infants. A neonatal care bundle (NCB) was implemented as an in-house guideline at a tertiary neonatal intensive care unit to reduce the incidence of IVH in preterm infants. The NCB [...] Read more.
Germinal matrix intraventricular hemorrhage (IVH) remains a severe and common complication in preterm infants. A neonatal care bundle (NCB) was implemented as an in-house guideline at a tertiary neonatal intensive care unit to reduce the incidence of IVH in preterm infants. The NCB was applied either to preterm infants <1250 g birth weight or <30 weeks gestational age or both, and standardized patient positioning, nursing care, and medical procedures within the first week of life. A retrospective cohort study was performed to investigate the effect of the NCB and other known risk factors on the occurrence and severity of IVH. Data from 229 preterm infants were analyzed. The rate of IVH was 26.2% before and 27.1% after implementing the NCB. The NCB was associated neither with reducing the overall rate of IVH (odds ratio (OR) 1.02; 95% confidence interval (CI) 0.57–1.84; p = 0.94) nor with severe IVH (OR 1.0; 95% CI 0.67–1.55; p = 0.92). After adjustment for group differences and other influencing factors, amnion infection syndrome and early intubation were associated with an increased risk for IVH. An NCB focusing on patient positioning, nursing care, and medical interventions had no impact on IVH in preterm infants. Known risk factors for IVH were confirmed. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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Review

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18 pages, 379 KiB  
Review
Assessment and Management of Pain in Preterm Infants: A Practice Update
Children 2022, 9(2), 244; https://doi.org/10.3390/children9020244 - 11 Feb 2022
Cited by 24 | Viewed by 6341
Abstract
Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive [...] Read more.
Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
12 pages, 286 KiB  
Review
Delivery Room Care for Premature Infants Born after Less than 25 Weeks’ Gestation—A Narrative Review
Children 2021, 8(10), 882; https://doi.org/10.3390/children8100882 - 02 Oct 2021
Cited by 5 | Viewed by 2178
Abstract
Premature infants born after less than 25 weeks’ gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks’ gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. [...] Read more.
Premature infants born after less than 25 weeks’ gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks’ gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks’ gestation at the threshold of viability. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
14 pages, 1592 KiB  
Review
Neonates with Maternal Colonization of Carbapenemase-Producing, Carbapenem-Resistant Enterobacteriaceae: A Mini-Review and a Suggested Guide for Preventing Neonatal Infection
Children 2021, 8(5), 399; https://doi.org/10.3390/children8050399 - 15 May 2021
Cited by 7 | Viewed by 2798
Abstract
Carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) are highly drug-resistant Gram-negative bacteria. They include New Delhi metallo-ß-lactamase (NDM)-producing carbapenemase (50.4% of all species in Ontario). Antibiotic challenges for resistant bacteria in neonates pose challenges of unknown dosing and side effects. We report two antenatally diagnosed CP-CRE [...] Read more.
Carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) are highly drug-resistant Gram-negative bacteria. They include New Delhi metallo-ß-lactamase (NDM)-producing carbapenemase (50.4% of all species in Ontario). Antibiotic challenges for resistant bacteria in neonates pose challenges of unknown dosing and side effects. We report two antenatally diagnosed CP-CRE colonization scenarios with the NDM 1 gene. The case involves extreme preterm twins who had worsening respiratory distress at birth requiring ventilator support, with the first twin also having cardiovascular instability. They were screened for CP-CRE, and a polymyxin antibiotic commenced. In the delivery room, neonatal intensive care unit (NICU) and the follow-up clinic, in collaboration with the interdisciplinary group, contact precautions and isolation procedures were instituted. None of the infants exhibited infection with CP-CRE. Consolidating knowledge with regard to CP-CRE and modifying human behavior associated with its spread can mitigate potential negative consequences. This relates to now and later, when travel and prolific human to human contact resumes, from endemic countries, after the current COVID-19 pandemic. Standardized efforts to curb the acquisition of this infection would be judicious given the challenges of treatment and continued emerging antibiotic resistance. Simple infection control measures involving contact precautions, staff education and parental cohorting can be useful and cost-effective in preventing transmission. Attention to NICU specific measures, including screening of at-risk mothers (invitro fertilization conception) and their probands, careful handling of breastmilk, judicious antibiotic choice and duration of treatment, is warranted. What does this study add? CP-CRE is a nosocomial infection with increasing incidence globally, and a serious threat to public health, making it likely that these cases will present with greater frequency to the NICU team. Only a few similar cases have been reported in the neonatal literature. Current published guidelines provide a framework for general hospital management. Still, they are not specific to the NICU experience and the need to manage the parents’ exposure and the infants. This article provides a holistic framework for managing confirmed or suspected cases of CP-CRE from the antenatal care through the NICU and into the follow-up clinic targeted at preventing or containing the spread of CP-CRE. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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31 pages, 474 KiB  
Review
Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants
Children 2021, 8(4), 298; https://doi.org/10.3390/children8040298 - 13 Apr 2021
Cited by 20 | Viewed by 10585
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review [...] Read more.
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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19 pages, 375 KiB  
Review
Neuroimaging at Term Equivalent Age: Is There Value for the Preterm Infant? A Narrative Summary
Children 2021, 8(3), 227; https://doi.org/10.3390/children8030227 - 16 Mar 2021
Cited by 2 | Viewed by 2215
Abstract
Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. [...] Read more.
Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
8 pages, 238 KiB  
Review
The E-Nurture Project: A Hybrid Virtual Neonatal Follow Up Model for 2021
Children 2021, 8(2), 139; https://doi.org/10.3390/children8020139 - 12 Feb 2021
Cited by 6 | Viewed by 1851
Abstract
Neonatal follow-up has long focused on a model of surveillance and identification of short-term outcomes. This model has long become outdated, with evidence documenting the need for longer follow-up with known school-based challenges and significant gaps in knowledge by educators. This article reviews [...] Read more.
Neonatal follow-up has long focused on a model of surveillance and identification of short-term outcomes. This model has long become outdated, with evidence documenting the need for longer follow-up with known school-based challenges and significant gaps in knowledge by educators. This article reviews the history of neonatal follow-up and demonstrates a novel approach to neonatal follow-up, built largely with a hybrid virtual platform, which then became essential with the declaration of the pandemic in 2020. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
6 pages, 188 KiB  
Review
Patent Ductus Arteriosus Clinical Trials: Lessons Learned and Future Directions
Children 2021, 8(1), 47; https://doi.org/10.3390/children8010047 - 15 Jan 2021
Cited by 11 | Viewed by 5042
Abstract
The identification of an optimal management strategy for the patent ductus arteriosus (PDA) in the context of extreme prematurity remains elusive. Observational studies have reported a persistent association between PDA and neonatal adverse outcomes, but by and large, no clinical trial, to date, [...] Read more.
The identification of an optimal management strategy for the patent ductus arteriosus (PDA) in the context of extreme prematurity remains elusive. Observational studies have reported a persistent association between PDA and neonatal adverse outcomes, but by and large, no clinical trial, to date, has demonstrated that treating a PDA results in a reduction of those morbidities. This discrepancy has led many to assume that the PDA is an innocent bystander in the physiological mechanisms responsible for such complications and a reluctance to actively pursue shunt elimination. It would be remiss to discount the volume of evidence available clearly documenting a strong association between longstanding PDA exposure and negative outcomes. There needs to be a radical change in the design, patient selection and possible outcome assessment in any further trials addressing the PDA. The purpose of this review is to explore the reasons that preclude existing clinical trials from definitively ascribing a causal relationship between PDA patency and adverse outcomes in the context of extreme prematurity, why previous studies have failed to demonstrate significant beneficial effects following PDA treatment and how future research may be conducted to allow us to draw concrete conclusions regarding the potential merits of ductal closure. Full article
(This article belongs to the Special Issue Health Care in Premature Infants)
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