Zambia,which is officially the Republic of Zambia , is a landlocked country at the crossroads of Central, Southern and East Africa. Its neighbors are the Democratic Republic of the Congo to the north, Tanzania to the north-east, Malawi to the east, Mozambique to the Southeast, Zimbabwe and Botswana to the south, Namibia to the southwest, and Angola to the west. The capital city of Zambia is Lusaka, located in the south-central part of Zambia. The population is concentrated mainly around Lusaka in the south and the Copperbelt Province to the north, the core
Zambia contains abundant natural resources, including minerals, wildlife, forestry, freshwater and arable land.[13] In 2010, the World Bank named Zambia one of the world’s fastest economically reformed countries.[14] The Common Market for Eastern and Southern Africa (COMESA) is headquartered in Lusaka.
Source: https://en.wikipedia.org/wiki/Zambia
Healthcare: Zambia’s healthcare system is decentralized, therefore it is broken up into three different levels: hospitals, health centers and health posts. Hospitals are separated into primary (district), secondary (provincial) and tertiary (central). It offers universal healthcare for its citizens, yet the health care system in Zambia remains one of the most inadequate in the world.
Universal Health Care
Zambia is working on implementing universal health care coverage for its citizens to diminish the burden of accessing life-saving treatments. At the moment, Zambia’s government-run health facilities offer basic healthcare packages at the primary (district)level free-of-charge. Their services are under the National Health Care Package (NHCP). With this being said, due to “capacity constraints” and limited funding, the services sometimes do not reach those who need it most. Luckily, the Ministry of Health (MoH) of Zambia and Japan International Cooperation Agency (JICA) have come together in order to help restore the health care system in Zambia. They are investigating ways to effectively set priorities so that processes in health facilities can run faster and smoother.
Source: https://borgenproject.org/health-care-system-in-zambia/
PRETERM BIRTH RATES –Zambia
Rank:37 –Rate: 12.9% Estimated # of preterm births per 100 live births (USA – 12 %, Global Average: 11.1%)
COMMUNITY
Determinants of Preterm Births at a National Hospital in Zambia: Application of Partial Proportional Odds Model
Received: 27 March 2021; Accepted: 06 April 2021; Published: 11 June 2021 Obstet Gynecol Res 2021; 4 (2): 117-130 Citation: Moses Mukosha, Choolwe Jacobs, Patrick Musonda, John Mathias Zulu, Sheila Masaku, Chipo Nkwemu, Bellington Vwalika, Kunda Mutesu Kapembwa, Patrick Kaonga. Determinants of Preterm Births at a National Hospital in Zambia: Application of Partial Proportional Odds Model. Obstetrics and Gynecology Research 4 (2021)
Abstract
Background: Preterm birth (PTB), the delivery of a baby before 37 completed weeks of gestation, is responsible for increased childhood morbidity and mortality globally. However, in most developing countries, the determinats of PTB are usually underestimated and content-specific. Therefore, we assessed the determinants of ordered preterm birth levels at the Women and Newborn Teaching Hospital, Lusaka, Zambia.
Results: The study included a total of 3243 case records of women with a median age of 26 years (IQR, 22-33), of whom 399 (12.3%) delivered very preterm infants, 914 (28.18%) delivered moderate-term infants, 957 (29.51%) delivered late-term infants and 973 (30%) delivered term infants. There were disparities across infants born to HIV uninfected and HIV infected women, with the latter being more likely to be on the lower levels of preterm birth. However, attending antenatal clinic and a unit increase in maternal age were more likely to be on the higher levels of preterm birth. Pre-eclampsia’s effect was not constant across the binary logistic regression models but generally showed a reduced odds of being in higher preterm birth levels for women with the condition.
Conclusion: HIV infection and pre-eclampsia predict lower preterm birth levels while attending antenatal care (ANC), and increased maternal age is protective. Pregnant women presenting with pre-eclampsia and HIV infection should receive special considerations. Our findings support interventions aimed at increasing ANC uptake in the Zambian and other sub-Saharan Africa settings.
Charmaine Sipatonyana a nurse midwife at Kaoma District Hospital in Western Province attending to a client during COVID-19 pandemic Photo credit ©UNFPA Zambia 2020
How midwives are contributing to averting maternal and newborn deaths amid COVID-19
23 June 2021
As the COVID-19 pandemic continues to rage, the role of skilled midwives towards averting maternal and newborn deaths continues to be key. Unfortunately, in most underserved communities with high maternal and neonatal deaths, significant gaps in availability of well-trained health care workers remains.
Charmaine Sipatonyana is a midwife placed at Kaoma District Hospital in the Western Zambia, with support from UNFPA and funding from the United Kingdom’s Foreign, Commonwealth and Development Office (FCDO). Prior to her arrival, the hospital was experiencing significant gaps in providing quality maternal health services due to limited availability of skilled staff.
“From the time I arrived, we have not recorded any maternal deaths, and we only had a few neonatal deaths for which we are working hard to close that gap as a matter of urgency. The Hospital is engaging with the community to continuously sensitize expectant mothers on the importance of antenatal visits and close monitoring during pregnancy and postpartum period.” says Charmaine because of the training and support she has received as part of UNFPA support to the Province, Charmaine further narrates how this has given her confidence to execute her very sensitive role of facilitating safe deliveries and saving lives.
In 2020, through the Government of Zambia/FCDO/UN Joint Programme on Health Systems Strengthening, a total of 69 midwives were mobilised and deployed to primary healthcare facilities in Western, Luapula and Central Provinces to help reduce key gaps in health workforce shortages and ensure continuity of essential service during COVID-19 pandemic. This contributed to 14,900 health facility deliveries between October and December 2020.
The role of a midwife goes beyond facilitating safe deliveries. When adequately skilled, midwives also play a critical role in delivering all other essential sexual, reproductive, maternal, and new-born health services including providing family planning and counselling services.
UNFPA Zambia | How midwives are contributing to averting maternal and newborn deaths amid COVID-19
Judy Yo – Always On My Mind
Premiered Apr 24, 2021
Judy Yo performing Always On My Mind produced by Shenky Sugah For Kalandanya Music promotions Official Video Shot By Bang Bang Media Download Always on my mind
Focus on Fathers for Promoting Safe Sleep and Breastfeeding
Alison Jacobson, Corresponding Author
In 2020 First Candle hosted a series of focus groups in Georgia, Michigan, and Connecticut to understand the impact of implicit bias, cultural norms, and socio-economic issues on individuals’ access to information about the American Academy of Pediatrics’ infant safe sleep guidelines and the choice to adopt them. We had five groups in each state: moms, breastfeeding moms, dads, grandparents, and in-home care providers.
It was among the dads where we discovered the greatest opportunities to increase behavior change regarding safe sleep. Here are some highlights of the insights we gleaned from our focus groups:
Dads are more engaged than ever. Each of the dads spoke passionately about caring for his baby and equally sharing responsibility with mom. They shared stories with each other about how they care for their baby and want to be involved in parenting.
Dads feel marginalized by health care providers. Many dads spoke about how they felt ignored by in-home care providers and medical staff both during the birth and at the pediatrician’s office. Because of COVID-19 restrictions, most dads could not even attend prenatal and well-baby visits, but when they did, they felt the conversation and questions were directed towards mom. There was very little acknowledgment of their presence.
Dads do not have enough information. Whether it was due to COVID-19 or the inability to be present during in-home or office visits, dads do not feel they receive much information about safe sleep and breastfeeding. What they learn about safe sleep usually is what they hear from mom second-hand. Because of this, they are unsure about how to support mom in breastfeeding and how to create a safe sleep environment. One dad, an emergency medical technician who had been present at a Sudden Unexplained Infant Death (SUID) event, felt that the safe sleep guidelines are “mere opinions,” not facts, and therefore do not necessarily need to be adopted.
Dads always defer to mom. Dads have strong opinions, especially around bed-sharing, but they generally do not share this with mom. Many dads expressed that they “freak out” having a baby in bed with them, and it makes them nervous. But, they believe that “mom knows best” and that their opinions will always be second to mom. Dads want to receive information in different ways. Dads are less likely to read brochures about safe sleep or breastfeeding, as they feel the information is directed towards mom. It is generally images of mom and baby on brochures, and there is no specific information geared towards dad. They do not see themselves reflected in the materials. Dads also prefer to learn information from other dads. They are less inclined to read materials or listen to a care provider but would be open to listening to recommendations in a group setting of other men in places they frequent, such as gyms, barbershops, and men’s organizations.
PLEASE ALSO References: 1. https://firstcandle.org/straight-talk-for-infant-safe-sleep/ 2.https://neonatologytoday.net/newsletters/nt-jul21.pdf
BORN TO SOON- PREMATURE BABIES
Nov 18, 2020 ZNBC Today
At least 60 percent of babies admitted to the Neonatal Unit at the University Teaching Hospital -UTH- are premature.
HEALTH CARE PARTNERS
Neonatal Airway Monitoring System
Jun 10, 2021 Purdue Engineering
After 30 years of development, a medical device designed to continuously monitor the airways of the tiniest ventilated patients could become the standard of care for babies worldwide. Since 2016, five neonatal intensive care units in the U.S. have been using what George Wodicka and his students later invented as a solution: the first and only FDA-approved medical device that alerts nurses when a baby’s breathing tube is in the wrong position or obstructed. To make the device available to babies in every NICU, one of the world’s largest medical technology companies, Medtronic, recently added the Purdue invention to its product line as the SonarMedTM Airway Monitoring System. The company adopted the technology through its acquisition of SonarMed Inc. in December 2020, a startup Wodicka co-founded to bring the device to market.
NANN has provided a comprehensive Medication Position Statement addressing medication safety in the NICU. We strongly recommend this article for review by our esteemed healthcare provider community serving our preterm birth babies.
Medication Safety in the NICU Position Statement #3073 NANN Board of Directors June 2021 As the professional voice of neonatal nurses, the National Association of Neonatal Nurses (NANN) recommends a comprehensive approach to medication safety in the NICU that integrates available technology, focused healthcare provider medication safety education, standardized medication processes, and robust medication error reporting and prevention efforts. NICU patients are uniquely vulnerable to medication errors and require additional safeguards embedded within the medication-use process to reduce medication errors and mitigate harm. NICU healthcare providers should be proactive in evaluation and implementation of safe medication practices.
Please review full statement
http://nann.org/uploads/About/PositionPDFS/Final_MedicationInfo.pdf
Transition to a Safe Home Sleep Environment for the NICU Patient
Michael H. Goodstein, Dan L. Stewart, Erin L. Keels and Rachel Y. Moon; COMMITTEE ON FETUS AND NEWBORN, TASK FORCE ON SUDDEN INFANT DEATH SYNDROME Pediatrics July 2021, 148 (1) e2021052045; DOI: https://doi.org/10.1542/peds.2021-052045
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report “Transition to a Safe Home Sleep Environment for the NICU Patient,” included in this issue of Pediatrics.
COMMITTEE ON FETUS AND NEWBORN, TASK FORCE ON SUDDEN INFANT DEATH SYNDROME
Source: https://pediatrics.aappublications.org/content/148/1/e2021052045
Hero Nurse Who Saved Preemie Babies After Beirut Blast Speaks Out | TODAY
TODAY Aug 13, 2020
More than a week after a deadly explosion shook Beirut, Pamela Zaynoun, a NICU nurse, describes how she saved three babies from the rubble of a hospital and ran three miles with them in her arms. Her heroic act was captured in images that have gone viral. NBC’s Molly Hunter reports for TODAY.
PREEMIE FAMILY PARTNERS
Love is not Enough
Jun 1, 2013 Child Health BC
Your Own Happiness is a Gift to Your Child. Parents may need to put their life goals on hold and look after their own emotional needs so that they can create an environment where their child is connected and secure. Babies are not blank slates but rather, born with tremendous potential for self-realization. Or self-negation. Parents may need to deal with their own stress and seek support as needed. Attachment Patterns have a Multigenerational Aspect When parents focus on the comfort, security and happiness of their young child, the child benefits and so do future generations. The human brain develops, not only according to genetics, but largely in response to input from the environment. In other words, a baby’s capacity for intimate relationships, connection, self-regulation, attention and stress regulation are directly shaped by the emotional availability of the parents. During the critical first three months the right conditions need to be met for healthy brain development. Babies need caregivers who are non-stressed, non-depressed, emotionally available and consistently available. Babies and toddlers need a safe and low-stress environment. Featuring: Dr. Gabor Maté
When Extreme Preemies Get to School, Check Their Screen Time
Study suggests extra cognitive and behavioral risk for those with heavy device use by John Gever, Contributing Writer, MedPage Today July 12, 2021
Young schoolchildren who had been born very early and who logged “screen time” in excess of 2 hours daily were more likely also to show neurobehavioral problems than similar children spending less time with electronic devices, researchers found.
In a follow-up study conducted with a cohort of extremely premature infants, those with high screen time showed significant deficits in IQ, executive function, inhibition, and attention relative to the low screen-time children, according to Betty R. Vohr, MD, of Women & Infants Hospital of Rhode Island in Providence, and colleagues.
Having a television or computer in the bedroom was also associated with certain problems, the researchers reported in JAMA Pediatrics.
The 414 children in the study were about 6 to 7 years old at evaluation; all were born at less than 28 weeks gestation with a mean of 26 weeks. Just under 240 of the children logged screen time of at least 2 hours daily, and 266 had a TV or computer in the bedroom. Some 55% of the cohort were boys.
Overall, according to Vohr and colleagues, the results add to the already substantial literature connecting electronic device use to a variety of adverse outcomes. How a history of prematurity might play into this, however, is less clear. The researchers cited another study published in 2019 that linked high levels of screen time to abnormal “microstructural integrity” in white matter in preschool-age children.
Vohr and colleagues noted that several other groups have found a variety of structural brain defects in children born at extreme prematurity, and these in turn are “associated with cognitive, behavior, and language outcomes.” Thus, it’s not a great stretch to see a causal chain between birth prior to 28 weeks and neurobehavioral deficits associated with screen time, such that the risk with device use is “amplified,” the researchers suggested.
Study Details
Participants had been enrolled from 2005 to 2009 in an NIH study called SUPPORT NEURO, itself a secondary analysis of another cohort study called NEURO designed to evaluate short-term management strategies for extreme preemies. In the NEURO substudy, participants underwent cranial ultrasonography up to first or second grade, with clinical parameters evaluated as well.
Numerically, deficits in the high screen time group reached 3.92 points for full-scale IQ (SE 1.64, P=0.02) and 0.79 points for inhibition as assessed with the Developmental Neuropsychological Assessment (SE 0.38, P=0.03). Scores for inattention on the Conners 3rd Edition Parent Short Form were 3.32 points greater (SE 1.67, P<0.05).
Executive function was measured for different domains with the Behavior Rating Inventory of Executive Function. Scores for metacognition and global executive function were significantly lower among children with more than 2 hours/day of screen time, at 8.81 and 7.49 points, respectively (both P=0.01).
These figures included adjustments for a host of covariates, including sex, gestational age, and social determinants of health. Among the latter were maternal age and education, race, and public insurance; kids who were Black, on Medicare or Medicaid, or with mothers younger than age 20 when delivering — all were more likely to have high screen time and to have a TV or computer in the bedroom. Children whose mothers hadn’t completed high school were also more likely to have these devices in the bedroom, but not to have more screen time than those with more educated mothers.
Postpartum Depression… in Dads! – PediaCast 493
Posted by Dr. Mike on June 16, 2021
Parents have questions. PediaCast has answers.
Each episode of our award-winning audio program provides trustworthy, detailed and up-to-date answers to your questions. How do we do it? We start by searching the latest peer-reviewed journals. We find current evidence-based answers. Then we work a little translation magic, turning scientist-talk into parent-talk. The result is an entertaining listen that’s not elementary.
Of course, your child’s doctor is the best source of information for specific questions regarding your child’s health. We believe in keeping the practice of medicine in the examination room. But we also know parents have many questions that don’t get answered. Why do kids get so many ear infections? Is a fever dangerous? When should tonsils come out? Many parents think about these questions AFTER leaving the doctor’s office. Others remember to ask, but get the short answer instead of details.
Enter PediaCast–a supplemental source of educational information you can trust. We also provide a healthy dose of news parents can use and lively interviews with pediatric and parenting experts.
Please enjoy the example podcast below and note the abundance of Pod Casts available for your review and for future interactive participation.
Topic: Depression and Anxiety in Fathers after the Birth of a Baby Guest: Dr David Levin Pediatrician, Atlantic Medical Group Director of Professional Outreach Postpartum Support International Links to Empowering Resources are listed on website
Please enjoy the example podcast below and note the abundance of Pod Casts available for your review and for future interactive participation.
Source:https://www.pediacast.org/
INNOVATIONS
Preemies’ Blood Type Tied to Risk for Serious Intestinal Infections
AB blood group associated with risk of necrotizing enterocolitis and focal intestinal perforation-by Zaina Hamza, Staff Writer, MedPage Today July 7, 2021
AB blood type was associated with a higher risk for necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) in preterm infants, as compared with other blood types, a German population-based study found.
Among very low birth weight infants enrolled in a prospective study, surgery for NEC/FIP was more likely to be performed in those with blood group AB versus all other blood groups in both univariate (OR 1.51, 95% CI 1.07-2.13, P=0.017) and multivariate analyses (OR 1.58, 95% CI 1.10-2.26, P=0.013), reported Illya Martynov, MD, of the University of Leipzig in Germany, and colleagues.
AB blood type was associated with a higher risk for necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) in preterm infants, as compared with other blood types, a German population-based study found.
Among very low birth weight infants enrolled in a prospective study, surgery for NEC/FIP was more likely to be performed in those with blood group AB versus all other blood groups in both univariate (OR 1.51, 95% CI 1.07-2.13, P=0.017) and multivariate analyses (OR 1.58, 95% CI 1.10-2.26, P=0.013), reported Illya Martynov, MD, of the University of Leipzig in Germany, and colleagues.
“Blood group AB may be considered as a novel risk factor for developing NEC/FIP in very low birth weight infants besides the well-known factors including gestational age, hemodynamically relevant PDA [patent ductus arteriosus], and male gender,” wrote Martynov and co-authors in Nature Scientific Reports.
Factors that proved protective against NEC/FIP needing surgery included greater gestational age (OR 0.73, 95% CI 0.68-0.78), female sex (OR 0.68, 95% CI 0.55-0.83), and higher birth weight (OR 0.89, 95% CI 0.83-0.94; P<0.0001 for all), according to their findings. While use of ibuprofen or indomethacin for PDA showed a higher risk for NEC/FIP requiring surgery (OR 1.50, 95% CI 1.21-1.85, P<0.0001).
For their study, the researchers aimed to identify the associated risk factors of NEC/FIP in preterm infants with birth weights less than 1,500 grams (3.3 lb), where early diagnosis and intervention could be initiated. The two conditions typically affect infants born at 22 to 28 weeks of gestation and present within the first few weeks after birth. NEC/FIP can cause necrosis in the intestinal mucosa, leading to bowel perforation.
“Although FIP and NEC have been recognized as distinct entities, the clinical features and timing of presentation are frequently overlapping, making both diseases clinically indistinguishable in many cases,” the authors wrote.
In cases requiring surgery, neonatal mortality is higher in premature infants with NEC compared to those with FIP (35% vs 21%, respectively). A prior retrospective study had found a higher mortality risk for premature infants with NEC and type AB blood.
NEC risk factors can include formula feeding (after exposure to cow’s milk), immune system dysregulation, or any change to the microbiota.
“Blood group antigens are not only on the surface of red blood cells but also occur in other tissues, including the intestinal surface,” explained Martynov and coauthors, adding that these antigens are released into the lumen of the intestines and can serve as receptors for toxins or bacteria.
In the current study, data on the premature infants came from the German Neonatal Network, and included 10,257 infants with very low birth weight, 441 of whom required surgery for NEC/FIP. Most infants had type A blood (46.5%), followed by type O (34.5%), type B (13%), and type AB (6%). In regards to birth weight, mode of delivery, gestational age, gender, and corticosteroid exposure, no differences were reported according to blood type.
Most infants had an average gestational age of 28.5 weeks, and the average birth weight was 1,051 grams (2.3 lb) for the AB blood group and 1,037 grams (2.3 lb) for the non-AB group (P=0.26).
NEC/FIP requiring surgery was observed in 6.2% of infants with AB blood versus 4.2% of those with non-AB blood and 4.4% of those with type O blood. Mortality from NEC/FIP was 7.7% for the AB blood type group and 6.8% for the non-AB blood groups (P=0.385).
Multivariate analyses included gestational age, multiple birth, sex, and PDA medical/surgical treatments as covariates.
Limitations of the study included the small number of patients in the cohort who required surgery for FIP/NEC, as well as the low prevalence of AB blood type in infants with NEC/FIP (5.9%). Variability also may have existed among unrecognized confounders, such as donor milk availability and center protocols for feeding advancement.
Source:https://www.medpagetoday.com/gastroenterology/generalgastroenterology/93461
Gestational Weight Gain and Its Effects on Maternal and Neonatal Outcome in Women With Twin Pregnancies: A Systematic Review and Meta-Analysis
Front. Pediatr. | https://doi.org/10.3389/fped.2021.674414
Wei Zhong1†, Xiaojiao Fan2†, Fang Hu1, Meiqin Chen1 and Fanshu Zeng3*
Background: The incidence of twin pregnancies has risen recently. Such pregnancies are associated with an increased risk for poor maternal and infant outcomes. Gestational weight gain, particularly in singleton pregnancies, has been well-linked with maternal and infant outcomes. The aim of the current meta-analysis was to evaluate the effects of gestational weight gain on maternal and fetal outcomes in women with twin pregnancies.
Methods: A systematic search was conducted using the PubMed, Scopus, and Google Scholar databases. Studies, either retrospective or prospective in design, evaluating the effects of gestational weight gain (defined using Institute of Medicine (IOM) guidelines) maternal and/or fetal/neonatal outcomes in women with twin pregnancies were included. Statistical analysis was performed using STATA software.
Results: Eleven studies were included in the meta-analysis. Mothers with inadequate weight gain had increased risk for gestational diabetes mellitus (OR 1.19; 95% CI: 1.01, 1.40) and decreased risk for gestational hypertension (OR 0.58; 95% CI: 0.49, 0.68) and cesarean section (OR 0.94; 95% CI: 0.93, 0.96). Neonates born to mothers with inadequate weight gain were susceptible to increased risk for preterm delivery (OR 1.17; 95% CI: 1.03, 1.34), very preterm delivery (gestational age <32 weeks) (OR 1.84; 95% CI: 1.36, 2.48), small for gestational age status (OR 1.41; 95% CI: 1.15, 1.72), low birth weight status (<2,500 g) (OR 1.27; 95% CI: 1.17, 1.38), and neonatal intensive care unit (NICU) admission (OR 1.16; 95% CI: 1.08, 1.24). The pooled findings indicate an increased risk for gestational hypertension (OR 1.82; 95% CI: 1.60, 2.06) and cesarean section (OR 1.07; 95% CI: 1.05, 1.08) among mothers with excessive weight gain. Neonates born to mothers with excessive weight gain were susceptible to increased risk for preterm delivery and very preterm delivery but were associated with a decreased risk for low birth weight status and small for gestational age status.
Conclusions: Gestational weight gain in twin pregnancy, either lower or higher than IOM recommended guidelines, is associated with poor maternal and neonatal outcomes. Our findings call for incorporating counseling on optimal weight gain during pregnancy as part of routine antenatal visits.
https://www.frontiersin.org/articles/10.3389/fped.2021.674414/full
Clinical Pearl: Age is just a number: Evidence of Accelerated Biological Aging in Adults Born Extremely Low Birthweight (ELBW)
Melanie Wielicka, MD, PhD, Joseph R Hageman, MD
With the increasing rates of preterm birth and survival worldwide, a number of studies have started to focus not only on the immediate consequences of prematurity seen in the neonatal intensive care units but also on its long-term effects on adult health. There is now evidence that individuals with a history of preterm birth are at a greater risk of developing hypertension, strokes as well as type 1 and type 2 diabetes (1, 2). These chronic medical conditions have been classically associated with increasing age, raising whether ex-preemies are at risk for accelerated aging.
The extent of DNA methylation increases with chronological age. Various “epigenetic clocks” are available to quantify the relationship between methylation and chronological age to determine an individual’s “epigenetic” or “biological” age. Increased biological age has been linked to a greater risk of age-related morbidities (3). In their study, Van Lieshout and colleagues collected buccal cells from 45 extremely low birth weight (ELBW) survivors and 49 normal birthweight controls at 30-35 years of age. Epigenetic age was calculated from the weighted average of DNA methylation at 353 cytosine-phosphate-guanine sequences within the DNA methylation sites. The technique used is called the Illumina Infinium Human Methylation EPIC 850k BeadChip array devised by Horvath. They found that men born at ELBW demonstrated accelerated biological aging when compared to age-matched adults born at normal birth weight. The authors suggest that these findings could potentially be related to the increased psychological and physiologic stress premature infants endure (4, 5).
At this time, further studies are still needed to establish the link between accelerated cellular aging in individuals with a history of prematurity and specific outcomes, as well as to identify which subgroups are at the highest risk. Van Lieshout and colleagues point out that male preterm infants are susceptible to worse outcomes, and thus, are at risk for increased stress, which could potentially explain why the differences were only found in males (4, 5). Their findings appear to be supported by Parkinson et al., who used a different molecular marker, telomere length, to study cellular aging in patients with a history of prematurity. They have demonstrated a greater proportion of shorter telomeres in preterm men when compared to term men but were unable to find similar differences in women (6). Interestingly, in a recent study by Raffington et al., the authors analyzed DNA methylation to determine a methylation-based “pace of aging” in children. They have found that a greater socioeconomic disadvantage among white and Hispanic children was associated with a significantly faster pace of aging. This topic should be explored further. It would be imperative to determine if racial and socioeconomic disparities enhance the risk of accelerated aging in individuals with a history of prematurity (7).
All the emerging evidence has important implications for clinicians, researchers, and policymakers. At the policy level, more data is still needed to establish appropriate screening and preventative guidelines. However, when caring for children, adolescents, and adults with a history of prematurity, physicians should closely monitor blood pressure and weight and encourage appropriate nutrition and physical activity. They should also be reminded of the importance of inquiring about preterm birth when obtaining routine medical history, even when encountering patients later in life. Lastly, family members of children born preterm should be counseled on the risk for accelerated aging and increased risk of cardiovascular and metabolic disorders.
Source:https://neonatologytoday.net/newsletters/nt-jul21.pdf
Have neurodevelopmental outcomes improved in extremely preterm children?
July 21, 2021 Miranda Hester
As more extremely preterm infants survive delivery, a study examines whether the advances that allowed for that survival also improve neurodevelopmental outcomes.
Medical advancements in perinatal and neonatal care have led to greater survival for extremely preterm infants. A report in JAMA Pediatrics examined whether these advances had also led improvements in the neurodevelopmental outcomes in children who were born <28 weeks’ gestation.1
The investigators used 4 prospective longitudinal cohort studies that included all live extremely preterm births 22 to 27 weeks’ gestation in the state of Victoria, Australia in 1991-1992, 1997, 2005, and 2016-2017. The main outcomes looked at were survival, blindness, cerebral palsy, developmental delay, deafness, and neurodevelopmental disability at 2 years’ corrected age. Delays in development included a developmental quotient that was less than -1 SD relative to the control group averages on the Bayley Scales. A major neurodevelopmental disability involved moderate to severe cerebral palsy, blindness, deafness, or a developmental quotient less than −2 SDs.
Data were available for 1152 children across the 4 studies. The investigators found that survival to 2 years of age was highest in the 2016-2017 cohort (73% [215 of 293]) in comparison with the other cohorts: 1991-1992: 53% (225 of 428); 1997: 70% (151 of 217); 2005: 63% (170 of 270). Additionally, cerebral palsy was not as common in 2016-2017 (6%) than the other 3 time periods (1991-1992: 11%; 1997: 12%; 2005: 10%). No notable changes in the rates of developmental quotient less than -2 SDs (1991-1992: 18%; 1997: 22%; 2005: 7%; 2016-2017: 15%) or rates of major neurodevelopmental disability (1991-1992: 20%; 1997: 26%; 2005: 15%; 2016-2017: 15%) were found across the eras. Across all 4 cohorts, both blindness and deafness were not common. Furthermore, the rate of survival that was also free from major neurodevelopmental disability went up steadily over time 42% (1991-1992), 51% (1997), 53% (2005), and 62% (2016-2017) (odds ratio, 1.30; 95% CI, 1.15-1.48 per decade; P < .001).
The investigators concluded that children who are born extremely preterm are increasingly surviving to age 2 years without a major disability. Furthermore, this increased rate of survival was not linked to an increase in neurodevelopmental disability.
Reference
- Cheong J, Olsen J, Lee K, et al. Temporal trends in neurodevelopmental outcomes to 2 years after extremely preterm birth. JAMA Pediatr. July 19, 2021. Epub ahead of print. doi:10.1001/jamapediatrics.2021.2052
Rates of Neuropsychiatric Disorders and Gestational Age at Birth in a Danish Population
Yuntian Xia, MPH1; Jingyuan Xiao, MPH1,2; Yongfu Yu, PhD3,4; et alWan-Ling Tseng, PhD5; Eli Lebowitz, PhD5; Andrew Thomas DeWan, PhD1,6; Lars Henning Pedersen, MD, PhD7,8,9; Jørn Olsen, MD, PhD3; Jiong Li, MD, PhD3; Zeyan Liew, PhD, MPH1,2 Obstetrics and Gynecology-June 29, 2021: JAMA Netw Open. 2021;4(6):e2114913. doi:10.1001/jamanetworkopen.2021.14913
Key Points
Question Are there associations between gestational age, analyzed in 6 subgroups covering the full range of gestational duration, and the rate of neuropsychiatric diagnoses?
Findings In this Danish, nationwide, registry-based cohort study, shortened gestational duration was associated with the rate of both child-onset and adult-onset neuropsychiatric diseases. Beyond the traditional threshold of fetal maturity (≥37 weeks), the early term group (37-38 weeks) had a slightly elevated rate of multiple neuropsychiatric disorders compared with the full-term group, whereas the late-term and postterm groups had the lowest rates for most disorders except pervasive developmental disorders.
Meaning These findings suggest that neuropsychiatric disorders might be associated with factors related to early development and that interventions focusing on perinatal risk factors and obstetric practices might lower the risk for neuropsychiatric disorders in the population.
Abstract
Importance Nonoptimal gestational durations could be associated with neurodevelopmental disabilities, yet evidence regarding finer classification of gestational age and rates of multiple major neuropsychiatric disorders beyond childhood is limited.
Objective To comprehensively evaluate associations between 6 gestational age groups and rates of 9 major types and 8 subtypes of childhood and adult-onset neuropsychiatric disorders.
Design, Setting, and Participants This cohort study evaluated data from a nationwide register of singleton births in Denmark from January 1, 1978, to December 31, 2016. Data analyses were conducted from October 1, 2019, through November 15, 2020.
Exposures Gestational age subgroups were classified according to data from the Danish Medical Birth Register: very preterm (20-31 completed weeks), moderately preterm (32-33 completed weeks), late preterm (34-36 completed weeks), early term (37-38 completed weeks), term (39-40 completed weeks, reference), and late or postterm (41-45 completed weeks).
Main Outcomes and Measures Neuropsychiatric diagnostic records (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes F00-F99) were ascertained from the Danish Psychiatric Central Register up to August 10, 2017. Poisson regression was used to estimate the incidence rate ratio (IRR) and 95% CI for neuropsychiatric disorders, adjusting for selected sociodemographic factors.
Results Of all 2 327 639 singleton births studied (1 194 925 male newborns [51.3%]), 22 647 (1.0%) were born very preterm, 19 801 (0.9%) were born moderately preterm, 99 488 (4.3%) were born late preterm, 388 416 (16.7%) were born early term, 1 198 605 (51.5%) were born at term, and 598 682 (25.7%) were born late or postterm. A gradient of decreasing IRRs was found from very preterm to late preterm for having any or each of the 9 neuropsychiatric disorders (eg, very preterm: IRR, 1.49 [95% CI, 1.43-1.55]; moderately preterm: IRR, 1.23 [95% CI, 1.18-1.28]; late preterm: IRR, 1.17 [95% CI, 1.14-1.19] for any disorders) compared with term births. Individuals born early term had 7% higher rates (IRR, 1.07 [95% CI, 1.06-1.08]) for any neuropsychiatric diagnosis and a 31% higher rate for intellectual disability (IRR, 1.31 [95% CI, 1.25-1.37]) compared with those born at term. The late or postterm group had lower IRRs for most disorders, except pervasive developmental disorders, for which the rate was higher for postterm births compared with term births (IRR, 1.06 [95% CI, 1.03-1.09]).
Conclusions and Relevance Higher incidences of all major neuropsychiatric disorders were observed across the spectrum of preterm births. Early term and late or postterm births might not share a homogeneous low risk with individuals born at term. These findings suggest that interventions that address perinatal factors associated with nonoptimal gestation might reduce long-term neuropsychiatric risks in the population.
Source:https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781499
“From fear and freezing to trust and letting go”– an interview with Ingeborg Anna Martens on preterm birth and the consequences of separation policies
Ingeborg Anna Martens was born in gestational week 30/31 in the 1970s. As was the common practice back then, she was separated from her parents who could only “visit” their daughter at the ward and look at her from a distance, for about two months. Over the years, Ingeborg has reflected a lot on the long-term influence her preterm birth had had on herself and on her relationship with herself and to those close to her. With GLANCE, she shared how she emerged stronger from the past and looks into the future with courage and self-acceptance.
GLANCE:
Since the outbreak of the pandemic, many hospitals and neonatal intensive care units
(NICUs) have introduced the practice of separating preterm babies and otherwise sick
newborns from their parents, allowing only very limited contact or none at all.
When you as an adult who was born preterm and separated from your parents, hear or read about this practice, does it trigger anything in you?
Ingeborg:
Absolutely this triggers something in me. I understand that in a pandemic choices have to be made and safety comes before anything else. But separating parents from their child also results in insecurity, in the sense of feeling unsafe. In a child, this can leave lifelong marks.
Knowing this fills me with sadness, heartache.
G: You were separated from your parents for 2 months after your birth. Looking back, do you have the impression that this had lasting consequences? For example, on your (emotional) development or on interpersonal relationships like the one you had with your parents?
Ingeborg:
In life, we all take our own journey, with our own desires, needs and ideals.
A common thread in my life is my health. As young as I was, I often expressed ‘ how wonderful it would be if my body could be baked over again’. From an early age on, I have had a strong drive to get things done, a hard worker, wanting to do well, to prove to myself that I can do it. The urge to prove? I think so. But also the need to feel to be seen heard and understood. To know that I am loved, although I do not always believe it myself deep inside.
I found out pretty quickly that body and mind are connected. My willpower is enormous I am blessed with a strong positive mindset. And yet? Why has my body overpowered my mind several times in the past? After all these years I realise that my premature birth and my time in the incubator had a lot of impact on my life. For a long time, I didn’t want to face that.
Emotional connection and unconditional love are at the core of our basic trust and right to exist.
During the incubator period, my parents were allowed to admire me only from a distance and so they did. There was no touch, let alone skin-to-skin contact. (Except the physical contact during medical procedures, of course). So emotional nourishment was out of the question basically. Fortunately, this was later rectified and some holes in my (attachment) web were repaired.
Despite a safe home, I think that, in retrospect, I have ‘survived’ most of my life; full in my survival mode.
In the meantime, I have taken a lot of steps in this and gathered knowledge to get out of this survival mode. By immersing myself in the workings of our stress system, I have become aware of several things and have set to work. Mostly by myself, but I also called for help. After all, we don’t have to do everything on our own. I have mapped out my birth and unmet needs, tapped into my body memory, felt things through and had several conversations. Thankfully.
I became aware of various triggers, which still occasionally set my survival mechanism into motion. I then go into a kind of ‘rigidity’, in my head. With bodywork and meditation, I manage to find the connection with my heart, soul and body again and how to relax. That is very nice.
From fear and freezing to trust and letting go. Because of this, I am also able to guard my own boundaries better and I don’t let others cross them so quickly anymore. I have learned to take up my own space, without feeling guilty. I do matter as a person and I am safe because, in the end, it is all about feeling safe and comfortable with and within yourself. The result is that I feel the love in myself again, the love of others, and I feel welcome. Sometimes not yet, but every day we learn, by trial and error. For a lifetime.
G: You were born preterm in the 70s when it was very common to restrict the parents’ access to their baby. Now we observe that in many hospitals practices like this are still or again in use as they were 40 years ago. What lessons do you think neonatal units and hospitals should learn from the pandemic?
Ingeborg:
I think it’s important to think in terms of possibilities and solutions. Even in these times, full of challenges. The first 1000 days of a child’s life are decisive for the rest of their lives. A good attachment, feeling seen, heard, loved and understood. These are incredibly important building blocks for a strong bond between an infant and parent.
No matter how small you are, all the early experiences and impressions are saved in your brain. You can’t put words to it yet, but the body saves all this information. This creates stress and has an influence on your emotional and physical development.
I always say: ‘You always take yourself with you’. As a child, a parent, but also for example in your role as a professional. Be aware of your own emotions and stress.
Individual developmental care should really be key in the care of the sick and/or premature baby. It takes into account the needs of each individual baby and the relationship with his parents. (So, no separation!)
With an optimal start, you can prevent much suffering later. Not only in the period in the hospital, but also in the period when the baby comes home. Give everyone a ‘soft landing’ in this respect.
Connected, no matter what or how your start has been.
Reflecting on the article interviewing Ingeborg Anna Martens, I felt a significant connection to the insight she shared. As a fellow preemie survivor I too have experienced challenges in interpersonal relationships in setting my boundaries, getting in touch with my emotions, and feeling safe. Always keeping myself at arm’s length to maintain control has become second nature. This is a response I am working to change as an adult empowered with access to information, an informed community, and a sense of curiosity like that of which Ingeborg has courageously shared.
Preemie’s are impacted by the circumstances we face in our fight to survive. Survival mode as expressed by Ingeborg at such a visceral, sub-conscious level was validating for me, and empowering towards my journey.
I, too, feel a sense of sadness knowing worldwide many preemies born today and their families are experiencing an increased period of separation. While much of the knowledge Ingeborg has shared in my opinion has traditionally been met with hesitation from the medical and research community, my hope is that increased engagement with fellow preemie survivors and NICU community members may advance discussion, research, and outlets of information sharing. I hope such dialogue will support parents and families of young preemies in their awareness and ability to positively impact their child’s long-term health and wellness. Healthcare providers and facilities have the opportunity to make this information accessible and attractive to our preemie parents, families, and survivors.
Microlight flight over Victoria Falls (Livingstone, Zambia)
Jan 11, 2018
Flying over the 7th Natural Wonder of the World : Victoria Falls (Zambia & Zimbabwe, Africa) !
The Neonatal Womb Warriors 