Impact of sex, race, and social determinants of health on neonatal outcomes.

Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.

Sex-Specific Differences in Nutrient Intake in Late Preterm Infants.

Challenging the assumption of uniform nutritional needs in preterm feeding, this study identifies crucial sex-specific disparities in formula milk intake and growth among late preterm infants. Premature infants have difficulty regulating their oral intake during feeds, which is why clinicians prescribe feeding volume, calories, and protein via the nasogastric route. However, premature male and female infants have different body compositions at birth, and, subsequently, there is no evidence to suggest that male and female preterm infants differ in their nutritional consumption once they begin feeding ad libitum. This study investigates whether there are any differences in the volume and nutrient intake between the sexes when fed formula ad libitum. METHODS: The study involved a retrospective analysis of preterm infants admitted to the NICU and evaluated between 34 0/7 and 36 6/7 weeks of corrected gestation. Late preterm infants appropriate for gestational age who were spontaneously fed formula milk ad-lib and free of any respiratory support for at least two days were included. The study excluded infants with short gut syndrome, severe chromosomal anomalies, or congenital heart conditions. We included 85 male and 85 female infants in this study. The data collected included sex, gestational age, birth weight, anthropometric data at birth, maternal data, nutritional intake, and neonatal morbidity. RESULTS: This study found that female infants consumed more volume, protein, and calories than male infants. The mean formula intake in female and male infants was 145.5 ± 20.8 mL/kg/d and 135.3 ± 19.3 mL/kg/d, respectively, with p = 0.002. However, ad-lib feeding duration was not different between the sexes. Growth velocity was also higher in female infants. CONCLUSIONS: This study is the first to demonstrate differences in formula milk intake among late preterm infants fed ad libitum. Additional research is needed to confirm our findings and understand sex-specific differences in neonatal nutrition in extremely early preterm infants.

Association between Weight for Length and the Severity of Respiratory Morbidity in Preterm Infants.

Association Between Weight for Length and the Severity of Respiratory Morbidity in Preterm Infants. OBJECTIVE: To determine whether higher weight-to-length z-scores after 32 weeks of gestation are associated with higher pulmonary scores (PSs) in preterm infants requiring respiratory support using a prospective observational study. METHODS: Infants born at <30 weeks, with a post-menstrual age (PMA) of 30-33 weeks, were enrolled. The infant's weight, length, and head circumference were measured weekly. Data on calories/kg/d, protein g/kg/d, weight-for-length percentiles, z-scores, and BMI at 33 through 40 weeks PMA were collected. The PS was calculated. RESULTS: We analyzed 91 infants. The mean gestational age was 26.9 ± 1.7 weeks. The mean birthweight was 0.898 ± 0.238 kgs. They were predominantly African American (81.3%) and girls (56%). Postnatal steroids were administered in 26.4% of the infants. The mean duration of invasive ventilation was 19.23 days ± 28.30 days. There was a significant association between the PS and W/L z-score (p < 0.0001). For every one-unit increase in W/L z-score, the PS increased by 0.063. There was a significant association between the PS and W/L percentile (p = 0.0017), as well as BMI (p ≤ 0.0001). For every unit increase in W/L percentile, the PS increased by 0.002, and for a unit increase in BMI, the PS increased by 0.04. The association remained significant after postnatal steroid use, sex, and corrected and birth gestational ages were included in the regression analysis. Nutrition did not affect the anthropometric measurements. CONCLUSIONS: Our study is the first to demonstrate that a higher BMI and W/L may adversely affect the respiratory severity in preterm infants. Studies with larger sample sizes are needed to confirm our findings.

Sex differences in preterm nutrition and growth: the evidence from human milk associated studies.

Sexual dimorphism of the fetus manifests itself even during pregnancy. Preterm births are more common in pregnancies with male fetuses. Intrauterine and postnatal growth nomograms are sex-specific. The human milk composition in term infants appears to be sex-specific. Early nutrition has sex-specific effects and neurodevelopmental outcomes. A large same-sex twin study suggests that a mother's own milk (MOM) provides sex-specific growth advantages probably related to the calibration of a mother's milk based on her newborn's sex. Formula composition does not vary with infant sex, which may be one reason why body composition data favors the use of MOM over formula. However, given the lack of data on this subject, we need more detailed information on how the sex-specific micronutrients in MOM influence infant well-being. We also need more information to ascertain the sex differences in infants' macronutrient requirements, such as whether preterm females have higher fat requirements and preterm males have higher protein requirements for optimal growth and neurodevelopmental outcomes. This information may also influence milk banking and the use of donor human milk (DBM). Further research may help us determine if we should provide sex-specific DBM to those preterm infants who cannot get their MOM.

Hypochloremia Secondary to Diuretics in Preterm Infants: Should Clinicians Pay Close Attention?

Diuretic therapy, commonly used in the newborn intensive care unit, is associated with a variety of electrolyte abnormalities such as hyponatremia, hypokalemia, and hypochloremia. Hypochloremia, often ignored, is associated with significant morbidities and increased mortality in infants and adults. Clinicians respond in a reflex manner to hyponatremia than to hypochloremia. Hypochloremia is associated with nephrocalcinosis, hypochloremic alkalosis, and poor growth. Besides, the diuretic resistance associated with hypochloremia makes maintaining chloride levels in the physiological range even more logical. Since sodium supplementation counters the renal absorption of calcium and lack of evidence for spironolactone role in diuretic therapy for bronchopulmonary dysplasia (BPD), alternate chloride supplements such as potassium or arginine chloride may need to be considered in the management of hypochloremia due to diuretic therapy. In this review, we have summarized the current literature on hypochloremia secondary to diuretics and suggested a pragmatic approach to hypochloremia in preterm infants.

Calorie intake is associated with weight gain during transition phase of nutrition in female extremely low birth weight infants.

We sought to determine whether there are sex-based differences in the requirements for calories or protein for optimal growth during the transition phase (TP) when an extremely low birth weight (ELBW) infant, defined as a preterm infant with a birth weight of < 1000 g, is progressing from parenteral to enteral feeds. A retrospective review of ELBW infants born from 2014 to 2016 was performed at a tertiary NICU. Infants with necrotizing enterocolitis, short bowel syndrome, or chromosomal anomalies were excluded. TP was defined as the period when the infant's enteral feeds were increased from 30 up to 120 ml/kg/day while weaning parenteral nutrition (PN). Effects of sex and protein-calorie intake on the change in growth parameters from the beginning to the end of TP were analyzed. Pre-TP growth percentiles and calorie and protein intake were similar in both sexes. There was a significant (r = 0.22, p = 0.026) correlation of total calorie intake with a change in weight percentiles (wt.pc) for the whole group, but on sex-specific analysis, this correlation was more robust and significant only in girls (r = 0.28, p = 0.015). Protein intake did not correlate with the changes in wt.pc in either sex. Despite a similar intake of calories and protein during the TP, we found a significant decrease in wt.pc only in girls. More extensive studies are needed to understand the sex-based differences in caloric needs and metabolic rate in ELBW infants.

Sex Differences in Nutrition, Growth, and Metabolism in Preterm Infants.

Biological differences between the sexes are apparent even from the early part of the pregnancy. The crown-rump length is larger in male fetuses compared to females in the first trimester. Placentae of male and female fetuses have different protein and gene expressions, especially in adverse conditions. Even within the intrauterine milieu, the same extracellular micro RNA may show upregulation in females and downregulation in male fetuses. There appears to be a natural survival advantage for females. Maternal glucocorticoids (GC) play an important role in fetal growth and organ maturation. However, excess glucocorticoids can not only affect growth but the response may be sex-specific and probably mediated through glucocorticoid receptors (GR) in the placenta. Mild pre-eclampsia and asthma are associated with normal growth pattern in males, but in female fetuses, they are associated with a slowing of growth rate without causing IUGR probably as an adaptive response for future adverse events. Thus, female fetuses survive while male fetuses exhibit IUGR, preterm delivery and even death in the face of another adverse event. It is thought that the maternal diet may not influence growth but may influence the programming for adult disease. There is growing evidence that maternal pre-pregnancy overweight or obesity status is directly associated with a higher risk of obesity in a male child, but not in a female child, at 1 year of age. It is observed that exposure to gestational diabetes is a risk factor for childhood overweight in boys but not in girls. It is fascinating that male and female fetuses respond differently to the same intrauterine environment, and this suggests a fundamental biological variation most likely at the cellular and molecular level.

Postnatal Growth Restriction Is Reduced If Birth Weight Is Used for Nutritional Calculations in ELBW Infants.

Since fluid and nutrition needs and delivery in ELBW infants are calculated based on their body weights, there could be a measurable difference in fluid, nutrition, and protein intake calculations based on birth weight (BW) or current weight of the infant, especially in the first two weeks of life. Theoretically, the use of current daily weight (CW) for calculations may result in decreased fluid, nutrition, and protein delivery as well as a cumulative protein deficit (cPD) over the first two weeks of life until the infant regains birth weight. However, there have been no clinical studies comparing the clinical and nutritional impact of these two strategies is unknown. Aims. The aims of this study were to quantify the amount of protein intake and to compare growth parameters at hospital discharge (as measured by discharge weight and head circumference percentiles) when using two different methodologies (BW vesrsus current daily weight until BW is regained) for calculating fluid and protein intake in the first two weeks after birth in ELBW infants. Methods. A retrospective review of infants weighing ≤ 1kg at birth was conducted from January 2005 to December 2009 (Phase 1; P1) and January 2012 to December 2014 (Phase 2; P2) in a tertiary care NICU. At this center, in P1 (2005-09) CW was exclusively used for calculating fluid, calorie, and protein administration till BW was regained. In P2 (2012-14), BW was exclusively used for all calculations. Both P1 and P2 periods were compared and analyzed for differences in demographics, nutritional intake, comorbid conditions, and growth outcomes. Results. We studied 146 infants with 84 and 62 infants in P1 and P2 periods, respectively. The mean gestational age was lower during Phase 1 (25.74 ±1.32 vs. 26.47 ±1.82 weeks. P value =0.01). However, the birth weights were not different between the two periods. When the multiple-regression analysis was done using a discharge weight of >10th percentile as the dependent variable, protein intake before regaining of BW (OR of 4.126 with 95th CI of 2.03-8.36, a P value of 0.00) and AGA status at birth (OR of 8.37 with 95th CI of 2.67-26.24) remained significant factors. Compared to P1, babies in P2 received 1g/kg/day more protein till BW was regained. In P1, 27% of babies who were appropriate for gestational age (AGA) for head circumference at birth became microcephalic by discharge, compared to 15.6% in P2 (p=0.03). Similarly, 75.3% of the babies who were AGA for weight at birth in P1 became small for gestational age (SGA) by discharge, compared to 16.7% in P2 (p=<0.0001). The number of days it took to regain BW was 9.6 days in P1 vs. 7 days in P2 (p=<0.0001). Conclusions. Basing nutrition calculations in ELBW on birth weight rather than current daily weight until the birth weight is regained resulted in significantly greater protein delivery, a significant decrease in the incidence of failure to thrive and smaller head circumference percentiles at discharge in ELBW infants.

Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review.

BACKGROUND: To determine the comprehensiveness of neonatal resuscitation documentation and to determine the association of various patient, provider and institutional factors with completeness of neonatal documentation. METHODS: Multi-center retrospective chart review of a sequential sample of very low birth weight infants born in 2013. The description of resuscitation in each infant's record was evaluated for the presence of 29 Resuscitation Data Items and assigned a Number of items documented per record. Covariates associated with this Assessment were identified. RESULTS: Charts of 263 infants were reviewed. The mean gestational age was 28.4 weeks, and the mean birth weight 1050 g. Of the infants, 69 % were singletons, and 74 % were delivered by Cesarean section. A mean of 13.2 (SD 3.5) of the 29 Resuscitation Data Items were registered for each birth. Items most frequently present were; review of obstetric history (98 %), Apgar scores (96 %), oxygen use (77 %), suctioning (71 %), and stimulation (62 %). In our model adjusted for measured covariates, the institution was significantly associated with documentation. CONCLUSIONS: Neonatal resuscitation documentation is not standardized and has significant variation. Variation in documentation was mostly dependent on institutional factors, not infant or provider characteristics. Understanding this variation may lead to efforts to standardize documentation of neonatal resuscitation.

Do bulb syringes conform to neonatal resuscitation guidelines?

OBJECTIVE: To reduce airway injury secondary to high suction pressures, the American Academy of Pediatrics Neonatal Resuscitation Program (NPR) recommends that suction pressures be less than 100 mm Hg. This study was conducted to determine if suction bulbs conform to these recommendations. STUDY DESIGN: In this prospective in vitro study, 25 personnel involved in neonatal resuscitation squeezed a new bulb three times for each of six commercially available bulbs using their delivery suite technique. A calibrated, pneumatic transducer measured the pressure of each squeeze. RESULTS: Only one bulb met the NRP guidelines with none of the participants exceeding 100mm Hg (p<0.001). CONCLUSIONS: Only one bulb met the NRP guidelines of generating pressures less than 100 mm Hg. This bulb's large size (3 oz) may preclude its use in premature infants. Individuals involved in resuscitating newborns need to be aware of the pressures generated to avoid injuring the delicate oral airway.

Medical teaching websites: do they reflect the learning paradigm?

Phenomenal evolution of the Internet in recent times is shifting the mode of distribution of medical knowledge from conventional lecture rooms to one that is web based. No guidelines are yet set for medical teaching websites. Hence, the authors set out to determine whether these sites uniformly reflected the Learning Paradigm. Most of the medical teaching websites were endowed with good technical support but were surprisingly falling short in reflecting the principles of learning. It is strongly suggested that a team consisting of a clinician as content provider, a web designer and a medical educationist is required to create an ideal medical teaching website.

Epidemiology of infants of diabetic mothers in indigent Micronesian population-Guam experience.

Diabetes complicating pregnancy has not yet been properly evaluated in Guam and the prevalence and morbidity of infants of diabetic mothers (IDM) in Micronesian population on Guam is described. The prevalence of IDM among the Micronesian population is 5.0% vs non-Micronesian's 3.7%. 82.5% were gestational diabetic mothers (GDM) diet controlled, 10.2% were GDM insulin controlled and 6.9% had Insulin Dependent Diabetes Mellitus. LGAs were 11% of IDMs in contrast to 6.4% of total births. Ten infants (NICU) spent total of 29 days on ventilator. Cesarean delivery, LGA, oxygen and ventilatory requirements were higher in Micronesian IDMs than in the non-Micronesian IDMs. The incidence is also higher in the Micronesian population (5.0%) compared to non Micronesian population (3.7%) on Guam. Micronesian IDMs were at higher risk for cesarean delivery, recurrent hypoglycemia, oxygen and ventilatory requirements than their non-Micronesian counterparts were. There is also a higher incidence of LGA among the Micronesian population and Chuukese had the highest incidence probably because they seek late or no prenatal care. We report 5.0% prevalence of diabetes during pregnancy in Micronesian population on Guam which imposes a significant economic burden on the local government's hospital resources. Micronesian IDMs were at higher risk for cesarean delivery, LGA, recurrent hypoglycemia, oxygen and ventilatory requirements than their non-Micronesian counterparts were. Chuukese had the highest LGA incidence in the study group. About 2/3rd of the IDM stayed 1110 extra days in hospital. IDMs accounted for the majority of expensive off-island transports.