Objective To describe discordance in antenatal corticosteroid use and resuscitation following extremely preterm birth and its relationship with infant survival and neurodevelopment. Study design A multicenter cohort study of 4858 infants 22-26 weeks of gestation born 2006-2011 at 24 US hospitals participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, with follow-up through 2013. Survival and neurodevelopmental outcomes were available at 18-22 months of corrected age for 4576 (94.2%) infants. We described antenatal interventions, resuscitation, and infant outcomes. We modeled the effect on infant outcomes of each hospital increasing antenatal corticosteroid exposure for resuscitated infants born at 22-24 weeks of gestation to rates observed at 25-26 weeks of gestation. Results Discordant antenatal corticosteroid use and resuscitation, where one and not the other occurred, were more frequent for births at 22 and 23 but not 24 weeks (rate ratio [95% CI] at 22 weeks: 1.7 [1.3-2.2]; 23 weeks: 2.6 [2.2-3.2]; 24 weeks: 1.0 [0.8-1.2]) when compared with 25-26 weeks. Among infants resuscitated at 23 weeks, adjusting each hospital's rate of antenatal corticosteroid use to the average at 25-26 weeks (89.2%) was projected to increase infant survival by 7.1% (95% CI 5.4-8.8%) and survival without severe impairment by 6.4% (95% CI 4.7-8.1%). No significant change in outcomes was projected for infants resuscitated at 22 weeks, where few (n = 22) resuscitated infants received antenatal corticosteroids. Conclusions Infants born at 23 weeks were more frequently resuscitated without antenatal corticosteroids than other extremely preterm infants. When resuscitation is intended, consistent provision of antenatal corticosteroids may increase infant survival and survival without impairment.

IMPORTANCE Birth weight (BW) is an important predictor of mortality and morbidity. At extremely early gestational ages (GAs), BW may influence decisions regarding initiation of resuscitation. OBJECTIVE To characterize outcomes of liveborn infants with a BW less than 400 g. DESIGN, SETTING, AND PARTICIPANTS This retrospective multicenter cohort study analyzed extremely preterm infants born between January 2008 and December 2016 within the National Institute of Child Health and Human Development Neonatal Research Network. Infants with a BW less than 400 g and a GA of 22 to 26 weeks were included. Active treatment was defined as the provision of any potentially lifesaving intervention after birth. Survival was analyzed for the entire cohort; neurodevelopmental impairment (NDI) was examined for those born between January 2008 and December 2015 (birth years with outcomes available for analysis). Neurodevelopmental impairment at 18 to 26 months' corrected age (CA) was defined as a Bayley Scales of Infant and Toddler Development, Third Edition, cognitive composite score less than 85, a motor composite score less than 85, moderate or severe cerebral palsy, gross motor function classification system score of 2 or greater, bilateral blindness, and/or hearing impairment. Data were analyzed from September 2017 to October 2018. EXPOSURES Birth weight less than 400 g. MAIN OUTCOMES AND MEASURES The primary outcome was survival to discharge among infants who received active treatment. Analysis of follow-up data was limited to infants born from 2008 to 2015 to ensure children had reached assessment age. Within this cohort, neurodevelopmental outcomes were assessed for infants who survived to 18 to 26 months' CA and returned for a comprehensive visit. RESULTS Of the 205 included infants, 121(59.0%) were female, 133 (64.9%) were singletons, and 178 (86.8%) were small for gestational age. Almost half (101of 205 [49.3%]) received active treatment at birth. A total of 26 of 205 infants (12.7%; 95% CI, 8.5-18.9) overall survived to discharge, and 26 of 101 actively treated infants (25.7%; 95% CI, 17.6-35.4) survived to discharge. Within the subset of infants with a BW less than 400 g and a GA of 22 to 23 weeks, 6 of 36 actively treated infants (17%; 95% CI, 6-33) survived to discharge. Among infants born between 2008 and 2015, 23 of 90 actively treated infants (26%; 95% CI, 17-36) survived to discharge. Two infants died after discharge, and 2 were lost to follow-up. Thus, 19 of 90 actively treated infants (21%; 95% CI, 13-31) were evaluated at 18 to 26 months' CA. Moderate or severe NDI occurred in 14 of 19 infants (74%). CONCLUSIONS AND RELEVANCE Infants born with a BW less than 400 g are at high risk of mortality and significant morbidity. Although 21% of infants survived to 18 to 26 months' CA with active treatment, NDI was common among survivors.

Objective To assess the frequency of gastrostomy tube (GT) placement in extremely low birth weight (ELBW) infants, associated comorbidities, and long-term outcomes. Study design Analysis of ELBW infants from 25 centers enrolled in the National Institute of Child Health and Human Development Neonatal Research Network's Generic Database and Follow-up Registry from 2006 to 2012. Frequency of GT placement before 18-22 months, demographic and medical factors associated with GT placement, and associated long-term outcomes at 18-22 months of corrected age were described. Associations between GT placement and neonatal morbidities and long-term outcomes were assessed with logistic regression after adjustment for center and common co-variables. Results Of the 4549 ELBW infants included in these analyses, 333 (7.3%) underwent GT placement; 76% had the GT placed postdischarge. Of infants with GTs, 11 % had birth weights small for gestational age, 77% had bronchopulmonary dysplasia, and 29% severe intraventricular hemorrhage or periventricular leukomalacia. At follow-up, 56% of infants with a GT had weight <10th percentile, 61 % had neurodevelopmental impairment (NDI), and 55% had chronic breathing problems. After adjustment, small for gestational age, bronchopulmonary dysplasia, intraventricular hemorrhage/periventricular leukomalacia, poor growth, and NDI were associated with GT placement. Thirty-two percent of infants with GTs placed were taking full oral feeds at follow-up. Conclusions GT placement is common in ELBW infants, particularly among those with severe neonatal morbidities. GT placement in this population was associated with poor growth, NDI, and chronic respiratory and feeding problems at follow-up. The frequency of GT placement postneonatal discharge indicates the need for close nutritional follow-up of ELBW infants.

Background: Limited data are available evaluating language outcomes of preterm infants in early childhood. Furthermore, the relationship between language outcomes, medical morbidities and developmental trajectory in early infancy is unclear.Aims: The goal of this study was to evaluate language outcomes among extremely low birth weight (ELBW) infants at 30 months adjusted age (AA).Study design: The Bayley Scales of Infant Development II and the Peabody Picture Vocabulary Test or Expressive One Word Picture Vocabulary Test/Receptive One Word Picture Vocabulary Test were administered at 30 months AA to a prospective cohort of ELBW infants who participated in the NICHD Neonatal Network Glutamine Trial and Neurodevelopmental Follow-Up Study. A standardized history and physical examination and query regarding feeding behaviors were performed at 18 months AA and 30 months AA.Results: Of the 467 infants evaluated, 55% had receptive language delay at 30 months with 23% having severe delays. Fewer (26%) had expressive language delays, with 16% of those being severe delays. Non-English speaking infants had poorer performance on all language measures compared to English-speaking infants. Forty-seven percent of the cohort required assistance with feeds at 18 months. These children were more likely to have language delay at the 30 month assessment compared to infants who could feed themselves.Conclusions: ELBW infants are at risk of language delay in early childhood. Additional research is needed to further explore the relationship between early predictors of language delay and the use of monolingual language assessments in non-English speaking patients with a history of prematurity. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Comprehend the existence of feeding difficulties in formerly preterm infants.

A health education program was evaluated which used child development specialists as home visitors and served a population of first-time mothers living in rural communities. The evaluation compared health and safety outcomes between intervention and control groups. The research staff, separate from the intervention staff, collected data in the homes of 156 intervention and 107 control mothers when the infants were 6 and 12 months old. Significant group differences were found on health and safety outcomes. As compared with controls, the intervention mothers (i) had safer homes; (ii) were more likely to use birth control, thus had fewer pregnancies since birth of their first child; (iii) reported smoking fewer cigarettes; (iv) knew more about effects of smoking on their child's health and (v) were more likely to use health department services. In sum, mothers who received early education home visits from child development specialists experienced positive health and safety outcomes. It is highly recommended that a program such as this be implemented as part of health delivery program with new mothers and infants.

Background Delivery room cardiopulmonary resuscitation (DR-CPR) is used in VLBW infants, but its impact on long-term outcome has not been studied or accounted for in follow up studies. Objective To identify if DR-CPR in infants < 1251 g is a risk factor for poor neurodevelopmental outcome. Methods Live-born infants < 1251 g who survived to discharge between 1999 and 2002 at two Emory University perinatal centers (Grady Memorial Hospital and Emory Crawford Long Hospital) were included in the study; DR-CPR was defined as chest compressions and/or epinephrine use in the DR; infants were followed by neurologic examinations and tested using the Bayley Scales of Infant Development at 18 months corrected age (CA). Chi square and Student t-test were used as appropriate to compare DR-CPR and no-CPR groups; multivariate analysis was done to control for significant differences. Statistical difference was if p < .05. Results A total of 253 inborn infants survived; 28 (11%) received DR-CPR, 14 of them (50%) were evaluated at 18 months of age (19.4 ± 1.9) CA. Of the 225 infants that did not receive DR-CPR, 82 (36.4%) had an evaluation at 18 months of age (19.3 ± 2.1) CA. The mean gestational age and birth weight were not significant between the DR-CPR and no-CPR groups (26.9 ± 2.7 weeks vs. 26.7 ± 1.9 weeks [p = .79]; 808 ± 156 vs. 886 ± 189 g [p = .15]). Infants who were lost to follow-up did not differ from these two groups in demographic variables or clinical indicators of illness severity. The Bayley Mental Developmental Index (MDI) scores were different in the groups (DR-CPR: 69.1 ± 14.0 vs 80.6. ± 18.8 in no-CPR; p = .038). Psychomotor development (PDI) was also different (74.2 ± 20.8 vs 84.3 ± 15.9 respectively; p = .049). The proportion of infants with MDI ≤ 70 in DR-CPR was 53.8% vs. 21.3% (p = .021); for PDI ≤ 70 it was 38.5% vs 13.5% (p = .043). Conclusion These findings indicate that the need for DR-CPR markedly increases the risk for poor neuromotor and cognitive delay at 18 months CA in surviving infants < 1251 g. This needs to be informed to parents and accounted for in long-term outcome data analysis.

Background Mortality in severe congenital diaphragmatic hernia (CDH), defined as requirement for extracorporeal membrane oxygenation (ECMO), remains variable. Predictors of mortality and poor long-term neurodevelopmental outcome have not been well described. Objective To describe mortality and poor neurodevelopmental outcome in CDH-ECMO infants and identify associated risk factors pre-ECMO. Methods We retrieved data for CDH-ECMO infants at CHOA (1991-2004). Predictive risk factors included pre-ECMO birth weight (BW), gestational age (GA), pH, PaO2, PaCO2, oxygenation index (OI), mean airway pressure (MAP), prothrombin time (PT), and others. Chi square, Student t-test, and logistic regression were used when appropriate (significance: p Results Of 70 infants with CDH-ECMO, 12 (17.14%) were placed on venoarterial ECMO, 58 (82.85%) on venovenous ECMO (3 converted to arterial). GA was 38.2 ± 1.9 w; BW was 3160 ± 480 g. A total of 47 (67%) infants survived. There was no difference in pre-ECMO MAP (18.3 ± 3.9 CM H2O vs. 18.8 ± 4.7 CM H2O) or OI (54.6 ± 23.4 vs. 66.3 ± 32.9) between survivors and nonsurvivors. Before ECMO, nonsurvivors had a significantly higher PaCO2 (70 ≤ 24.2 vs. 57.9 ± 19.8 torr; p = .034), lower pH (7.17 ± 0.14 vs. 7.24 ± 0.14; p = .038) and higher PT (44.6 ± 6.2 vs. 18.7 ± 4.9; p = .042). A total of 23 (49%) survivors had neurodevelopmental evaluation (Bayley Scales of Infant Development) at 12 months and 18 (38%) at 24 months of age. At 12 months, mean Mental Developmental Index (MDI) was 84.77 ± 17.59 (50 to 107) and the Psychomotor Developmental Index (PDI) was 75.16 ± 21.29 (50 to 108). At 24 months, MDI was 84.23 ± 18.34 (50 to 115) and PDI was 71.58 ± 19.61 (50 to 103). At 12 and 24 months 13% of the infants had an MDI ≤ 70 and 38% had a PDI ≤ 70. A significantly higher OI pre-ECMO was predictive of MDI/PDI > 70 (59.1 ± 11.1 vs. 42.4 ± 15.6; p = .017). Conclusion In this population, 67% of infants CDH-ECMO survive to discharge. Higher PaCO2, lower pH, and higher PT pre-ECMO were significant predictors for mortality. CDH-ECMO survivors are at risk for cognitive delay and more severe neuromotor delay at 12 and 24 months of age. Higher OI pre-ECMO was a significant predictor for worse long-term outcome. Risk/benefit of using ECMO before prolonged hypercarbia, acidemia, coagulopathy, and high OI needs to be evaluated.

This study set out to assess the mitigative effects of curcumin on AFB1-induced necroptosis and inflammation in chicken liver. Ninety-six one-day-old AA broiler chickens were separated into four groups, including control group, AFB1 (1 mg/kg) group, curcumin (300 mg/kg) + AFB1 (1 mg/kg) group and curcumin (300 mg/kg) group. After 28 days treatment, livers were collected for different experimental analyses. The morphological observation results showed obvious necrotic characteristics, including cell swelling, rupture of cell and mitochondrial membranes and inflammation in chicken livers. AFB1 exposure increased oxidative stress index (ROS and MDA) and decreased the antioxidant activity markers (SOD, CAT and GSH) and ATPase activities in chickens’ liver. ELISA results showed that AFB1 exposure significantly induced the cytokines (TNF-α, iNOS, IL-6 and IL-1β) release from the liver tissues. While, western blot and qRT-PCR results showed that the protein and mRNA expressions of inflammatory (TLR4/myd88/NF-κB) and necroptosis (RIPK1/RIPK3/MLKL) genes were up-regulated by AFB1 exposure. We suspect that signal crosstalk between TLR4 and TNF-α triggers inflammation and RIPK1/RIPK3 mediating necroptosis in AFB1-induced chicken liver injury. Curcumin can regulate the TLR4/RIPK signaling pathway, reduced oxidative stress biomarkers and inflammatory cytokines levels and attenuated the expression of necroptosis and inflammation genes altered by AFB1 to reduce necroptosis of chicken liver tissue. In conclusion, curcumin can protect against AFB1-induced necroptosis and inflammation by TLR4/RIPK pathway in chicken liver.

Adolescent mothers frequently experience problems in mother-infant interaction. However, intervention can be very difficult, particularly when complicated by unresolved conflicts involving relationships in the young woman's past. This article describes a therapeutic intervention, based on the work of Fraiberg, which allows the young mother to learn to interpret her infant's cues while also encouraging her to express her own emotions in the context of the mother-infant relationship. Two case studies are discussed to illustrate the use of the technique as part of a program of mother-infant intervention.