Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis.

OBJECTIVE: Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model. DESIGN: Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors. SETTING: An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study. POPULATION: Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257). METHODS: Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables. MAIN OUTCOME MEASURES: Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth. RESULTS: After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86). CONCLUSIONS: Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.

A better understanding of the association between maternal perception of foetal movements and late stillbirth-findings from an individual participant data meta-analysis.

BACKGROUND: Late stillbirth continues to affect 3-4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Reduced foetal movements are frequently reported by women prior to foetal death, but there remains a poor understanding of the reasons and how to deal with this symptom clinically, particularly during the preterm phase of gestation. We aimed to determine which women are at the greatest odds of stillbirth in relation to the maternal report of foetal movements in late pregnancy (≥ 28 weeks' gestation). METHODS: This is an individual participant data meta-analysis of all identified case-control studies of late stillbirth. Studies included in the IPD were two from New Zealand, one from Australia, one from the UK and an internet-based study based out of the USA. There were a total of 851 late stillbirths, and 2257 controls with ongoing pregnancies. RESULTS: Increasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio (aOR) = 0.20, 95% CI 0.15 to 0.27). Compared to no change in strength or frequency women reporting decreased frequency of movements in the last 2 weeks had increased odds of late stillbirth (aOR = 2.33, 95% CI 1.73 to 3.14). Interaction analysis showed increased strength of movements had a greater protective effect and decreased frequency of movements greater odds of late stillbirth at preterm gestations (28-36 weeks' gestation). Foetal hiccups (aOR = 0.45, 95% CI 0.36 to 0.58) and regular episodes of vigorous movement (aOR = 0.67, 95% CI 0.52 to 0.87) were associated with decreased odds of late stillbirth. A single episode of unusually vigorous movement was associated with increased odds (aOR = 2.86, 95% CI 2.01 to 4.07), which was higher in women at term. CONCLUSIONS: Reduced foetal movements are associated with late stillbirth, with the association strongest at preterm gestations. Foetal hiccups and multiple episodes of vigorous movements are reassuring at all gestations after 28 weeks' gestation, whereas a single episode of vigorous movement is associated with stillbirth at term.

Associations between symptoms of sleep-disordered breathing and maternal sleep patterns with late stillbirth: Findings from an individual participant data meta-analysis.

BACKGROUND AND OBJECTIVES: Sleep-disordered breathing (SDB) affects up to one third of women during late pregnancy and is associated with adverse pregnancy outcomes, including hypertension, diabetes, impaired fetal growth, and preterm birth. However, it is unclear if SDB is associated with late stillbirth (≥28 weeks' gestation). The aim of this study was to investigate the relationship between self-reported symptoms of SDB and late stillbirth. METHODS: Data were obtained from five case-control studies (cases 851, controls 2257) from New Zealand (2 studies), Australia, the United Kingdom, and an international study. This was a secondary analysis of an individual participant data meta-analysis that investigated maternal going-to-sleep position and late stillbirth, with a one-stage approach stratified by study and site. Inclusion criteria: singleton, non-anomalous pregnancy, ≥28 weeks' gestation. Sleep data ('any' snoring, habitual snoring ≥3 nights per week, the Berlin Questionnaire [BQ], sleep quality, sleep duration, restless sleep, daytime sleepiness, and daytime naps) were collected by self-report for the month before stillbirth. Multivariable analysis adjusted for known major risk factors for stillbirth, including maternal age, body mass index (BMI kg/m2), ethnicity, parity, education, marital status, pre-existing hypertension and diabetes, smoking, recreational drug use, baby birthweight centile, fetal movement, supine going-to-sleep position, getting up to use the toilet, measures of SDB and maternal sleep patterns significant in univariable analysis (habitual snoring, the BQ, sleep duration, restless sleep, and daytime naps). Registration number: PROSPERO, CRD42017047703. RESULTS: In the last month, a positive BQ (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.02-2.04), sleep duration >9 hours (aOR 1.82, 95% CI 1.14-2.90), daily daytime naps (aOR 1.52, 95% CI 1.02-2.28) and restless sleep greater than average (aOR 0.62, 95% CI 0.44-0.88) were independently related to the odds of late stillbirth. 'Any' snoring, habitual snoring, sleep quality, daytime sleepiness, and a positive BQ excluding the BMI criterion, were not associated. CONCLUSION: A positive BQ, long sleep duration >9 hours, and daily daytime naps last month were associated with increased odds of late stillbirth, while sleep that is more restless than average was associated with reduced odds. Pregnant women may be reassured that the commonly reported restless sleep of late pregnancy may be physiological and associated with a reduced risk of late stillbirth.

Association of Supine Going-to-Sleep Position in Late Pregnancy With Reduced Birth Weight: A Secondary Analysis of an Individual Participant Data Meta-analysis.

Importance: Supine maternal position in the third trimester is associated with reduced uterine blood flow and increased risk of late stillbirth. As reduced uterine blood flow is also associated with fetal growth restriction, this study explored the association between the position in which pregnant women went to sleep and infant birth weight. Objective: To examine the association between supine position when going to sleep in women after 28 weeks of pregnancy and lower birth weight and birth weight centiles. Design, Setting, and Participants: Prespecified subgroup analysis using data from controls in an individual participant data meta-analysis of 4 case-control studies investigating sleep and stillbirth in New Zealand, Australia, and the United Kingdom. Participants were women with ongoing pregnancies at 28 weeks' gestation or more at interview. Main Outcomes and Measures: The primary outcome was adjusted mean difference (aMD) in birth weight. Secondary outcomes were birth weight centiles (INTERGROWTH-21st and customized) and adjusted odds ratios (aORs) for birth weight less than 50th and less than 10th centile (small for gestational age) for supine vs nonsupine going-to-sleep position in the last 1 to 4 weeks, adjusted for variables known to be associated with birth size. Results: Of 1760 women (mean [SD] age, 30.25 [5.46] years), 57 (3.2%) reported they usually went to sleep supine during the previous 1 to 4 weeks. Adjusted mean (SE) birth weight was 3410 (112) g among women who reported supine position and 3554 (98) g among women who reported nonsupine position (aMD, 144 g; 95% CI, -253 to -36 g; P = .009), representing an approximate 10-percentile reduction in adjusted mean INTERGROWTH-21st (48.5 vs 58.6; aMD, -10.1; 95% CI, -17.1 to -3.1) and customized (40.7 vs 49.7; aMD, -9.0; 95% CI, -16.6 to -1.4) centiles. There was a nonsignificant increase in birth weight at less than the 50th INTERGROWTH-21st centile (aOR, 1.90; 95% CI, 0.83-4.34) and a 2-fold increase in birth weight at less than the 50th customized centile (aOR, 2.12; 95% CI, 1.20-3.76). Going to sleep supine was associated with a 3-fold increase in small for gestational age birth weight by INTERGROWTH-21st standards (aOR, 3.23; 95% CI, 1.37-7.59) and a nonsignificant increase in small for gestational age birth weight customized standards (aOR, 1.63; 95% CI, 0.77-3.44). Conclusions and Relevance: This study found that going to sleep in a supine position in late pregnancy was independently associated with reduced birth weight and birth weight centile. This novel association is biologically plausible and likely modifiable. Public health campaigns that encourage women in the third trimester of pregnancy to settle to sleep on their side have potential to optimize birth weight.

An Individual Participant Data Meta-analysis of Maternal Going-to-Sleep Position, Interactions with Fetal Vulnerability, and the Risk of Late Stillbirth.

BACKGROUND: Maternal supine going-to-sleep position has been associated with increased risk of late stillbirth (≥ 28 weeks), but it is unknown if the risk differs between right and left side, and if some pregnancies are more vulnerable. METHODS: Systematic searches were undertaken for an individual-level participant data (IPD) meta-analysis of case-control studies, prospective cohort studies and randomised trials undertaken up until 26 Jan, 2018, that reported data on maternal going-to-sleep position and stillbirth. Participant inclusion criteria included gestation ≥ 28 weeks', non-anomalous, singleton pregnancies. The primary outcome was stillbirth. A one-stage approach stratified by study and site was used for the meta-analysis. The interaction between supine going-to-sleep position and fetal vulnerability was assessed by bi-variable regression. The multivariable model was adjusted for a priori confounders. Registration number: PROSPERO, CRD42017047703. FINDINGS: Six case-control studies were identified, with data obtained from five (cases, n = 851; controls, n = 2257). No data was provided by a sixth study (cases, n = 100; controls, n = 200). Supine going-to-sleep position was associated with increased odds of late stillbirth (adjusted odds ratio [aOR] 2.63, 95% CI 1.72-4.04, p < 0.0001) compared with left side. Right side had similar odds to left (aOR 1.04, 95% CI 0.83-1.31, p = 0.75). There were no significant interactions between supine going-to-sleep position and assessed indicators of fetal vulnerability, including small-for-gestational-age infants (p = 0.32), maternal obesity (p = 0.08), and smoking (p = 0.86). The population attributable risk for supine going-to-sleep position was 5.8% (3.2-9.2). INTERPRETATION: This IPD meta-analysis confirms that supine going-to-sleep position is independently associated with late stillbirth. Going-to-sleep on left or right side appears equally safe. No significant interactions with our assessed indicators of fetal vulnerability were identified, therefore, supine going-to-sleep position can be considered a contributing factor for late stillbirth in all pregnancies. This finding could reduce late stillbirth by 5.8% if every pregnant woman ≥ 28 weeks' gestation settled to sleep on her side.

An anthropometric approach to characterising neonatal morbidity and body composition, using air displacement plethysmography as a criterion method.

BACKGROUND: With the greatest burden of infant undernutrition and morbidity in low and middle income countries (LMICs), there is a need for suitable approaches to monitor infants in a simple, low-cost and effective manner. Anthropometry continues to play a major role in characterising growth and nutritional status. METHODS: We developed a range of models to aid in identifying neonates at risk of malnutrition. We first adopted a logistic regression approach to screen for a composite neonatal morbidity, low and high body fat (BF%) infants. We then developed linear regression models for the estimation of neonatal fat mass as an assessment of body composition and nutritional status. RESULTS: We fitted logistic regression models combining up to four anthropometric variables to predict composite morbidity and low and high BF% neonates. The greatest area under receiver-operator characteristic curves (AUC with 95% confidence intervals (CI)) for identifying composite morbidity was 0.740 (0.63, 0.85), resulting from the combination of birthweight, length, chest and mid-thigh circumferences. The AUCs (95% CI) for identifying low and high BF% were 0.827 (0.78, 0.88) and 0.834 (0.79, 0.88), respectively. For identifying composite morbidity, BF% as measured via air displacement plethysmography showed strong predictive ability (AUC 0.786 (0.70, 0.88)), while birthweight percentiles had a lower AUC (0.695 (0.57, 0.82)). Birthweight percentiles could also identify low and high BF% neonates with AUCs of 0.792 (0.74, 0.85) and 0.834 (0.79, 0.88). We applied a sex-specific approach to anthropometric estimation of neonatal fat mass, demonstrating the influence of the testing sample size on the final model performance. CONCLUSIONS: These models display potential for further development and evaluation in LMICs to detect infants in need of further nutritional management, especially where traditional methods of risk management such as birthweight for gestational age percentiles may be variable or non-existent, or unable to detect appropriately grown, low fat newborns.

Antenatal management of gestational diabetes mellitus can improve neonatal outcomes.

OBJECTIVE: Pregnancies complicated with gestational diabetes mellitus (GDM) are at a higher risk for caesarean and instrumental deliveries as well as adverse neonatal outcomes such as fetal overgrowth, hypoglycaemia and neonatal intensive care admission. Our primary objective was to describe neonatal outcomes in a sample that included term infants of both GDM mothers and mothers with normal glucose tolerance (NGT). DESIGN AND SETTING: this cross-sectional study included 599 term babies born between September and October 2010 at Royal Prince Alfred Hospital, Sydney, Australia. Maternal and neonatal data were collected from medical records and a questionnaire. Glycaemic control data was based on third trimester HbA1c levels and self-monitoring blood glucose levels (BGL). Univariate associations between GDM status and maternal demographic factors, as well as pregnancy outcomes, were estimated using χ(2) tests and t-tests, as appropriate. FINDINGS: of 599 babies, 67(11%) were born to GDM mothers. GDM mothers were more likely to be overweight/obese and of Asian ethnicity. Good glycaemic control was achieved in most GDM mothers. GDM babies were more likely to have been induced (p=0.013) and delivered earlier than non-GDM mothers (p<0.001), and they were also more likely to be breastfed within one hour of birth. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: in this study, GDM infants were more likely to be induced and delivered earlier but otherwise they did not have significantly different neonatal outcomes compared to infants of NGT mothers. This can be attributed to the good GDM control by lifestyle modification and insulin if necessary. The role of labour induction in GDM pregnancies should be further investigated. Midwives have an important role in maternal education during pregnancy and in the postnatal period.

Differential estimates of underweight-for-age and growth related morbidity according to different growth standards in Indian children.

OBJECTIVE: To compare the four different growth standards currently used in India [WHO (World Health Organization); NCHS (National Center for Health Statistics); ICDS (Integrated Child Development Scheme); IAP (Indian Academy of Pediatrics)] and determine which better predicts growth related morbidity in children after 3 mo of follow-up. METHODS: The present cohort study was done at Indira Gandhi Government Medical College and Hospital, Nagpur, India. Eligible children were those who had; > 3 unformed stools in the prior 24 h, the duration of their diarrhea was up to 72 h; and they were able to accept oral fluids or feeds. Main outcome measures were classification of the malnutrition status as per each of the four growth standards by weight-for-age and weight-for-height z scores at three months follow-up. RESULTS: A total of 724 children were included. Mean age was 17.8 mo; 40.6 % were ≤ 12 mo and 59.1 % were males. Estimates of malnourished varied by the four standards, (NCHS, 62.2 % to IAP, 7.4 %). When separated into 'malnourished' and 'severely malnourished' categories, differences were greater, (NCHS, 27.9 % vs. ICDS, 1.9 %). Overall agreement was 'fair' (0.2435, z = 22.21, p = 0.0000). After follow-up, children who were 'severely malnourished' gained more weight than the 'malnourished'group; however, mean weight differed by the four charts [e.g., IAP 767 g (SD ± 611 g), vs. ICDS 884.7 g (SD ± 778 g)]. CONCLUSIONS: Growth standards reported different rates of malnourished categories. The utility of the standards to detect children who are constitutionally vs. pathologically small is questionable. Monitoring the nutritional status of children at both the individual level and at population level has implications for clinical practice, policy development and resource allocation.

Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women.

BACKGROUND: Fetal growth restriction is defined as failure to reach growth potential and considered one of the major complications of pregnancy. These infants are often, although not universally, small for gestational age (SGA). SGA is defined as a weight less than a specified percentile (usually the 10th percentile). Identification of SGA infants is important because these infants are at increased risk of perinatal morbidity and mortality. Screening for SGA is a challenge for all maternity care providers and current methods of clinical assessment fail to detect many infants who are SGA. Large observational studies suggest that customised growth charts may be better able to differentiate between constitutional and pathologic smallness. Customised charts adjust for physiological variables such as maternal weight and height, ethnicity and parity. OBJECTIVES: To assess the benefits and harms of using population-based growth charts compared with customised growth charts as a screening tool for detection of fetal growth in pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 March 2014), reviewed published guidelines and searched the reference lists of review articles. SELECTION CRITERIA: Randomised, quasi-randomised or cluster-randomised clinical trials comparing customised versus population-based growth charts used as a screening tool for detection of fetal growth in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: No randomised trials met the inclusion criteria. AUTHORS' CONCLUSIONS: There is no randomised trial evidence currently available. Further randomised trials are required to accurately assess whether the improvement in detection shown is secondary to customised charts alone or an effect of the policy change. Future research in large trials is needed to investigate the benefits and harms (including perinatal mortality) of using customised growth charts in different settings and for both fundal height and ultrasound measurements.

Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding?

OBJECTIVE: to establish how well postnatal ward neonatal hypoglycaemia guidelines facilitate breast feeding and adhere to UNICEF UK Baby Friendly Initiative (BFI) recommendations, and to compare compliance with different recommendations. DESIGN: an appraisal of guidelines obtained via email survey using a UNICEF UK BFI checklist tool. Information about Baby Friendly Health/Hospital Initiative (BFHI) accreditation status was obtained by email questionnaire. SETTING: tertiary neonatal centres in Australia and New Zealand. PARTICIPANTS: 22 guidelines were returned from 23 centres eligible to participate. FINDINGS: guidelines generally scored poorly. On a scale ranging from 31 to 124 of overall guideline quality, the median score was 71. On a scale of 9 to 36 for adherence to recommendations to facilitate breast feeding, the median guideline score was 20. Compliance with the recommendation to promote skin-to-skin contact and early breast feeding was poor across all centres, achieving a score of 59 out of 88. Nine of 22 guidelines mentioned skin-to-skin contact after birth and 14 advised feeding within one hour of birth. The recommendation about discussing artificial milk supplementation with parents received a score of 44 out of 88. Fourteen guidelines listed Large for Gestational Age (LGA) infants to be at risk of hypoglycaemia. Few guidelines included up-to-date references or flowcharts. KEY CONCLUSIONS: guidelines need to recommend early skin-to-skin contact and discussion with parents before artificial milk supplementation. Guidelines suggest LGA neonates are being screened unnecessarily. IMPLICATIONS FOR PRACTICE: guidelines need constant revision as evidence for best practice expands. The UNICEF UK BFI checklist provides a readily available quality improvement tool.

Is body fat percentage a better measure of undernutrition in newborns than birth weight percentiles?

BACKGROUND: Undernutrition in neonates increases the risk of serious morbidities. The objective of this study was to describe neonatal morbidity associated with low body fat percentage (BF%) and measure the number of undernourished neonates defined by BF% and compare this with birth weight percentiles (<10th). METHODS: Eligibility included term (≥37 wk) neonates. BF% measurements were undertaken by air displacement plethysmography. Data on neonatal outcomes were extracted from medical records and used to develop a measure of neonatal morbidity. We assessed the association between neonatal morbidity and population-based birth weight percentiles compared with the BF% measurements. RESULTS: Five hundred and eighty-one neonates were included. Low BF% was defined by 1 SD below the mean and identified in 73 per 1,000 live births. Neonatal morbidity was found in 3.4% of neonates. Birth weight percentile was associated with neonatal morbidity (odds ratio (OR): 1.03 (95% confidence interval (CI): 1.01, 1.05); P = <0.001). BF% was associated with a higher risk of neonatal morbidity (OR: 1.30 (95% CI: 1.15, 1.47); P = <0.001). CONCLUSION: In this population, measuring BF% is more closely associated with identification of neonates at risk of neonatal morbidity as compared with birth weight percentiles. BF% measurements could assist with identifying neonates who are appropriately grown yet undernourished and exclude small neonates not at risk.

Customized versus population-based birth weight charts for the detection of neonatal growth and perinatal morbidity in a cross-sectional study of term neonates.

Customized birth weight charts that incorporate maternal characteristics are now being adopted into clinical practice. However, there is controversy surrounding the value of these charts in the prediction of growth and perinatal outcomes. The objective of this study was to assess the use of customized charts in predicting growth, defined by body fat percentage, and perinatal morbidity. A total of 581 term (≥37 weeks' gestation) neonates born in Sydney, Australia, in 2010 were included. Body fat percentage measurements were taken by using air displacement plethysmography. Objective composite measurements of perinatal morbidity were used to identify neonates who had poor outcomes; these data were extracted from medical records. The value of customized charts was assessed by calculating positive predictive values, negative predictive values, and odds ratios with 95% confidence intervals. Customized versus population-based charts did not improve the prediction of either low body fat percentage (59% vs. 66% positive predictive value and 87% vs. 89% negative predictive value, respectively) or high body fat percentage (48% vs. 53% positive predictive value and 90% vs. 89% negative predictive value, respectively). Customized charts were not better than population-based charts at predicting perinatal morbidity (for customized charts, odds ratio = 1.02, 95% confidence interval: 1.01, 1.04; for population-based charts, odds ratio = 1.03, 95% confidence interval: 1.01, 1.05) per percentile decrease in birth weight. Customized birth weight charts do not provide significant improvements over population-based charts in predicting neonatal growth and morbidity.

Fetal and maternal factors associated with neonatal adiposity as measured by air displacement plethysmography: a large cross-sectional study.

BACKGROUND: There is evidence that the fetal and early postnatal environments play a role in determining the risk of lifetime obesity, diabetes and cardiovascular disease. Neonatal body composition, as a surrogate marker of the in-utero environment, can be reliably and accurately measured by air displacement plethysmography (ADP). Our primary objective was to identify preconception, fetal and maternal factors affecting neonatal body composition. METHODS: This cross-sectional study included 599 term babies born between September and October 2010 at Royal Prince Alfred Hospital, Sydney, Australia. Neonatal body fat percentage (BF%) was measured within 48 h of birth using ADP. Maternal demographic, anthropometric and medical data as well as neonatal gestational age and sex were used to develop a regression model that predicted body composition and birthweight. RESULTS: The mean (SD) neonatal BF% in our whole population was 9.2(4.4)%. Significant variables in the model for neonatal BF% were neonatal sex, gestational age, maternal ethnicity, gestational weight gain (GWG), pre-pregnancy BMI, parity and maternal hypertension (p<0.05); together, these explained 19% of the variation in BF%. GDM status was not a significant variable. Neonatal female sex, maternal Caucasian ethnicity and increased gestational weight gain explained the most variation and were most strongly associated with increased BF%. CONCLUSIONS: This study highlights maternal obesity and increased gestational weight gain as two factors that are amenable to intervention as risk factors for newborn adiposity, which is important in the future study of the "developmental origins of health and disease" hypothesis.

Audit of a clinical guideline for neonatal hypoglycaemia screening.

AIM: This study aims to evaluate adherence to a clinical guideline for screening and prevention of neonatal hypoglycaemia on the post-natal wards. METHODS: Retrospective chart review of 581 healthy term neonates born at a tertiary maternity hospital. Indications for hypoglycaemia screening included small for gestational age (SGA), infants of diabetic mothers (IDM; gestational, Type 1 or 2), symptomatic hypoglycaemia, macrosomia and wasted (undernourished) appearance. Outcomes were protocol entry and adherence with hypoglycaemia prevention strategies including early and frequent feeding and timely blood glucose measurement. RESULTS: Of 115 neonates screened for hypoglycaemia, 67 were IDM, 19 were SGA (including two both IDM and SGA), and two were macrosomic. One IDM and one SGA were not screened. Twenty-two neonates were screened for a reason not identifiable from the medical record, and 13 neonates were SGA by a definition different to the guideline definition, including five who were also IDM. Guideline adherence was variable. Few neonates (41 of 106, 39%) were fed in the first post-natal hour, and blood glucose measurement occurred later than recommended for 41 of 106 (39%) of neonates. CONCLUSIONS: Most IDM and SGA neonates were screened. While guideline adherence overall was comparable with other studies, neonates were fed late. We recommend staff education about benefits of early (within the first hour) frequent breastfeeding for neonates at risk.

A cross-sectional study of maternal perception of fetal movements and antenatal advice in a general pregnant population, using a qualitative framework.

BACKGROUND: Maternal perception of fetal movements has been used as a measure of fetal well-being. Yet a Cochrane review does not recommend formal fetal movement counting compared to discretional fetal movement counting. There is some evidence that suggests that the quality of fetal movements can precede quantitative changes however there has been almost no assessment of how women describe movements and whether these descriptions may be useful in a clinical setting. Therefore we aimed to examine maternal perception of fetal movements using a qualitative framework. METHODS: Using a cross-sectional design we identified women during routine antenatal care at a tertiary referral hospital, in Sydney, Australia. Eligible women were pregnant ≥ 28 weeks, carrying a single child, > 18 years old, and with sufficient English literacy to self-complete a questionnaire. Post-natally the medical records were reviewed and demographic, pregnancy and fetal outcome data were extracted. Text responses to questions regarding maternal descriptions of fetal movements throughout pregnancy, were analysed using thematic analysis in an explicit process. RESULTS: 156 women participated. There was a general pattern to fetal movement descriptions with increasing gestation, beginning with words such as "gentle", to descriptions of "strong" and "limb" movements, and finally to "whole body" movements. Women perceived and described qualitative changes to fetal movements that changed throughout gestation. The majority (83%) reported that they were asked to assess fetal movements in an implicit qualitative method during their antenatal care. In contrast, only 16% regularly counted fetal movements and many described counting as confusing and reported that the advice they had received on counting differed. CONCLUSIONS: This is the first study to use qualitative analysis to identify that pregnant women perceive fetal movements and can describe them in a relatively homogenous way throughout pregnancy that follow a general pattern of fetal growth and development. These findings suggest that women's perception of fetal wellbeing based on their own assessment of fetal movement is used in an ad hoc method in antenatal care by clinicians.

Neonatal length inaccuracies in clinical practice and related percentile discrepancies detected by a simple length-board.

AIM: The study aims to assess accuracy of standard practice measurement of neonatal length compared with a gold-standard length-board technique. METHODS: Data were obtained from a population-based, cross-sectional study of 602 term babies at Royal Prince Alfred Hospital, Sydney, Australia, in 2010. Neonatal length was measured by standard clinical practice and by a length-board (gold standard) and measurements compared. Standard growth curve percentiles were used to plot length measurements. The Bland and Altman method was used to assess agreement, and acceptable levels of agreement were set at ≤1 cm and ≤0.5 cm. RESULTS: The limits of agreement were between -3.06 cm (95% CI -3.08 to -3.04) and 2.67 cm (95% CI 2.65 to 2.69). Neonates whose standard-practice length fell within 0.5 cm of the gold standard totalled 41% (241 neonates), while 59% (342) were >0.5 cm. The change in length resulted in a change in the percentile range of 53% (309) on a standard growth curve percentile. When examining neonates whose length was plotted at the extremes of percentile regions, the positive predictive value results of the standard practice compared with the gold standard were poor, with positive predictive values of 37.5%, 57.1% and 31.3% for neonates who were measured as <3rd, <10th and ≥90th percentile, respectively. CONCLUSIONS: In current clinical practice, measures of neonatal length are often inaccurate, which has implications for potentially erroneous clinical care. Health-care providers should be educated on the importance of length and trained in how to measure length with the correct technique using a length-board.

Body composition is normal in term infants born to mothers with well-controlled gestational diabetes mellitus.

OBJECTIVE: This study aims to describe body composition in term infants of mothers with gestational diabetes mellitus (GDM) compared with infants of mothers with normal glucose tolerance (NGT). RESEARCH DESIGN AND METHODS: This cross-sectional study included 599 term babies born at Royal Prince Alfred Hospital, Sydney, Australia. Neonatal body fat percentage (BF%) was measured within 48 h of birth using air-displacement plethysmography. Glycemic control data were based on third-trimester HbA(1c) levels and self-monitoring blood glucose levels. Associations between GDM status and BF% were investigated using linear regression adjusted for relevant maternal and neonatal variables. RESULTS: Of 599 babies, 67 (11%) were born to mothers with GDM. Mean ± SD neonatal BF% was 7.9 ± 4.5% in infants with GDM and 9.3 ± 4.3% in infants with NGT, and this difference was not statistically significant after adjustment. Good glycemic control was achieved in 90% of mothers with GDM. CONCLUSIONS: In this study, neonatal BF% did not differ by maternal GDM status, and this may be attributed to good maternal glycemic control.

Sleep apnea in early childhood associated with preterm birth but not small for gestational age: a population-based record linkage study.

STUDY OBJECTIVES: Investigate the relationship between gestational age and weight for gestational age and sleep apnea diagnosis in a cohort of children aged up to 6 years old. DESIGN: A cohort study, using record linked population health data. SETTING: New South Wales, Australia. PARTICIPANTS: 398,961 children, born between 2000 and 2004, aged 2.5 to 6 years. MEASUREMENTS: The primary outcome was sleep apnea diagnosis in childhood, first diagnosed between 1 and 6 years of age. Children with sleep apnea were identified from hospital records with the ICD-10 code G47.3: sleep apnea, central or obstructive. RESULTS: A total of 4,145 (1.0%) children with a first diagnosis of sleep apnea were identified. Mean age at first diagnosis was 44.2 months (SD 13.9). Adenoidectomy, tonsillectomy, or both were common among the children diagnosed with sleep apnea (85.6%). Children born preterm compared to term were significantly more likely to be diagnosed with sleep apnea (< 32 weeks versus term hazard ratio 2.74 [95% CI: 2.16, 3.49]) this remained even after adjustment for known confounding variables. Children born small for gestational age were not at increased risk of sleep apnea compared to children born appropriate for gestational age, hazard ratio 0.95 (95% CI 0.86-1.06). CONCLUSIONS: This is the largest study investigating preterm birth and sleep apnea diagnosis and suggests that diagnosis of sleep disordered breathing is more prevalent in children born preterm, but not those who are small for gestational age.