Matthew A. Rysavy

To predict mortality of 22-25 weeks' gestation neonates in a population-based cohort using characteristics available at birth. This observational study included 8981 actively treated 22-25 weeks' gestation infants born between 2008 and 2018 at CPQCC hospitals. Proposed models were used to relate maternal, infant, and birth hospital factors to the primary outcome of death before hospital discharge. These models were compared based on predictive discrimination and calibration. Death before hospital discharge occurred in 2824 (32%) infants. In addition to the five factors in the NICHD model, we found two additional variables, receipt of prenatal care and maternal age, were associated with death. The c-statistics ranged from 0.72 to 0.75 across all models. When compared to the NICHD 5-factor model, our models showed similar discrimination. We found additional factors to the NICHD 5-factor model associated with death before hospital discharge, although these factors did not improve prediction performance.

Among the most pressing topics in neonatal-perinatal medicine today is intensive care for infants born at ≤24 weeks’ gestation. Infants born at 22–24 weeks comprise ~1 in 500 live births, with ~7500 liveborn infants annually in the U.S.—more common than Down syndrome or critical congenital heart disease—and make up 1 in 5 U.S. infant deaths. Major uncertainties exist about clinical decisions, including regarding obstetric care, delivery room procedures, incubator management, nutrition, respiratory support, and the optimal developmental environment. Partnering with families, we can develop a sound basis for safe and effective medical care of pregnant women and infants affected by birth at ≤24 weeks.

Increased survival of preterm infants born <28 weeks’ gestation brings new challenges for healthcare teams and families, particularly in the absence of high-quality, population-specific evidence to guide optimal skin care. Skin integrity is critical for preventing infection, reducing pain, and minimizing fluid loss. However, variations in care, delivery models, geographic settings, and clinician expertise continue to influence outcomes—impacting both immediate survival, long-term morbidity and mortality. This review outlines the key challenges associated with delivering safe and effective skin care for extremely preterm infants; identifies priority areas for research and benchmarking, and proposes a collaborative approach to address these gaps. The Skin InteGrity in extreme preterms research NETwork (SIGNET) collaborative seeks to align outcome measures, generate essential physiological data, promote knowledge exchange, and develop practical, evidence-based tools to support consistent, high-quality care for these uniquely vulnerable patients.

Point-of-care (POC) testing offers expedited results with lower blood volume requirements than central laboratory (CL) tests, particularly for low-birth-weight infants. A retrospective cohort included 118 patients with paired POC and CL tests within one hour in the first 14 postnatal days. Differences and agreement were assessed using linear mixed-effect models that account for within and between-subject variations. Compared to CL, POC testing underestimated sodium (6.0 mEq/L), potassium (0.1 mEq/L), chloride (5.1 mEq/L), and glucose (2.3 mg/dL), and overestimated hemoglobin (0.08 g/dL) and hematocrit (0.8%). Differences (CL- POC) varied by postnatal age and sample type, with larger differences for sodium and chloride that decreased with age and smaller differences in capillary and venous than arterial samples. Glucose and hemoglobin differences increased over time, while hematocrit remained stable. POC results underestimated sodium, potassium, chloride, and glucose, and overestimated hemoglobin and hematocrit.

Background: There is a paucity of data on neurodevelopmental outcomes in preterm infants who undergo transcatheter patent ductus arteriosus (PDA) closure (TCPC). Objective: To evaluate neurodevelopmental impairment (NDI) or death at 2 years among preterm infants treated with TCPC compared to surgical ligation. Methods: Retrospective cohort study of infants born at <27 weeks’ gestation at NICHD NRN sites. Comparisons were made between infants who underwent TCPC and PDA ligation. Results: TCPC and surgical ligation were performed on 99 and 279 infants, respectively. Death or severe NDI occurred in 49% of infants with TCPC and 40% with surgical ligation. There was no difference in odds of death or severe NDI between the two groups [aOR 1.12 95% CI: 0.55–2.26)]. Conclusion: TCPC had similar odds of death or severe NDI compared to surgical ligation. These findings need to be evaluated in large prospective studies as the management practice around the TCPC evolves. Clinical trial registration: ClinicalTrials.gov ID: Generic Database: NCT00063063.

The steroid hormone cortisol plays crucial roles in innate stress response, downregulation of inflammation, and promotion of glucose homeostasis. Infants born extremely preterm may be prone to cardiovascular compromise and inflammation-mediated respiratory disease due in part to insufficient cortisol production. Current data show that hydrocortisone, the exogenous medication form of cortisol, may help prevent or treat complications associated with relative adrenal insufficiency, although the full balance of treatment risks and benefits is uncertain. Prophylactic administration of hydrocortisone beginning in the first 1–2 postnatal days in extremely preterm infants likely results in earlier initial weaning from invasive ventilation and may reduce in-hospital mortality and the composite outcome of death or bronchopulmonary dysplasia (BPD). However, such use may increase the risk of sepsis in infants born less than 26 weeks’ gestation and gastrointestinal perforation with concurrent exposure to indomethacin. Whether prophylactic hydrocortisone affects childhood neurodevelopment has not been adequately studied. Initiation of hydrocortisone after the first postnatal week in infants receiving invasive ventilation promotes successful extubation but does not affect risks of mortality, BPD, or neurodevelopmental impairment. In extremely preterm infants with hypotension, hydrocortisone can increase blood pressure, but short- and long-term safety for this indication and usefulness compared to other anti-hypotensive agents are not well established.

Intestinal perforation occurring in extremely low gestational age neonates is a devastating complication, associated with high mortality and morbidity. Multiple phenotypes of bowel perforation in premature infants have been described, with the most common being spontaneous, or isolated, intestinal perforation and perforated necrotizing enterocolitis. The purpose of this article is to summarize literature describing “meconium obstruction of prematurity”, increasingly recognized as a distinct clinical phenotype in the smallest and most immature neonates. The goal of this review is to improve international recognition and understanding of this high-risk clinical condition. The lack of standardized nomenclature has been an obstacle to progress in understanding, preventing, and treating this important and more frequently encountered condition. The recognition of meconium obstruction requiring medical or surgical management is a clear distinguishing factor from other bowel pathologies of prematurity.