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The genetics of prematurity

It has long been known that the most important risk factor for a preterm delivery is a previous pre-term delivery, suggesting the influence of a genetic predisposition. This is what Zhang et al (N Engl J Med 2017;377:1156–67) investigated recently. They identified six gene variants associated with gestational duration, and a further three variants with preterm birth. The gene products were proteins associated with uterine development, the selenocysteine pathway (suggesting specific aspects of maternal nutrition), and vascular control, so the associations were biologically as well as statistically plausible. The dataset was over 43 000 women: such large numbers are necessary when evaluating genetic associations, but they also show how unlikely it is that preterm birth could ever be predicted accurately from an individual’s genetic information.

The meaning of gastric residual volumes

Have you ever wondered whether the close enquiry about gastric residuals in newborn babies was any advance on the inspection of the entrails of a ritually sacrificed chicken? Here’s an answer, courtesy of Riskin et al (J Pediatr 2017;189:128–34): you, or rather the babies, are better off not knowing. Without the ‘benefit’ of this knowledge, babies reached full enteral feeds more quickly in this before-and-after study, with no attributable complications. Whether this would apply in the smallest babies was not answered, as the lowest gestational age of the subjects was 29 weeks; but Kaur et al (J Pediatr Gastroenterol Nutr 2015;60:259–63) came to similar conclusions in an RCT comparing measurement of residual volumes with measurement of abdominal circumference in babies of 27–33 weeks.

Warmed wet gas

Everyone knows that a preterm baby’s admission temperature is an important determinant of mortality (except if you have read the only relevant RCT: J Pediatr 2015;166:262–8), so we are all keen on keeping preterm babies warm. The latest contribution to this endeavour comes from McGrory et al (DOI:10.1016/j.jpeds.2017.09.006) who randomised 273 babies<30 weeks to resuscitation and stabilisation with and without heated-humidified gases. There was a significant reduction in the rates of hypothermia (27% vs 43%) and a non-significant increase in hyperthermia among babies receiving warm, wet gas. Mortality was identical in each group.

Music and the mind

Hyperion has noticed that there have been quite a few evaluations of music in newborn care in recent years. Music seems to do good things for babies as for older humans, but we don’t really know why. Stokes et al (Acta Paediatrica, DOI:10.1111/apa.14079) decided to investigate this further by randomising 30 babies of 33+0–36+6 weeks in a masked crossover design to a rather saccharine English version of Brahms’s famous cradle song Op.49, No. 4 (youtube.com/watch?v=g8 hItcjQZVM), and measuring amplitude integrated EEG to ascertain maturity of sleep architecture using the Burdjalov score. The effect of the music on increasing the Burdjalov score was substantial for between a third and a half of the subjects; the rest, as far as aEEG was concerned, were unmoved. It appears that they did not think to ask the mothers what sort of music they listened to during pregnancy even though we know that prenatal exposure to music influences neonatal responses to it.

Antibiotic prescribing and media pressure

What influences antibiotic prescribing in neonatal intensive care? Local policies, hospital guidelines, shifts in bacterial susceptibility? Probably all of these, but you might not expect it to be ‘what you read in the papers’. But following significant infection outbreaks in NICUs in Maintz, Bremen and Berlin, Härtel et al (Infect Control Hosp Epidemiol 2016;37:924–930), found a strong association between the prescription of carbapenems or piperacillin-tazobactam and relevant articles in the print media around these cities. The temporal associations for each of these centres have to be seen against a background of a general increase in prescriptions of third line antibiotics, as well as declining infection rates and mortality; also it is not entirely clear whether the influence was principally on senior or more junior doctors.

Growth restriction and long term outcome

We now know a lot about long term functional outcomes in extremely preterm babies, but much less about the specific impact of being severely growth restricted as well. Korzeniewski et al (Pediatrics 2017;140:e20170697) have now reported the effect of size-for-gestation in the ELGAN study of 889 babies <28 weeks: there were 52 babies more than 2 SD below the mean, and another 113 between 1 and 2 SD below the mean. At the age of 10 years, their smallness correlated with a wide spectrum of neurodevelopmental dysfunction, including features of autism spectrum, and poor school achievement, in comparison to their normally grown peers. The main preceding obstetric factor was pre-eclampsia. The authors speculate as to whether there is a common influence giving rise both to maternal pre-eclampsia and disordered fetal brain development, or whether the fetal outcome is purely mediated by reduced fetal nutrient supply. These observational data can’t answer that one.

Are men monkeys?

Finally I must draw your attention to an excellent and thought-provoking Editorial in Acta Paediatrica by Malin Bergstrom. The paper to which the Editorial refers (DOI:10.1111/apa.13970) is also interesting, but the Editorial (DOI:10.1111/apa.14046) stands on its own. The issue under discussion is the tendency to focus on mothers to the exclusion of fathers in the preparation for parenthood and in subsequent programmes, interventions and contacts between health professionals and families. I’ll leave you with a tasty quotation from the piece: ‘…in institutions that were originally created for physical care and are populated by medically trained women, the readiness to include fathers has been surprisingly low’.

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