American journal of perinatology最新文献

Respiratory support use in neonatal intensive care units (NICUs) varies worldwide, influenced by clinical practices, resources, and patient populations. Whether high-altitude independently affects the duration of respiratory support in preterm infants remains unclear. This study aimed to determine whether altitude is independently associated with the duration of respiratory support in preterm infants ≤32 weeks' gestational age (GA) admitted to Latin American NICUs.We performed a multicenter, observational cohort study by secondary analysis of prospectively collected data from the EpicLatino Network, a registry of NICUs across Latin America (2015-2022). Infants ≤32 weeks who received invasive or non-invasive respiratory support were included; supplemental oxygen delivered via low-flow nasal cannula or oxygen hood was not considered respiratory support, and those with missing outcome data were excluded. The primary outcome was total duration of respiratory support, measured as total days of support until discontinuation, discharge, transfer, or truncation by death. Altitude was classified as high (≥2,000 m) or low (<2,000 m). Multivariable analyses were adjusted for neonatal, maternal, and unit characteristics.A total of 4,428 infants were included; 2,723 (61.5%) in low-altitude NICUs and 1,705 (38.5%) in high-altitude NICUs. Overall, 81.4% discontinued respiratory support and 18.6% died. Mortality was 19.1% in low-altitude and 17.9% in high-altitude NICUs. Median duration of support was 8 days (interquartile range [IQR]: 5-14) overall, with 9 days (IQR: 4-27) in low-altitude and 7 days (IQR: 3-17) in high-altitude NICUs. High-altitude centers showed shorter respiratory support in unadjusted analyses. After adjustment for neonatal, maternal, and unit factors, altitude was not independently associated with support duration.After adjustment for neonatal, maternal, and unit factors, altitude was not independently associated with the duration of respiratory support. Importantly, high altitude was never associated with worse outcomes. · High-altitude NICUs showed shorter respiratory support use, likely reflecting environmental hypoxemia, but this association disappeared after adjusting for clinical and unit factors.. · Mortality was similar at high and low altitudes, indicating that shorter duration at altitude was not explained by earlier deaths.. · Altitude may influence initial decisions on invasive support, but patient and institutional characteristics appear more relevant in determining total duration..

Metformin is increasingly being used to treat gestational diabetes mellitus (GDM). But pharmacotherapy with metformin frequently requires insulin supplementation to achieve glucose control, and this remains poorly characterized. We identified factors associated with insulin supplementation of metformin versus receipt of metformin alone, and then examined whether these two groups differed in the frequency of adverse pregnancy outcomes (APOs) among individuals with GDM.We conducted a retrospective analysis of a U.S. GDM care program from 2018 to 2021, which first initiated metformin.Modified Poisson regression was used to identify risk factors associated with later insulin supplementation after initial metformin treatment, and stepwise regression was used to identify the most predictive factors. A propensity matched analysis was used to examine the association between metformin with insulin supplementation versus metformin alone (reference) with APOs (hypertensive disorders of pregnancy [HDP], preterm birth [PTB], small for gestational age [SGA], large for gestational age [LGA], and neonatal intensive care unit [NICU] admission).Among 399 deliveries with GDM that initiated metformin, 28.8% required insulin supplementation. Factors associated with an increased risk of insulin supplementation were older age, private insurance, and a higher mean screening glucose tolerance test; factors associated with a decreased risk were later GDM diagnosis and Black and Hispanic race and ethnicity. Individuals who required metformin with insulin supplementation had a higher risk of LGA birth (28.6 vs. 13.9%; adjusted risk ratio [aRR]: 1.89; 95% CI: 1.18, 3.02) and NICU admission (25.8 vs. 13.5%; aRR: 1.79; 95% CI: 1.11, 2.88).Multiple patient characteristics were associated with insulin supplementation after starting metformin to treat GDM. Pregnant individuals with GDM who required insulin supplementation of metformin had a higher risk of LGA and NICU admission. · Multiple patient characteristics were associated with insulin supplementation of metformin for GDM.. · Individuals treated with insulin supplementation of metformin had a higher risk of LGA and NICU admission versus those treated with metformin alone.. · Data about whether identification of individuals who require metformin supplementation with insulin results in improved outcomes are needed..

Continuous glucose monitoring (CGM) use among patients with type 1 diabetes mellitus (T1DM) has been associated with improved glycemic control, though improvement in non-glycemic outcomes is less consistent. We hypothesize that CGM use in patients with T1DM in a real-world clinical setting is associated with both improved glycemic and clinical outcomes.This was a retrospective cohort study of patients with T1DM receiving care at a large health system from 2016 to 2023. Primary outcomes included (1) glycemic control and (2) a composite comprising severe maternal morbidity, preeclampsia with severe features, delivery prior to 34 weeks, and admission for diabetic ketoacidosis. Primary glycemic outcome was hemoglobin A_1c (HbA_1c) <6% in the second trimester. We compared patients using CGM, our exposure group, to patients using traditional blood glucose monitoring (TBGM). During initial data abstraction, we noted variation in CGM target blood glucose settings. A subgroup analysis was performed in which patients using CGM were evaluated by device setting, with those set to targets consistent with American Diabetes Association (ADA) recommendations compared with those with more permissive goals. Adjusted odds ratios were calculated using multivariable logistic regression to adjust for potential confounding variables.Among 288 patients with T1DM, there were 145 deliveries in the CGM group and 143 in the traditional capillary blood glucose monitoring group. Midtrimester on-target glycemic control was improved in the CGM group compared with traditional monitoring (40.7 vs. 17.5%, adjusted odds ratio [aOR] = 2.32; 95% confidence interval [CI]: 1.21-4.12). There was no difference in the rate of the composite outcome (CGM: 42.8% vs. TBGM: 49.0%, aOR = 0.70; 95% CI: 0.40-1.22), nor was there a difference in secondary outcomes. In patients using CGM, those with stricter targets had improved glycemic control as well as reduced rates of preterm delivery prior to 37 weeks (18.8 vs. 56.9%, aOR = 0.16, 95% CI: 0.05-0.48) and neonatal intensive care unit admission (37.5 vs. 60.0%, aOR = 0.37, 95% CI: 0.14-0.96).CGM use in T1DM is associated with improved glycemic control throughout pregnancy; however, this does not uniformly translate to improved clinical outcomes. Lack of adherence to ADA blood glucose targets may contribute to these findings. · Glycemic control in pregnancy is improved with CGM use in patients with T1DM.. · CGM use does not translate to consistent improvement in clinical outcomes.. · Stricter CGM targets are associated with improvement in glycemic control and some clinical outcomes.. · Simply prescribing an intervention does not automatically lead to benefit..

Postresuscitation care (PRC) encompasses structured and systematic interventions aimed at promptly stabilizing at-risk newborns in order to improve clinical outcomes. This study aimed to assess PRC practices as reported by pediatricians who serve as instructors in the Brazilian Neonatal Resuscitation Program (BNRP) of the Brazilian Pediatric Society.We conducted a cross-sectional, descriptive survey among BNRP instructors. Data were collected via a 55-item online questionnaire (Google Forms), covering respondents' professional background, primary work setting, and specific PRC practices. A convenience sample was used, and descriptive statistics summarized the findings.A total of 740 responses were obtained, representing 63% of BNRP instructors. Of these, 79% were neonatologists, 88% with over 10 years of professional experience. Most worked in public (61%) and teaching hospitals (76%). Only 41% had received targeted PRC training; of these, 56% had exclusively theoretical instruction. Regarding the scope of PRC, 37% believed interventions were indicated solely for newborns requiring intubation, chest compression, or medications in the delivery room. Overall, 49% of respondents reported having written PRC protocols at their institutions, though their content and implementation varied considerably.PRC practices in Brazil are neither homogeneous nor systematically implemented across most neonatology services involving BNRP instructors. These findings highlight the pressing need for enhanced dissemination of standardized PRC protocols and comprehensive training for pediatricians engaged in neonatal care. · PRC can improve outcomes in high-risk newborns, but its real-world application remains poorly described in middle-income countries.. · This is the largest study to date on PRC practices, based on responses from instructors of the Brazilian Neonatal Resuscitation Program.. · Findings reveal the need for structured training and underscore the importance of further research on the impact of standardized PRC on neonatal outcomes..

This study aimed to describe a contemporary cohort of triplet pregnancies from two tertiary centers in a middle-income country and evaluate the association between gestational age (GA) at birth and perinatal death. We developed and internally validated a GA-based risk model.Retrospective cohort from two tertiary hospitals (2015-2024). The unit of analysis was the fetus/neonate, with cluster-robust standard errors at the mother level. Primary outcome: Perinatal death (stillbirth ≥23^0/7 weeks or neonatal death ≤28 days). GA was modeled with logistic regression using restricted cubic splines; Firth penalization addressed separation where applicable. Internal validation used 200 bootstrap resamples.The cohort included 150 neonates; perinatal death occurred in 23 (15.4%). Median GA was 33 (31-34) weeks overall, 34.0 (32.0-34.0) in survivors, and 25.0 (24.0-28.0) in perinatal deaths. In the adjusted spline model, GA was the dominant predictor (overall Wald χ² = 1,473.66, df = 3, p < 0.001; non-linearity χ² = 424.92, df = 2, p < 0.001), while severe preeclampsia was not significant (χ² = 0.10, p = 0.750). The category-based Firth model showed markedly elevated odds of perinatal death at earlier gestations versus ≥34 weeks: <28 weeks; adjusted odds ratio (aOR) = 871.15 (95% confidence interval [CI]: 81.25-124,006.80, p < 0.001); 28 to <32 weeks, aOR = 50.22 (5.45-6,682.53, p < 0.001); 32 to <34 weeks, aOR = 5.34 (0.26-804.14, p = 0.278); and severe preeclampsia, aOR = 1.02 (0.09-7.17, p = 0.984). The internally validated model demonstrated excellent discrimination (optimism-corrected area under the receiver operating characteristic curve [AUROC], 0.972) and good overall performance (Brier score, 0.047), with a calibration intercept of -0.129, a slope of 0.696, and a maximum absolute calibration error (E _max) of 0.104.In triplet pregnancies, GA at birth is the dominant determinant of perinatal death, with a steep risk gradient at earlier gestations. A GA-based model demonstrates excellent discrimination and acceptable calibration following bootstrap internal validation, supporting its use in informing counseling and timing-of-delivery decisions in this high-risk population. · Perinatal mortality in triplet pregnancies decreases sharply after 32 weeks.. · Most perinatal deaths occur before 32 weeks of gestation.. · These findings support delivery planning around 32 to 33 weeks.. · Data from low- and middle-income countries' settings provide guidance for counseling and NICU planning.. · A simple GA-only model showed excellent discrimination (area under the curve = 0.97)..

The social vulnerability index (SVI) is a place-based index used to stratify community risk. We evaluated the impact of SVI on pregnancy and infant outcomes in patients with surgically treatable congenital anomalies.This is a retrospective study of pregnant patients and infant dyads diagnosed from 2014 to 2022 with congenital anomalies amenable to surgical treatment. Dyads were grouped into SVI quartiles. Primary outcomes were infant morbidity and mortality, and secondary outcomes included prenatal care services, pregnancy course characteristics, and pregnant person co-morbidities. The area deprivation index and child opportunity index were also collected. Bivariate comparisons of patient characteristics and unadjusted odds ratios for death or morbidity stratified by SVI quartile were performed.Two hundred and ninety-five dyads met the inclusion criteria. Ten point two percent had low SVI, 23.7% low-medium, 35.3% medium-high, and 30.9% high. The only prenatal care service associated with SVI quartile was fetal MRI (p = 0.038), but no directional trend was observed. Infant diagnoses included 11.5% congenital diaphragmatic hernia, 27.5% gastroschisis, 18.6% intestinal atresia, 9.2% lower urinary tract obstruction, 20.3% myelomeningocele, 9.2% omphalocele, 0.3% sacrococcygeal teratoma, 8.5% tracheoesophageal fistula. The odds ratio of poor infant outcomes by SVI quartile showed a nonsignificant elevated odds ratio in the highest quartile SVI (low-medium SVI OR: 0.66 [95% CI: 0.14, 2.35], medium-high SVI OR: 0.78 [95% CI: 0.17, 2.63], and high SVI OR: 1.57 [95% CI: 0.32, 6.4]).SVI quartile was not associated with infant outcomes in patients with surgically treatable congenital anomalies. Future studies should examine the impact of SVI or other indices of social vulnerability on perinatal and long-term postnatal outcomes in these high-risk patients. · Healthcare inequities warrant exploration in congenital surgical pathologies.. · Explored SVI quartile association with infant outcomes.. · Primary outcomes were not associated with SVI quartile.. · Nonsignificantly higher odds of poor outcome in patients with high SVI quartile..

Pregestational diabetes mellitus (PGDM) is increasing in prevalence among pregnant individuals and is associated with adverse outcomes. Prior work suggests that offspring sex influences placental responses and may impact risk for adverse outcomes. We sought to assess the impact of offspring sex on adverse pregnancy and neonatal outcomes in individuals with PGDM.We conducted a retrospective cohort study of 503 pregnant individuals with PGDM and known offspring sex with care at a major urban academic center between 1998 and 2016. We assessed two co-primary composite outcomes: (1) a composite adverse pregnancy outcome of small for gestational age (SGA), hypertensive disorder of pregnancy (HDP), and stillbirth and (2) a composite adverse neonatal outcome of large for gestational age (LGA), hypoglycemia, hyperbilirubinemia, shoulder dystocia, and respiratory distress syndrome (RDS). Secondary outcomes of spontaneous preterm birth (PTB) and admission to the neonatal intensive care unit (NICU) were assessed. Mixed effects logistic regression models, accounting for multiple pregnancies and adjusting for first trimester body mass index (BMI), insurance, parity, and maternal race/ethnicity, were analyzed.Of the 503 pregnant individuals with PGDM, 67% had a diagnosis of type 2 DM and 33% had type 1 DM. The composite adverse pregnancy outcome occurred in 79 of 258 (31%) pregnancies with a female fetus and 76 of 245 (31%) pregnancies with a male fetus. The composite neonatal outcome occurred in 163 of 245 males (67%) and 154 of 258 females (60%). Male infants had significantly higher odds of requiring admission to the NICU (adjusted odds ratio 1.79 [95% confidence interval: 1.13, 2.80], p = 0.01). There were no observed sex differences in the incidence of spontaneous PTB.We identified high rates of both composite outcomes in pregnancies with PGDM, regardless of fetal sex. The significantly higher rate of NICU admission among males suggests an increased risk of neonatal morbidity in males exposed to PGDM. · A high incidence of adverse outcomes was observed in PGDM pregnancies.. · Male neonates are at greater risk of NICU admission.. · In individuals with type 2 DM, a trend toward increased risk of LGA was observed in male neonates..

This study aimed to describe and evaluate our single-center practice of serial cranial ultrasound (CUS) in preterm infants following the 2020 American Academy of Pediatrics (AAP) clinical report. To evaluate the rate of cranial abnormalities following the first normal scan and identify risk factors for severe intraventricular hemorrhage (IVH) in the first week of life.A single-center retrospective study over an 8-year study period, from 2016 to 2023. Rates and types of CUS are described and compared over pre- and post-AAP clinical report time epochs. Risk factors associated with severe IVH were analyzed with logistic regression.A total of 727 infants were included. Median number of CUS was 3 (IQR: 2, 4) in both pre- and post-AAP cohort periods. CUS were performed in 289 (39.8%) infants before 7 days of life (DOL), 595 (81.8%) at 7 to 10 DOL, 623 (85.7%) at 4 to 6 weeks, and 361 (49.7%) at term equivalent age (TEA). The rates of abnormal CUS were 139 (48.1%), 364 (61.2%), 401 (64.4%), and 227 (62.9%) of the infants who had CUS at less than 7 days, 7 to 10 days, 4 to 6 weeks, and TEA, respectively. New abnormalities were detected in 13% (48/364) of infants following a normal 7 to 10 DOL scan and 3% (9/290) following a normal 7 to 10 days and 4 to 6 weeks scan. Decreased birth gestational age (odds ratio [OR] = 0.7), advanced resuscitation (OR = 3.4), and birth at outside hospital (OSH; OR = 2.6) were associated with severe IVH before 7 DOL.Our single-center practice of serial CUS was largely consistent with the AAP clinical report. We report that new findings of abnormality following a normal 7 to 10 DOL scan are infrequent and predominantly limited to grade 1 IVH and benign cysts. We identified birth gestation below 25 weeks, birth at an OSH, and advanced resuscitation as risk factors for severe IVH. · Our single center practice of serial cranial ultrasound was largely consistent with the AAP policy statement.. · New abnormal findings after a normal 7-10 cranial ultrasound.. · Lower gestational age and advanced resuscitation at birth and transfer from outside hospital increased risk for severe IVH..

Acute kidney injury (AKI) is a clinically significant complication in preterm neonates, leading to increased morbidity, mortality, and risk of long-term kidney dysfunction. Within this vulnerable population, the presence of a hemodynamically significant patent ductus arteriosus (PDA) may further exacerbate AKI risk. The relationship between PDA and AKI is complex, involving both the pathophysiological consequences of altered hemodynamics (e.g., ductal steal) causing renal ischemia and the potential nephrotoxic effects of therapeutic interventions. However, the existing literature provided limited insight into the impact of PDA and its management on AKI in preterm infants, with most studies relying on retrospective designs. There is a notable absence of consensus regarding the comparative effects of conservative, pharmacologic, and surgical PDA management strategies on AKI outcomes. This study directly addresses these knowledge gaps by synthesizing findings from diverse clinical trials, cohort studies, and meta-analyses into a single, comprehensive resource, aiming to inform future research and guide best practices for managing PDA-related AKI in preterm neonates. · AKI in PDA involves ductal steal and nephrotoxic treatment effects.. · Early AKI detection in hsPDA requires monitoring and balanced treatment.. · hsPDA is a major risk factor for AKI in preterm infants.. · Understanding intervention impact on AKI needs well-designed studies..

Health care-associated infections (HAIs) remain among the most serious complications in neonatal surgery, particularly in resource-limited settings where infection control is often suboptimal. This study aimed to identify risk factors for HAIs following major thoracic and abdominal neonatal surgery in southern Tunisia.We conducted a retrospective cohort study of neonates who underwent major non-cardiac abdominal or thoracic surgery at Hedi Chaker University Hospital, Sfax, Tunisia, between April 2015 and March 2025.A total of 361 neonates underwent major abdominal or thoracic surgery during the 10-year study period. The male-to-female ratio was 1.3:1. The most common surgical conditions were esophageal atresia (n = 105), duodenal atresia (n = 42), and anorectal malformations (n = 39). Overall, 99 neonates (27.4%) developed one or more HAIs during their postoperative course. On multivariable logistic regression, four variables were independently associated with HAIs. These variables included cardiac comorbidities (odds ratio [OR] = 2.205; p = 0.007), gestational age <37 weeks (OR = 2.448; p = 0.009), postoperative intubation time >30 hours (OR = 2.338; p = 0.002), and surgery duration >120 minutes (OR = 2.471; p = 0.006).HAIs in neonatal surgery remain a major challenge in resource-constrained settings. In addition to patient- and surgery-related factors, structural limitations in perioperative care and infection control play a crucial role. Strengthening neonatal intensive care unit (NICU) capacity, ensuring consistent access to antibiotics and antiseptics, and optimizing perioperative protocols are essential to reduce infection rates and improve outcomes. · Cardiac anomalies emerged as a significant independent predictive factor of HAIs in our cohort.. · Prematurity is an independent risk factor for HAIs following neonatal surgery.. · Prolonged surgical duration was independently associated with an increased risk of HAIs.. · Prolonged postoperative intubation emerged as a strong independent predictive factor of HAIs..