Search

BACKGROUND AND OBJECTIVES High-risk infant follow-up programs (HRIFs) are a recommended standard of care for all extremely low birth weight (ELBW) infants to help mitigate known risks to long-term health and development. However, participation is variable, with known racial and ethnic inequities, though hospital-level drivers of inequity remain unknown. We conducted a study using a large, multicenter cohort of ELBW infants to explore within- and between-hospital inequities in HRIF participation. METHODS Vermont Oxford Network collected data on 19 503 ELBW infants born between 2006 and 2017 at 58 US hospitals participating in the ELBW Follow-up Project. Primary outcome was evaluation in HRIF at 18 to 24 months’ corrected age. The primary predictor was infant race and ethnicity, defined as maternal race (non-Hispanic white, non-Hispanic Black, Hispanic, Asian American, Native American, other). We used generalized linear mixed models to test within- and between-hospital variation and inequities in HRIF participation. RESULTS Among the 19 503 infants, 44.7% (interquartile range 31.1–63.3) were seen in HRIF. Twenty six percent of the total variation in HRIF participation rates was due to between-hospital variation. In adjusted models, Black infants had significantly lower odds of HRIF participation compared with white infants (adjusted odds ratio, 0.73; 95% confidence interval, 0.64–0.83). The within-hospital effect of race varied significantly between hospitals. CONCLUSIONS There are significant racial inequities in HRIF participation, with notable variation within and between hospitals. Further study is needed to identify potential hospital-level targets for interventions to reduce this inequity.

To test whether poor childhood pulmonary function explains the relationship between extremely preterm (EP) birth and attention-deficit/hyperactivity disorder (ADHD) symptoms in young adulthood.EPICure birth cohort participants include children born26 weeks' gestation in the United Kingdom and Ireland in 1995 and their term-born classmates. Predictor was EP birth. Outcomes were inattention/hyperactivity subscale z-scores at 19 years. Forced expiratory volume (FEV1) z-scores in childhood and young adulthood were mediators. We used recursive path analysis to determine the direct effect of EP birth on inattention/hyperactivity and its indirect effect through pulmonary function.Ninety EP and 47 term-born participants had pulmonary function testing at 11 and 19 years. Inattention z-scores were higher in the EP group (mean difference 0.55 [95% CI 0.11, 0.99]) but not hyperactivity. Compared to term-born peers, EP participants had lower FEV1 z-scores at 11 (mean difference-1.35 [95% CI -1.72, -0.98]) and 19 (mean difference-1.29 [95% CI -1.65, -0.92]). Path models revealed that childhood pulmonary function explained the relationship between EP birth and inattention.Extremely preterm young adults have increased risk for inattention compared to term-born peers. Poor pulmonary function appears to underlie this risk. The mechanisms responsible remain unclear and warrant further study.

Infant Follow Up Programs (IFUPs) provide developmental surveillance for preterm infants after hospital discharge but participation is variable. We hypothesized that infants born to Black mothers, non-English speaking mothers, and mothers who live in “Very Low” Child Opportunity Index (COI) neighborhoods would have decreased odds of IFUP participation. There were 477 infants eligible for IFUP between 1/1/2015 and 6/6/2017 from a single large academic Level III NICU. Primary outcome was at least one visit to IFUP. We used multivariable logistic regression to identify factors associated with IFUP participation. Two hundred infants (41.9%) participated in IFUP. Odds of participation was lower for Black compared to white race (aOR 0.43, p = 0.03), “Very Low” COI compared to “Very High” (aOR 0.39, p = 0.02) and primary non-English speaking (aOR 0.29, p = 0.01). We identified disparities in IFUP participation. Further study is needed to understand underlying mechanisms to develop targeted interventions for reducing inequities.

Objective The COVID-19 pandemic has altered the delivery of follow-up care for high-risk infants. We performed an audit to characterize programmatic responses in a quality improvement network. Study design We audited 43 North American-based follow-up programs of the Vermont Oxford Network Extremely Low Birth Weight Follow-up Study Group in October, 2020. Our electronic survey included yes/no, agree/disagree, and free text response items. Result The response rate was 67.4%. Most programs altered capacity and the timing, frequency, or content of clinical assessments. Most perceived practice changes compromised their ability to ascertain infants' medical and developmental needs. There was a rapid uptake of telemedicine services. Despite challenges with implementation, many endorsed improved connectedness with families. Conclusion Programs adapted rapidly to meet the needs of high-risk infants during the pandemic. Clinical operations, assessment procedures, and quality metrics will also need to evolve. Quality improvement study group collaboratives are well-positioned to coordinate such work.

Infants born preterm and with low birth weight have increased risk for neurodevelopmental challenges later in life compared to term-born peers. These include functional motor impairment, cognitive and speech delays, neurobehavioral disorders, and atypical social development. There are well-documented inequities in the population distributions of preterm birth and associated short-term morbidities by race, ethnicity, language, and nativity. Far less is known about how these inequities affect long-term outcomes, though the impact of unequal access to post-discharge support services for preterm infants raises concerns about widening gaps in health, development, and functioning. In this review, we describe what is currently known about the impact of race, ethnicity, nativity, and language on long-term outcomes. We provide a framework for understanding inequities in social, political, and historical context. And we offer guidance for next steps to delineate mechanistic pathways and to identify interventions to eliminate inequities in long-term neurodevelopmental outcomes through research, intervention, and advocacy.

Background Difficulties related to eating are often reported in children born preterm. The objective of this study was to quantitatively synthesize available data on the prevalence of problematic feeding in children under 4 years of age who were born preterm. Methods Literature was identified from PubMed, CINAHL, and PsycInfo. The search was limited to English language and publication years 2000–2020. To be included in the meta-analysis, the article had to report the prevalence of problematic oral feeding within a population of children born prematurely ( Results There were 22 studies that met inclusion criteria. Overall prevalence of problematic feeding (N = 4381) was 42% (95% CI 33–51%). Prevalence was neither significantly different across categories of gestational age nor by child age at the time of study. Few studies used psychometrically-sound assessments of feeding. Conclusion Problematic feeding is highly prevalent in prematurely-born children in the first 4 years of life regardless of degree of prematurity. Healthcare providers of children born preterm should consider screening for problematic feeding throughout early childhood as a potential complication of preterm birth. Systematic review registration number Not applicable.

ObjectiveSurvival rates of extremely premature infants are rising, but changes in neurodevelopmental impairment (NDI) rates are unclear. Our objective was to perform a systematic review of intrainstitutional variability of NDI over time.DesignSystematic review and meta-analysis.Data sourcesOvid MEDLINE, Embase, PubMed, Cochrane Library and Google Scholar.Study selectionStudy eligibility: (1) at least two discrete cohorts of infants born Main outcomeChange in NDI rates. Quality, validity and bias were assessed using Grading of Recommendations, Assessment, Development, and Evaluation and Quality in Prognosis Studies guidelines.ResultsOf 203 publications, 15 were eligible, including 13 229 infants. At the first time point, average NDI rate across study groups weighted by sample size was 41.0% (95% CI 34.0% to 48.0%). The average change in NDI between time points was −3.3% (95% CI −8·8% to 2.2%). For each added week of gestation at birth, the rate of NDI declined by 9.7% (95% CI 6.2% to 13.3%). Most studies exhibited moderate–severe bias in at least one domain, especially attrition rates.ConclusionsWhen comparing discrete same-centre cohorts over time, there was no significant change in NDI rates in infants born

Preterm infants are a population at high risk for mortality and adverse health outcomes. With recent improvements in survival to childhood, increasing attention is being paid to risk of long-term morbidity, specifically during childhood and young-adulthood. Although numerous tools for predicting the functional outcomes of preterm neonates have been developed in the past three decades, no studies have provided a comprehensive overview of these tools, along with their strengths and weaknesses. The purpose of this article is to provide an in-depth, narrative review of the current risk models available for predicting the functional outcomes of preterm neonates. A total of 32 studies describing 43 separate models were considered. We found that most studies used similar physiologic variables and standard regression techniques to develop models that primarily predict the risk of poor neurodevelopmental outcomes. With a recently expanded knowledge regarding the many factors that affect neurodevelopment and other important outcomes, as well as a better understanding of the limitations of traditional analytic methods, we argue that there is great room for improvement in creating risk prediction tools for preterm neonates. We also consider the ethical implications of utilizing these tools for clinical decision-making. Impact Based on a literature review of risk prediction models for preterm neonates predicting functional outcomes, future models should aim for more consistent outcomes definitions, standardized assessment schedules and measurement tools, and consideration of risk beyond physiologic antecedents.Our review provides a comprehensive analysis and critique of risk prediction models developed for preterm neonates, specifically predicting functional outcomes instead of mortality, to reveal areas of improvement for future studies aiming to develop risk prediction tools for this population.To our knowledge, this is the first literature review and narrative analysis of risk prediction models for preterm neonates regarding their functional outcomes.

Maternal nutrition is an important factor for infant neurodevelopment. However, prior magnetic resonance imaging (MRI) studies on maternal nutrients and infant brain have focused mostly on preterm infants or on few specific nutrients and few specific brain regions. We present a first study in term-born infants, comprehensively correlating 73 maternal nutrients with infant brain morphometry at the regional (61 regions) and voxel (over 300 000 voxel) levels. Both maternal nutrition intake diaries and infant MRI were collected at 1 month of life (0.9 ± 0.5 months) for 92 term-born infants (among them, 54 infants were purely breastfed and 19 were breastfed most of the time). Intake of nutrients was assessed via standardized food frequency questionnaire. No nutrient was significantly correlated with any of the volumes of the 61 autosegmented brain regions. However, increased volumes within subregions of the frontal cortex and corpus callosum at the voxel level were positively correlated with maternal intake of omega-3 fatty acids, retinol (vitamin A) and vitamin B12, both with and without correction for postmenstrual age and sex (P

To characterize state regulation and behavior of preterm infants after discharge from the neonatal intensive care unit (NICU).We recruited singleton infants born at ≤35 weeks of gestational age (GA) before NICU discharge. Parents completed surveys at discharge and 1, 3, and 6 months after discharge. Infant medical history was gleaned from the medical record. Surveys captured sociodemographic information and measures of infant state regulation (Baby Pediatric Symptom Checklist [BPSC]) and feeding behaviors. We calculated the median BPSC subscale scores at each time point and the proportion of infants with scores in the problem range (≥3/5). We explored longitudinal and cross-sectional correlates of BPSC scores.Fifty families completed the discharge questionnaire, and 42 (84%) completed the 6-month questionnaire. The median GA at birth was 34 weeks (IQR 30.1, 34.4 weeks); the median birth weight was 1930 g (IQR 1460, 2255 g). The median scores were above population norms for irritability and difficulty with routines. Twenty-one infants (40%) had irritability subscale scores in the problem range at 1 month, and 20 (38%) had problem scores on difficulties with routines. Only 9 infants (17%) had problem scores on the inflexibility subscale. Scores in all 3 domains showed different patterns from population norms from 1 to 6 months. BPSC scores were correlated with infant feeding behaviors at 1, 3, and 6 months.Scores for irritability and difficulty with routines among preterm infants were high compared with population norms and differed from normative values through 6 months after discharge. Preterm infants demonstrate problems with state regulation after NICU discharge that may require directed intervention.

The Side-by-Side (SBS) Hybrid is one of several Revolutionary Vertical Lift Technology (RVLT) concept aircraft identified by NASA to investigate Urban Air Mobility (UAM) requirements. This paper presents a dynamic model of the SBS Hybrid powertrain built using the Toolbox for the Modeling and Analysis of Thermodynamic Systems (T-MATS) and the Electrical Modeling and Thermal Analysis Toolbox (EMTAT). The model consists of the rotors, electrical power system, and turboshaft engines connected through freewheeling clutches, gearboxes, and multiple shafts. This research effort models the complex behavior of the powertrain, including the operation of the freewheeling clutches and electrical power system at the simulation time scale of the shaft dynamics. Several simulations highlight the key features present in the model and demonstrate its operation.

Quantification of proton magnetic resonance spectroscopy (1 H-MRS) data is commonly performed by referencing the ratio of the signal from one metabolite, or metabolite group, to that of another, or to the water signal. Both approaches have drawbacks: ratios of two metabolites can be difficult to interpret because study effects may be driven by either metabolite, and water-referenced data must be corrected for partial volume and relaxation effects in the water signal. Here, we introduce combined reference (CRef) analysis, which compensates for both limitations. In this approach, metabolites are referenced to the combined signal of several reference metabolites or metabolite groups. The approach does not require the corrections necessary for water scaling and produces results that are less sensitive to the variation of any single reference signal, thereby aiding the interpretation of results. We demonstrate CRef analysis using 202 1 H-MRS acquisitions from the brains of 140 infants, scanned at approximately 1 and 3 months of age. We show that the combined signal of seven reference metabolites or metabolite groups is highly correlated with the water signal, corrected for partial volume and relaxation effects associated with cerebral spinal fluid. We also show that the combined reference signal is equally or more uniform across subjects than the reference signals from single metabolites or metabolite groups. We use CRef analysis to quantify metabolite concentration changes during the first several months of life in typically developing infants.

Continuous quality improvement (CQI) has become a vital component of newborn medicine. Applying core principles - robust measurement, repeated small tests of change, collaborative learning through data sharing - have led to improvements in care quality, safety, and outcomes in the Neonatal Intensive Care Unit (NICU). High-risk infant follow-up programs (HRIF) have historically aided such quality improvement efforts by providing outcomes data about NICU interventions. Though as a discipline, HRIF has not universally embraced CQI for its own practice. In this review, we summarize the history of CQI in neonatology and applications of improvement science in healthcare and describe examples of CQI in HRIF. We identify the need for consensus on what defines 'high-risk' and constitutes meaningful outcomes. Last, we outline four areas for future investment: establishing evidence-based care delivery systems, standardizing outcomes and their measures, embracing a family-centered approach prioritizing parent goals, and developing professional standards of care for HRIF.

A simulation toolbox has been developed to model the electrical portions of Electrified Aircraft Propulsion (EAP) systems, including self-heating of electrical systems. Dynamic models of EAP systems often include turbomachinery, an electrical power system, and a thermal management system. These portions of the propulsion system can operate on timescales covering six orders of magnitude, which poses a challenging modeling task. Assumptions and approximations are made in an effort to capture the dynamics relevant to engine, electrical system, and thermal system interactions, while still allowing for fast simulations. These assumptions and approximations enable the electrical component models to run at the time scale of the turbomachinery, neglecting the very high frequency electrical dynamics, while demonstrating representative behavior of the end-to-end system. Thus the models execute in an acceptable time frame for what would otherwise be an extremely stiff simulation. The resulting simulations of EAP systems are appropriate for system-level control design and analysis. The objective of this paper is to present an overview of the Electrical Modeling and Thermal Analysis Toolbox (EMTAT). It will describe some of the approximations made to accommodate rapid execution, and some of the design tools that allow matching the model to component specifications. This paper will also provide some examples of EAP system modeling using EMTAT.

Supplemental Digital Content is available in the text., Objectives: To establish the first regional quality improvement collaborative solely dedicated to follow-through care of high-risk infants after Neonatal intensive care unit (NICU) discharge and to characterize extremely low birth weight (ELBW) follow-up in New England. Methods: Eleven of 14 follow-up programs in New England partnered with the Vermont Oxford Network (VON) ELBW project for an initial data collection project. We collected information about the health status and developmental outcomes of infants born ≤1,000 g or younger than 28 weeks 2014–2016 at the 18–24 months corrected for gestational age (CGA) follow-up visit. VON collected and compiled the data. Results: Of 993 eligible infants, 516 (52.0%) had follow-up visits. The rehospitalization rate was 33.9%, mostly respiratory illness. Ninety-six children (19.3%) had weight less than 10th percentile and 44 (8.9%) had weight less than third percentile at 18–24 months. Only 170 (61.4%) children had recommended hearing screening after NICU discharge. Forty-six (9.1%) had cerebral palsy; 81 of the 441 infants that completed all 3 sections of the Bayley Scales of Infant Development, third edition (18.4%) had any composite score less than 70. Over half of the social and demographic data were missing. Conclusion: Most quality initiatives in neonatology stop at NICU discharge. This first project by the New England Follow-up Network showed a low rate for clinical follow-up. It demonstrated many opportunities to improve postdischarge follow-through specific to NICU-based care. Future projects will aim to improve the quality of follow-through services through collaborative learning, data sharing, and comparative outcomes.

As the technical ability for genetic diagnosis continues to improve, an increasing number of diagnoses are made in infancy or as early as the neonatal period. Many of these diagnoses are known to be associated with developmental delay and intellectual disability, features that would not be clinically detectable at the time of diagnosis. Others may be associated with cognitive impairment, but the incidence and severity are yet to be fully described. These neonates and infants with genetic diagnoses therefore represent an emerging group of patients who are at high risk for neurodevelopmental disabilities. Although there are well-established developmental supports for high-risk infants, particularly preterm infants, after discharge from the NICU, programs specifically for infants with genetic diagnoses are rare. And although previous research has demonstrated the positive effect of early developmental interventions on outcomes among preterm infants, the impact of such supports for infants with genetic disorders who may be born term, remains to be understood. We therefore review the literature regarding existing developmental assessment and intervention approaches for children with genetic disorders, evaluating these in the context of current developmental supports postdischarge for preterm infants. Further research into the role of developmental support programs for early assessment and intervention in high-risk neonates diagnosed with rare genetic disorders is needed.

The normal development of thalamocortical connections plays a critical role in shaping brain connectivity in the prenatal and postnatal periods. Recent studies using advanced magnetic resonance imaging (MRI) techniques in neonates and infants have shown that abnormal thalamocortical connectivity is associated with adverse neurodevelopmental outcomes. However, all these studies have focused on a single neuroimaging modality, overlooking the dynamic relationship between structure and function at this early stage. Here, we study the relationship between structural and functional thalamocortical connectivity patterns derived from healthy full-term infants scanned with diffusion-weighted MRI and resting-state functional MRI within the first weeks of life (mean gestational age = 39.3 ± 1.2 weeks; age at scan = 24.2 ± 7.9 days). Our results show that while there is, in general, good spatial agreement between both MRI modalities, there are regional variations that are system-specific: regions involving primary-sensory cortices exhibit greater structural/functional overlap, whereas higher-order association areas such as temporal and posterior parietal cortices show divergence in spatial patterns of each modality. This variability illustrates the complementarity of both modalities and highlights the importance of multimodal approaches.

Pregnancy and lactation can change the maternal nutrient reserve. Non-invasive, quantitative markers of maternal nutrient intake could enable personalized dietary recommendations that improve health outcomes in mothers and infants. Macular pigment optical density (MPOD) is a candidate marker, as MPOD values generally reflect carotenoid intake. We evaluated the association of MPOD with dietary and breastmilk carotenoids in postpartum women. MPOD measurements and dietary intake of five carotenoids were obtained from 80 mothers in the first three months postpartum. Breastmilk samples from a subset of mothers were analyzed to determine their nutrient composition. The association between MPOD and dietary or breastmilk carotenoids was quantitatively assessed to better understand the availability and mobilization of carotenoids. Our results showed that dietary α-carotene was positively correlated with MPOD. Of the breastmilk carotenoids, 13-cis-lutein and trans-lutein were correlated with MPOD when controlled for the total lutein in breastmilk. Other carotenoids in breastmilk were not associated with MPOD. Maternal MPOD is positively correlated with dietary intake of α-carotene in the early postpartum period, as well as with the breastmilk content of lutein. MPOD may serve as a potential marker for the intake of carotenoids, especially α-carotene, in mothers in the early postpartum period.

Extremely low birth weight (ELBW;1kg) adolescents are at risk for special health care needs (SHCN) and poor math achievement compared to normal birth weight (NBW) peers. SHCN are associated with poor academic achievement among NBW children. We hypothesize that SHCN explain the effect of ELBW on math achievement.We compared age 14 Woodcock-Johnson Calculation standard scores between 181 ELBW infants and 115 NBW controls. Persistent SHCN included: 1) prescription medication or equipment use, 2) subspecialty or therapeutic service use, or 3) hospitalization. We used nonlinear marginal effects models to decompose the total effect of ELBW on math into the following 4 components: the effect of ELBW controlling for SHCN, the effect of SHCN controlling for ELBW, effect modification by SHCN, and mediated interaction where SHCN is both causal mediator and effect modifier. Models were adjusted for sociodemographic factors.ELBW adolescents had lower mean math scores than NBW peers (81.3 vs. 96.4). SHCN were more common among ELBW adolescents (54.1% vs. 27%). The total effect of ELBW on math scores was -15.7 points (95% CI -21.0, -10.5). The effect of birth weight alone was -7.6 points (95% CI -13.7, -1.4); the effect of SHCN alone was negligible. SHCN interaction and mediated interaction effects each accounted for 25% of the total effect.Birth weight alone explains only half of the effect of ELBW on math achievement. We found evidence of effect modification and mediation by SHCN. Understanding these explanatory pathways may lead to targeted interventions for improved outcomes.

Objective Children participating in early intervention (EI) vary in their medical needs and degree of delay, and previous studies have shown significant differences in EI enrollment based on the reason for referral. The effect of reason for referral on service provision and family satisfaction is largely unknown. Methods We used data from the National Early Intervention Longitudinal Study for our secondary data analysis. The main predictor was the reason for referral: a diagnosed condition, documented developmental delay, or other risk factors. Outcomes included unmet service needs, program dropout, and family satisfaction with services. Results The 2966 participants were mostly white (51.9%), male (60.3%), and had an annual household income at or below $50,000 (77.0%). There were 1924 referred due to diagnosis, 691 due to delay, and 351 due to other risks. Compared with the diagnosis group, children with delays were more likely (adjusted odds ratio [aOR] 1.38, 95% confidence interval [CI], 1.02-1.87) to have unmet service needs and to drop out of EI programs (aOR 1.44, 95% CI, 1.07-1.96); their families were less likely to report that services were highly individualized (aOR 0.80, 95% CI, 0.65-0.98) or had an impact on their children's development (aOR 0.77, 95% CI, 0.62-0.96). Conclusion Children participating in EI because of developmental delays are more likely to have unmet service needs, drop out of services because of a reason other than ineligibility (family or child-related reason), and have lower caregiver satisfaction than those participating because of diagnosed conditions. It is important to determine reasons for these differences and their impact on developmental outcomes.

Draper and colleagues present the results of their international, multicentre outcomes study of very preterm (VPT) infants.1 The study was performed in 11 of 19 centres participating in the Effective Perinatal Intensive Care in Europe (EPICE) collaboration. Study participants include infants born between 22 0/7 and 31 6/7 weeks in 2011 and 2012. The primary outcome measure was rate of moderate or severe neurodevelopmental impairment (NDI) using a parent report tool at 2 years of age. There was a high overall rate of moderate or severe NDI and a high degree of variability in rates of NDI between countries, even after adjusting for maternal and infant factors. Understanding and identifying sources of variability in the outcomes of VPT infants are important for guiding neonatal care and decision-making. The authors are to be commended for their international and interinstitutional approach to understanding outcomes and their predictors. Harmonising outcomes measures across centres and countries is no easy feat. This paper highlights an important and understudied problem in maternal and child health: regional variation in outcomes and the role of geography in determining health status. Much has been written about health disparities between rich and poor countries, with differences in disease prevalence and outcomes attributed to lack of medical services, poor sanitation and hygiene, and the scourge of poverty itself.2 But what about differences between middle-income and …

BACKGROUND: Extremely low birth weight (ELBW; 2500 grams) children followed to 8 years. ELBW children were more likely to have asthma (35.7% vs. 14.4%, p