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Background The developmental origin of health and disease concept identifies the brain, cardiovascular, liver, and kidney systems as targets of fetal adverse programming with adult consequences. As the limits of viability in premature infants have been pushed to lower gestational ages, the long-term impact of prematurity on kidneys still remains a significant burden during hospital stay and beyond. Objectives The purpose of this study is to summarize available evidence, mechanisms, and short- and long-term renal consequences of prematurity and identify nephroprotective strategies and areas of uncertainty. Results Kidney size and nephron number are known to be reduced in surviving premature infants due to disruption of organogenesis at a crucial developmental time point. Inflammation, hyperoxia, and antiangiogenic factors play a role in epigenetic conditioning with potential life-long consequences. Additional kidney injury from hypoperfusion and nephrotoxicity results in structural and functional changes over time which are often unnoticed. Nephropathy of prematurity and acute kidney injury confound glomerular and tubular maturation of preterm kidneys. Kidney protective strategies may ameliorate growth failure and suboptimal neurodevelopmental outcomes in the short term. In later life, subclinical chronic renal disease may progress, even in asymptomatic survivors. Conclusion Awareness of renal implications of therapeutic interventions and renal conservation efforts may lead to a variety of short and long-term benefits. Adequate monitoring and supplementation of microelement losses, gathering improved data on renal handling, and exploration of new avenues such as reliable markers of injury and new therapeutic strategies in contemporary populations, as well as long-term follow-up of renal function, is warranted.

Most clinicians rely on outcome data based on completed weeks of gestational of fetal maturity for antenatal and postnatal counseling, especially for preterm infants born at the margins of viability. Contemporary estimation of gestational maturity, based on ultrasounds, relies on the use of first-trimester scans, which offer an accuracy of ±3–7 days, and depend on the timing of the scans and the measurements used in the calculations. Most published literature on the outcomes of babies born prematurely have reported on short- and long-term outcomes based on completed gestational weeks of fetal maturity at birth. These outcome data change significantly from one week to the next, especially around the margin of gestational viability. With a change in approach solely from decisions based on survival, to disability-free survival and long-term functional outcomes, the complexity of the parental and care provider’s decision-making in the perinatal and postnatal period for babies born at less than 25 weeks gestation remains challenging. While sustaining life following birth at the margins of viability remains our priority—identifying and mitigating risks associated with extremely preterm birth begins in the perinatal period. The challenge of supporting the normal maturation of these babies postnatally has far-reaching consequences and depends on our ability to sustain life while optimizing growth, nutrition, and the repair of organs compromised by the consequences of preterm birth. This article aims to explore the ethical and medical complexities of contemporary decision-making in the perinatal and postnatal periods. We identify gaps in our current knowledge of this topic and suggest areas for future research, while offering a perspective for future collaborative decision-making and care for babies born at the margins of viability.

Background Post-hemorrhagic ventricular dilatation (PHVD) in preterm infants can be assessed with ventricular size indices from cranial ultrasound. We explored inter-observer reliability of these indices for prediction of severe PHVD. Methods For all 139 infants with IVH, serial neonatal ultrasound at 3 time points (days 4–7, day 14, 36 weeks PMA) were assessed independently by 3 observers with differing levels of training/experience. Ventricular index (VI), anterior horn width (AHW), and fronto-temporal horn ratio (FTHR) were measured and used to diagnose PHVD. For all, inter-observer reliability and predictive values for receipt of surgical intervention were calculated. Results Inter-observer reliability for all observers varied from poor to excellent, with higher reliability for VI/AHW (ICC 0.49–0.84/0.51–0.81) than FTHR (0.41–0.82), particularly from the second week. Good–excellent inter-expertise reliability was found between observers with ample experience/training (0.65–0.99), particularly for VI and AHW, while poor–moderate when comparing with an inexperienced observer (0.28–0.88). Slightly higher predictive value for PHVD intervention ( n  = 12) was found for AHW (AUC 0.86–0.96) than for VI and FTHR (0.80–0.96/0.80–0.95). Conclusions AHW and VI are highly reproducible in experienced hands compared to FTHR, with AHW from the second week onwards being the strongest predictor for receiving surgical intervention for severe PHVD. AHW may aid in early PHVD diagnosis and decision-making on intervention. Impact While ventricular size indices from serial cUS are superior to clinical signs of increased intracranial pressure to assess PHVD, questions remained on their inter-observer reproducibility and reliability to predict severity of PHVD. AHW and VI are highly reproducible when performed by experienced clinicians. AHW from the second week of birth is the strongest predictor of PHVD onset and severity. AHW, combined with VI, may aid in early PHVD diagnosis and decision-making on need for surgical intervention. Consistent use of these indices has the potential to improve PHVD management and therewith the long-term outcomes in preterm infants.

Abstract Aim To evaluate the impact of outreach education targeting neuroprotection on outcomes of outborn infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Methods A retrospective cohort study of infants admitted with moderate-to-severe HIE was conducted following the implementation of outreach education in January 2016. Key interventions were early identification and referral of infants with encephalopathy utilizing telemedicine and a centralized communication system, hands-on simulation, and interactive case discussion and dissemination of clinical management guidelines and educational resources. The association between the intervention and a composite outcome of death and/or severe brain injury on brain magnetic resonance imaging (MRI) was tested controlling for the confounding factors. Results Of 165 neonates, 37 (22.4%) died and/or had a severe brain injury. This outcome decreased from 35% (27/77) to 11% (10/88) following the implementation of outreach education (P<0.001). Eligible infants not undergoing therapeutic hypothermia within 6 hours from birth decreased from 19.5% (15/77) to 4.5% (4/88). The use of inotropes decreased from 49.3% (38/77) to 19.6% (13/88). Any core temperature below 33°C was recorded for 20/53 (38%) before and 16/78 (21%) after, while those within the target range of 33°C to 34°C at admission to a tertiary care facility increased from (15/53) 28% to (51/88) 58%. Outreach education was independently associated with decreased composite outcome of death and/or severe brain injury on MRI (adjusted odds ratio 0.2; 95% confidence interval 0.07 to 0.52). Conclusion Outreach education targeting neuroprotection for infants with moderate-to-severe HIE was associated with a reduction in death and/or severe brain injury.

Abstract Objectives To determine the incidence and risk factors for pulmonary hypertension (PH) in preterm infants with moderate to severe bronchopulmonary dysplasia (BPD) and to compare short-term outcomes. Methods Preterm infants <32 weeks gestation born August 2013 through July 2015 with moderate to severe BPD at 36 weeks postmenstrual age were categorized into BPD-PH (exposure) and BPD-noPH (control) groups. Results Of 92 infants with BPD, 87 had echocardiographic assessment, of whom 24 (28%) had PH. On multiple logistic regression after adjustment for gestational age and sex, no significant risk factors for PH were identified based on data from this cohort. There were no differences in resource utilization or clinical outcomes including survival to discharge. Conclusion Approximately one out of four patients with moderate to severe BPD were identified as having PH. No significant risk factors for PH were identified. No differences in outcomes were identified for those with and without PH.

Our primary objective for this follow-up study was to compare the neurodevelopmental outcomes of a surviving cohort of infants using a split-week gestational model (early versus late) gestational age (GA) and the standard completed GA categorization. Neurodevelopmental outcomes using a split-week GA model defined as early (X, 0–3) and late (X, 4–6), with X being 23–26 weeks GA, were compared to outcomes using completed weeks GA. In total, 1012 infants were included in the study. Statistically significant differences were noted in outcomes between the early and late split of the gestational week at 23 weeks (early vs. late), with 13.3% vs. 54.5% for no neurodevelopmental impairment, and 53.3% vs. 22.7% for significant impairment (p = 0.034), respectively. There were no differences seen in the split week model for 24, 25, and 26 weeks. A trend towards improved neurodevelopmental outcomes was seen with each increasing gestation week. The split-week model did not provide additional information for pregnancies and infants between 24 and 26 weeks gestation. It did, however, provide information for counsel for infants at 23 weeks gestation, showing benefits in the late versus early half of the week.

Abstract Background Consensus on definition and management of hypotension in preterm neonates is lacking. Owing to this, there are wide variations in the reported incidence of hypotension in premature infants, especially during first week of life. Inotropes can often cause vasoconstriction, which may alter brain perfusion especially in the absence of established cerebral autoregulation. Use of these drugs is associated with multiple short- and long-term morbidities. Objectives To evaluate the effect of quality improvement (QI) bundle on rate of inotrope use and associated morbidities. Design/Methods Inborn preterm neonates born at <29weeks gestational age (GA) and admitted to level III NICU were included. Neonates with major congenital malformations, congenital heart diseases, antenatal diagnosed genetic defects, and neonates admitted after 72 hours of age were excluded from the study. We implemented a QI bundle (Figure 1) focussing on first 72hours from birth which included delayed cord clamping, avoidance of routine echocardiography, addition of clinical criteria to define hypotension, factoring iatrogenic causes of hypotension (ruling out lung hyperinflation), and standardization of respiratory management. Rate of use of inotropes in the first 72hours of life along with acute brain injury and mortality before and after implementation of the QI bundle were compared. The balancing measure was the rate of ischemic lesions in the form of cPVL. Cranial ultrasound was performed to screen for brain injury. Study was approved by the local research ethics board (REB14-1466). Figure 1. Smart driver diagram Results We included 671 neonates (301 before and 364 after the implementation of the bundle) among which 6 neonates were excluded based on the criteria. QI bundle implementation was associated with significant reduction in overall use of inotropes (24% vs 7%, p<0.001), dopamine (18% vs 5%, p<0.001), and dobutamine (17% vs 4%, p<0.001). Rate of acute brain injury decreased significantly: Acute brain injury of any grade (34% vs 20%, p<0.001) and severe brain injury (15% vs 6%, p<0.001). There was no difference in incidence of cPVL (1% vs 1.4%, p=0.66). Associations remained significant after adjusting for confounding factors. The QI bundle implementation was associated with a significant reduction in the use of inotropes when analyzed based on the 6 monthly time intervals (p = 0.006) (Figure 2) Figure 2. shows drop in inotrope use after the intervention Conclusion Our QI bundled approach resulted in reduction in inotrope use and associated brain morbidities in premature babies. Follow-up studies evaluating the impact of this initiative on long-term outcomes in survivors are required to complement findings of improved short-term outcomes seen in this study. Table 1. Baseline Characteristics of study population Characteristics Pre-QI bundle (n=301) Post-QI bundle (n=364) p value Gestation age, weeks, median (IQRa) 27 (25-28) 27 (25-28) 0.63 Caesarean section 89 (29.8) 241 (66.2) † Birth weight, g, mean (S.Db) 854 (236) 885 (239) 0.09 APGAR score <5 at 5min 63 (21) 82 (22.5) 0.70 Cord pH <7 11 (3.7) 7 (2) 0.23 Male 160 (53.2) 201 (55.2) 0.64 SGAc 41 (13.6) 34 (9.3) 0.09 Antenatal steroids 270 (90) 288 (79.8) † Multiple births 93 (30.9) 100 (27.5) 0.34 SNAPd II scores >20 128 (42.5) 113 (31) 0.003 Sedation 57 (18.9) 25 (6.9) † RDSe 249 (82.7) 248 (68.1) † Early onset sepsis 8 (2.6) 14 (3.8) 0.52 Medical treatment of PDAf 115 (38.9) 157 (43.3) 0.25 PDA treated in first 72h 32 (10.6) 32 (8.8) 0.29 DCCg 77 (25.8) 229 (64.3) † aInterquartile range, bStandard deviation, csmall for gestational age, dScore for neonatal acute physiology, eRespiratory distress syndrome, fPatent ductus arteriosus, gDelayed cord clamping, † <0.001 Unless noted otherwise, results are shown as number (%) Table 2. Inotrope use during pre and post QI bundle implementation Characteristics, n(%) Pre-QI bundle (n=301) Post-QI bundle (n=364) aOR* 95% CI p value Any inotrope use in the first 72h , n(%) 71 (23.6) 25 (6.9) 0.25 0.14-0.43 † Saline bolus, n(%) 112 (37.2) 68 (18.7) 0.28 0.18-0.43 † Dopamine, n(%) 53 (17.6) 18 (4.9) 0.24 0.13-046 † Dobutamine, n(%0 50 (16.6) 13 (3.6) 0.23 0.11-0.46 † Dopamine and Dobutamine, n(%) 35 (11.6) 6 (1.6) 0.15 0.55-0.38 † † <0.001 *adjusted for gestational age, birth weight, antenatal steroid usage, sex, mode of delivery, and APGAR score <5 at 5min of life Table 3. Outcomes during pre and post QI bundle implementation Characteristics, n(%) Pre-QI bundle (n=301) Post-QI bundle (n=364) aOR* 95% CI P value Any grade IVHa, n(%) 103 (34) 71 (19.5) 0.44 0.29-0.66 † IVH >grade I, n(%) 73 (24) 39 (11) 0.33 0.20-0.54 † Grade IV IVH, n(%) 24 (8) 11 (3) 0.38 0.17-0.89 0.025 Severe Brain injury, n(%) 44 (15) 21 (5.8) 0.31 0.17-0.58 † Death/Severe IVH, n(%) 58 (19.3) 28 (7.7) 0.34 0.20-0.59 † Cystic PVLb, n(%) 3 (1) 5 (1.4) 1.7 0.37-7.89 0.66 Death 1st week, n(%) 28 (9.4) 4 (1.6) 0.31 0.13-0.73 0.007 aIntraventricular hemorrhage, bPeriventricular leukomalacia, † <0.001 *adjusted for gestational age, birth weight, antenatal steroid usage, sex, mode of delivery, and APGAR score <5 at 5min of life

Abstract Objective The aim of this study was to evaluate if the presence of a physician in the neonatal transport team (NTT) affects transport-related outcomes and procedural success. Design Retrospective cohort study with propensity score matching. Setting Canadian national study. Patients Neonatal transports from nontertiary centres between January 2014 and December 2017. Interventions Comparison of transports conducted by NTTs with physicians (MD Group) and without physicians (noMD Group). Main outcome measures The primary outcome was the change in patient acuity as measured by the transport risk index of physiologic severity (TRIPS) score. Secondary outcomes included mortality within 24 hours of NICU admission, clinical complications during transport, procedural success, and stabilization time. Results Among 9,703 eligible cases, 899 neonatal transports attended by NTTs with physicians were compared to 899 neonatal transports without physicians using propensity score matching. No differences were seen in the improvement of TRIPS score or mortality ≤24 hours of NICU admission. The MD Group had more clinical complications (7.7% versus 5.0%, P=0.02). No differences were seen in success rates of invasive procedures. The MD Group had shorter stabilization times. In multivariable analysis, the MD Group was not a significant predictor for the improvement in TRIPS score after adjustment for covariates. Conclusions Neonatal transports conducted by teams including physicians compared to teams without physicians, did not have higher improvement in TRIPS scores and had similar success rates for procedures. These results provide insights for the planning of the structure and training of specialized interfacility neonatal transport programs.

To avoid these preventable distractions, it is recommended that nurses and other health care providers share patient information in designated areas away from distraction [28, 29]. [...]it has been suggested that it is imperative that the handoff process be standardized and trainees must be taught the most effective, safe, satisfying, and efficient ways to perform handoffs [24]. There was an increase in the frequency of critical patient event notes but not statistically significant (p = .07) and improvement in quality scores significantly from paper documentation to electronic SBAR-template notes. [...]100% documentation of nurse and attending physician communication was achieved during electronic SBAR note period. [...]this review mainly focuses on the use of SBAR communication tool for patient handoff between nurses and physicians, therefore, findings of this review are not necessarily applicable to other types of communications such as nurse to nurse or physician to physician handoffs. SBAR communication tool is easy to use and can be modified based on most of the clinical settings; however, it can be challenging to use for complex clinical cases such as ICU patients. [...]the use of SBAR communication tool requires educational training and culture change to sustain its clinical use.

There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.