Effects of advanced maternal age and race/ethnicity on placental weight and placental weight/birthweight ratio in very low birthweight infants.

To study the association of advanced maternal age (AMA) and race/ethnicity on placental pathology in very low birthweight (VLBW) infants. Retrospective analysis of placental pathology of inborn singleton VLBW infants from a regional level 3 NICU between July, 2002 and June, 2009. Subjects were stratified by age and race/ethnicity. Statistical analysis included One-way ANOVA, Chi Square and multivariable analyses. A total of 739 mother/infant dyads were included. AMA was associated with a decrease in placental weight and placental weight/birthweight ratio. Black/Non-Hispanic mothers ≥35 had a lower placental weight (p = 0.01) and lower placental weight/birth weight ratio (z-score, -0.45 ± 0.71 vs -0.04 ± 1.1, p = 0.01) compared to Black/Non-Hispanic mothers <35 years of age. After controlling for gestational age, race/ethnicity, maternal diabetes, maternal smoking, maternal hypertension and clinical chorioamnionitis, AMA, but not race/ethnicity, remained independently associated with placental weight/birthweight ratio z score (full model r(2) = 0.22, p < 0.01). In our study sample of VLBW infants, placental weight and placental weight/birthweight ratio were lower in mothers of advanced maternal age compared to mothers <35 years of age. Our data suggest that maternal age affects placentation in VLBW infants, which could influence maternal and neonatal outcomes.

Oxygen saturation and work of breathing indices in preterm infants with bronchopulmonary dysplasia compared to healthy preterm infants at discharge.

BACKGROUND: Thoracoabdominal asynchrony (TAA) is commonly seen in preterm infants. Respiratory inductive plethysmography (RIP) is a noninvasive way to objectively assess work of breathing (WOB) indices. The impact of bronchopulmonary dysplasia (BPD) on TAA at discharge has not been established. The aim of this study is to compare WOB indices in premature infants with a diagnosis of BPD to premature infants without a diagnosis of BPD at discharge. METHODS: A prospective, observational study of premature infants (<32 weeks gestation) at discharge during quiet breathing in the supine position. RIP noninvasively measured WOB indices. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. RESULTS: This study included thirty-one infants with BPD and thirty-four infants without BPD. Infants diagnosed with BPD had increased phase angle [BPD Φ = 73 . 90 (8.2) vs NoBPD Φ = 52.6 (8.2), p = 0.039]. Infants diagnosed with BPD had decreased saturations [BPD SpO2 = 96% (0.4) vs NoBPD Sp02 98% (0.3), p=<0.001], increased time with saturations less than 85% [BPD % =2.74 (0.7) vs NoBPD % =0.91 (0.4), p = .018], and increased time with saturations less than 80% [BPD % =1.57 (0.5) vs NoBPD % =0.52 (0.3), p = 0.045]. There was no difference in heart rate or breaths per minute for infants with BPD versus controls. CONCLUSION: Premature infants with BPD demonstrated increased TAA and had lower saturations compared to infants without BPD at discharge despite being chronologically older and being discharged at an older corrected gestational age. The impact of BPD on breathing patterns persists at discharge and suggests these patients may have residual lung and/or respiratory muscle dysfunction.

The impact of kangaroo mother care on work of breathing and oxygen saturation in very low birth weight infants with respiratory insufficiency.

BACKGROUND: Kangaroo mother care (KMC) is defined as prolonged skin to skin care between a mother and infant with the infant lying in prone position on mom's chest. KMC decreases morbidity and mortality and promotes physiologic stability. The aim of this study is to measure work of breathing (WOB) during KMC in very low birth weight (VLBW) infants on non-invasive respiratory support. METHODS: A prospective observational pilot study was conducted comparing WOB indices during standard care (SC) and KMC. Respiratory inductive plethysmography (RIP) measured WOB indices non-invasively: phase angle and labored breathing index. VLBW infants who were stable on non-invasive respiratory support were randomized to receive RIP measurements during KMC or during SC first. Summary statistics and mixed linear models were used to compare WOB and vital signs. RESULTS: A total of 32 infants were consented for the study, data collection and analysis was completed on 28 infants. There were no significant differences in mean phase angle during KMC or SC (73.5±4.6 SE deg vs 66.8±3.9 SE deg, p = 0.25). No differences in WOB and vital signs were detected. Controlling for respiratory support or randomization/first location did not change the results. CONCLUSION: In this pilot cohort, infants demonstrated no differences in work of breathing indices or oxygen saturation during KMC or SC while receiving non-invasive respiratory support. KMC appears to be safe and well tolerated with no worsened WOB. Larger studies should be performed to confirm our findings.

Constructing a relevant decision aid for parents of children with bronchopulmonary dysplasia.

BACKGROUND: To develop and test a decision aid for counseling parents of children with bronchopulmonary dysplasia (BPD).Local problem:Parental education about complex conditions is not standardized and communication and understanding may not be adequate. METHODS: Semi-structured interviews were conducted with 33 neonatal clinicians and 12 parents of children with BPD using a qualitative research design. The interviews were used to identify education topics that were felt to be important in BPD education. These topics were then used to create a visual decision aid to be used in counseling sessions with parents. The decision aid was then used in mock counseling sessions with 15 'experienced' participants and 7 'naïve' participants to assess its efficacy. The participants completed a pre and post test to assess change in knowledge as well as an 11-question Likert style acceptability survey. INTERVENTION: Implementation of a decision aid while educating parents about BPD. RESULTS: Topics identified during the interviews were used to create eight educational cards which included pictures, pictographs and statistics. Overall, participants thought the decision aid contained an appropriate amount of information, were easy to understand and improved their knowledge about BPD. Testing demonstrated a significant increase in knowledge in both the 'experienced' (P<0.0001) and 'naïve' group (P=0.0064). CONCLUSION: A decision aid for parents of children with BPD may improve understanding of the condition and help facilitate communication between parents and doctors.

Communicating with parents of premature infants: who is the informant?

OBJECTIVES: To determine what sources of information are most helpful for neonatal intensive care unit (NICU) parents, who provides NICU parents with the information, and also what expectations parents have regarding obtaining information. STUDY DESIGN: A 19-item questionnaire was given to the parents of infants 32 weeks or younger prior to discharge from the NICU. RESULTS: Out of the 101 parents who consented, almost all of the parents (96%) felt that 'the medical team gave them the information they needed about their baby' and that the 'neonatologist did a good job of communicating' with them (91%). However, the nurse was chosen as 'the person who spent the most time explaining the baby's condition, 'the best source of information,' and the person who told them 'about important changes in their baby's condition' (P<0.01). CONCLUSION: Although the neonatologist's role in parent education is satisfactory, the parents identified the nurses as the primary source of information.

Increased monocytes and bands following a red blood cell transfusion.

OBJECTIVE: The objective of this study is to analyze the white blood cell changes that occur after a transfusion of red blood cells in order to identify a subclinical inflammatory response in neonates. STUDY DESIGN: Retrospective analysis of infants who received a red blood cell transfusion in an intensive care nursery. White blood cell results within 24 h pre- to 48 h post-transfusion were collected and analyzed. Statistical analysis included ANOVA, T-test, Mann-Whitney U test, Pearson's correlation and multivariable linear regression. RESULT: Monocytes (P=0.02) and bands (P=0.035) were increased post-transfusion. There were no differences in monocytes (P=0.46) or bands (P=0.56) between groups who did or did not have blood cultures obtained. There was no difference in monocytes between groups who did or did not have sepsis (P=0.88). CONCLUSION: We identified an elevation in monocytes and bands in the 48 h following a transfusion in premature infants. Our findings support a possible pro-inflammatory response related to transfusion of red blood cells.

Use of neonatal simulation models to assess competency in bag-mask ventilation.

OBJECTIVE: Providing adequate bag-mask ventilation (BMV) is an essential skill for neonatal resuscitation. Often this skill is learned using simulation manikins. Currently, there is no means of measuring the adequacy of ventilation in simulated scenarios. Thus, it is not possible to ascertain proficiency. The first aim of this study was to measure the pressure generated during BMV as performed by providers with different skill levels and measure the impact of different feedback mechanisms. The second aim was to measure the pressure volume characteristics of two neonatal manikins to see how closely they reflect newborn lung mechanics. STUDY DESIGN: In Phase I to achieve the first aim, we evaluated BMV skills in different level providers including residents (n=5), fellows (n=5), neonatal nurse practitioners (n=5) and neonatologists (n=5). Each provider was required to provide BMV for 2-min epochs on the SimNewB (Laerdal), which had been instrumented to measure pressure-volume characteristics. In sequential 2-min epochs, providers were given different feedback including chest-wall movement alone compared to manometer plus chest-wall movement or chest-wall movement plus manometer plus laptop lung volume depiction. In Phase II of the study we measured pressure-volume characteristics in instrumented versions of the SimNewB (Laerdal) and NeoNatalie (Laerdal). RESULTS: In Phase I, all providers are compared with the neonatologists. All measurements of tidal volume (Vt) are below the desired 5 ml kg(-1). The greatest difference in Vt between the neonatologists and other providers occurs when only chest-wall movement is provided. A linear relationship is noted between Vt and PIP for both SimNewB and NeoNatalie. The compliance curves are not 'S-shaped' and are different between the two models (P<0.001). CONCLUSION: Phase I of this study demonstrates that the SimNewB with the feedback of chest-wall movement alone was the best method of distinguishing experienced from inexperienced providers during simulated BMV. Therefore this is likely to be the best method to ascertain proficiency. Phase II of the study shows that the currently available neonatal simulation manikins do not have pressure-volume characteristics that are reflective of newborn lung mechanics, which can result in suboptimal training.

Instability of delay classification and determination of early intervention eligibility in the first two years of life.

The purpose of this study was to determine the effectiveness of the Bayley Scales of Infant Development, Third Edition (Bayley-III) to track development and classify delays in low- and high-risk infants across the first two years of life. We assessed cognitive, language, and motor development in 24 low-risk full-term and 30 high-risk preterm infants via seven assessments performed between 3 and 24 months corrected age. The Bayley-III resulted in highly unstable delay classifications, low sensitivities, and poor positive predictive values across time. The results highlight that early intervention professionals, researchers, and policy makers should: (1) emphasize clinical opinion and prevalence of risk factors rather than standardized assessment findings when classifying delays and determining eligibility for services, and (2) develop more effective developmental assessments for infants and young children.

Work of breathing indices in infants with respiratory insufficiency receiving high-flow nasal cannula and nasal continuous positive airway pressure.

OBJECTIVE: To compare work of breathing (WOB) indices between two nCPAP settings and two levels of HFNC in a crossover study. STUDY DESIGN: Infants with a CGA 28-40 weeks, baseline of HFNC 3-5 lpm or nCPAP 5-6 cmH2O and fraction of inspired oxygen ≤40% were eligible. WOB was analyzed using respiratory inductive plethysmography (RIP) for each of the four modalities: HFNC 3 and 5 lpm, nCPAP 5 and 6 cmH2O. N=20; Study weight 1516 g (±40 g). RESULT: Approximately 12,000 breaths were analyzed indicating a high degree of asynchronous breathing and elevated WOB indices at all four levels of support. Phase angle values (means) (P<0.01): HFNC 3 lpm (114.7°), HFNC 5 lpm (96.7°), nCPAP 5 cmH2O (87.2°), nCPAP 6 cmH2O (80.5°). The mean phase relation of total breath (PhRTB) (means) (P<0.01): HFNC 3 lpm (63.2%), HFNC 5 lpm (55.3%), nCPAP 5 cmH2O (49.3%), nCPAP 6 cmH2O (48.0%). The relative labored breathing index (LBI) (means) (P≤0.001): HFNC 3 lpm (1.39), HFNC 5 lpm (1.31), nCPAP 5 cmH2O (1.29), nCPAP 6 cmH2O (1.26). Eighty-two percent of the study subjects-respiratory mode combinations displayed clustering, in which a proportion of breaths either occurred predominantly out-of-phase (relative asynchrony) or in-phase (relative synchrony). CONCLUSION: In this study, WOB indices were statistically different, yet clinically similar in that they were elevated with respect to normal values. These infants with mild-to-moderate respiratory insufficiency demonstrate a meaningful elevation in WOB indices and continue to require non-invasive respiratory support. Patient variability exists with regard to biphasic clustered breathing patterns and the level of supplemental fraction of inspired oxygen ≤40% alone does not provide guidance to the optimal matching of WOB indices and non-invasive respiratory support.

Is a small platelet mass associated with intraventricular hemorrhage in very low-birth-weight infants?

OBJECTIVE: We sought to determine whether, among very low-birth-weight (VLBW) neonates, the platelet mass was associated with common perinatal factors, and whether a low platelet mass in the first days following birth was associated with a higher incidence and/or severity of intraventricular hemorrhage (IVH). STUDY DESIGN: This was a cross-sectional, retrospective cohort analysis of VLBW infants admitted to a level 3 neonatal intensive care unit from June 2003 to July 2006, n=408. Platelet mass was calculated and recorded on the day of birth and for 2 consecutive days thereafter. All neonates had a screening cranial sonogram on day 4 of life. Statistical analysis included analysis of variance and Mann-Whitney U-test. RESULT: Neonates born to mothers with pre-eclampsia had a smaller platelet mass (1921 fl/nl ± 603 vs 2297 fl/nl ± 747; P<0.01). The same was found among neonates with intrauterine growth restriction (IUGR). In contrast, neonates born after histological chorioamnionitis had a larger platelet mass (2400 fl/nl ± 749 vs 2036 fl/nl ± 674; P<0.01). No effect of platelet mass, measured on the day of birth, was observed related the outcomes of IVH, severe IVH or death. However, those with a platelet mass <10th percentile on the 2 subsequent days following birth were more likely to have severe IVH or death. CONCLUSION: Among VLBW neonates, pre-eclampsia and IUGR are associated with a lower platelet mass, owing to their effect on platelet count. Histological chorioamnionits is associated with a larger platelet mass. A mass <10th percentile on the days following birth was associated with severe IVH and/or death, but it remains unclear whether this is a cause of, or an effect of, the IVH.

Reduced mortality and increased BPD with histological chorioamnionitis and leukocytosis in very-low-birth-weight infants.

OBJECTIVE: To investigate the association between leukocytosis, mortality and bronchopulmonary dysplasia (BPD) in very-low-birth-weight infants (VLBW) born to mothers with histological chorioamnionitis. STUDY DESIGN: A retrospective cohort study from a single level 3 neonatal intensive care unit. The study sample included infants born to mothers with histological chorioamnionitis (n=252). Total white blood cells (WBCs) after birth were measured. Leukocytosis was defined as a total WBC count >30 000 per mm(3) in the first 2 days of life. Outcomes investigated included BPD and death. Both unadjusted and multivariable analyses were carried out. RESULT: After controlling for potential confounding variables, infants who developed a leukocytosis after birth had increased odds of BPD (4.6, 95% confidence interval (95% CI): 2.0 to 10.3), but decreased odds of death (0.3, 95% CI: 0.1 to 0.90). CONCLUSION: In our population of VLBW infants born to mothers with histological chorioamnionitis, leukocytosis after birth is associated with a decrease in mortality but an increase in BPD.

Hematologic effects of placental pathology on very low birthweight infants born to mothers with preeclampsia.

OBJECTIVE: To investigate the effect of placental pathology on neonatal neutrophils, platelets, hematocrit and nucleated red blood cells in very low birthweight (VLBW) infants born to mothers with preeclampsia. STUDY DESIGN: Retrospective cohort study of infants with birthweight < 1500 g born to mothers with preeclampsia from july, 2002 to july, 2006 at a single level III neonatal intensive care unit. Placental pathology was reviewed for the presence of placental infarction and vasculopathy. Hematologic parameters from day of life 0, 1 and 2 were obtained. Statistical analysis included repeated-measures analysis of variance and multivariable analysis using logistic regression. RESULT: The study sample included 203 infants with estimated gestational age of 28+/-3 weeks; 45% had placental infarctions and 26% placental vasculopathy. Infants with neutropenia and thrombocytopenia did not have an increased occurrence of placental infarction or maternal vasculopathy but were more likely to be of small gestational age (SGA) and of lower gestational age compared with infants without neutropenia or thrombocytopenia. After multivariable analysis, gestational age and SGA remained associated with both neutropenia and thrombocytopenia whereas placental infarction and vasculopathy did not remain in the models. CONCLUSION: In our population of VLBW infants born to mothers with preeclampsia, placental pathology was common. There was no association of placental infarction or vasculopathy with neonatal neutropenia and thrombocytopenia. The data suggest that neonatal hematologic effects of maternal preeclampsia, if related to the placenta, are associated with factors other than placental histology.