Preterm infants have a high risk of post-discharge feeding problems, but there is a lack of population-based studies in infants born extremely preterm and little is known about underlying mechanisms. The objectives were to assess the incidence of post-discharge feeding problems and underweight in a population-based cohort of infants born extremely preterm in Sweden (EXPRESS) and identify perinatal risk factors.Perinatal health data and prenatal/postnatal growth data was prospectively collected in the cohort. Data on clinical diagnoses related to feeding problems were obtained from the Swedish Patient Register and population prevalence data was also obtained. The main outcome was a composite of post-discharge feeding problem diagnosis and/or underweight at 2.5 years of age.In total, 66 children (19%) had post-discharge feeding problems diagnosed before 2 years and/or underweight at 2.5 years of age. The risk of feeding problems when compared to the general population was significantly higher, with an odds ratio (OR) of 193  137.6–270.9). The strongest risk factors for feeding problems were the number of days on mechanical ventilation during the first 8 postnatal weeks, OR of 1.59 (CI 95% 1.29–1.98), and the Clinical Risk Index for Babies-score, OR of 1.14 (CI 95% 1.03–1.26).Post-discharge feeding problems and underweight are common in children born extremely preterm. The strongest perinatal risk factor for later feeding problems was early treatment with mechanical ventilation. Identifying infants at risk of post-discharge feeding problems might be useful for targeting of nutritional support. Infants born preterm are at risk of developing feeding problems after discharge.Underweight and stunting is commonly observed in very preterm infants at and after discharge.One in 5 infants born extremely preterm was diagnosed with feeding problems after discharge or underweight at 2.5 years of age.This study found that the risk of being diagnosed with feeding problems or being underweight at 2.5 years is significantly associated with the number of days treated with mechanical ventilation during the first 8 postnatal weeks.The last few decades have shown exceptional improvements in the survival rate of infants born extremely preterm . HoweverSeveral studies have suggested that preterm infants, especially very preterm infants, are at risk of feeding problems after hospital discharge, including swallowing difficulties, oral motor dysfunction, oral hypersensitivity, eating-behavior disorders, food refusal, difficulty to transition to solid foods, and longer meal durations ,7–11.Insufficient nutritional intakes during the first crucial months and years of life affect the growth of the child and, globally, malnutrition is a common cause of stunting . In extrVarious hypotheses have been proposed on the causal mechanisms resulting in later feeding problems. Prolonged treatment with feeding tubes and endotracheal intubation has been shown to be associated with impaired oral motor development, altered oral sensitivity, altered palatal development , and delayed feeding development in premature infants ,13,14. AIt has been described that preterm infants have a high risk of feeding problems after discharge, but there is a lack of population-based studies in infants born extremely preterm and little is known on clinical risk factors and underlying mechanisms. The objectives of this study were to assess the incidence of feeding problems up to 2 years of age in a population-based cohort of infants born before 27 gestational weeks in Sweden (EXPRESS) and to identify perinatal risk factors for later feeding problems and underweight at 2.5 years of age.The study population originate from the EXPRESS cohort, which included all infants born before 27 completed gestational weeks between April 1, 2004 and March 31, 2007 . Of 707 Infants with major congenital or chromosomal anomalies known to affect weight and height were excluded (n = 5), as well as infants with ileostomy or that underwent bowel surgery n = 14). The most common chromosomal anomaly was Trisomy 21. The reason for infants to undergo bowel surgery or had ileostomies was due to diagnosed or suspected necrotizing enterocolitis (NEC). We also excluded infants with neurological disorders that might affect feeding problems because of the effect on the developing brain: those diagnosed with intraventricular hemorrhage stage 3 and 4 and/or periventricular leucomalacia (n = 41), as well as infants who were diagnosed with cerebral palsy according to stage 2 or higher in the gross motor function classification system . GMFCS is a validated system used to differentiate a child with cerebral palsy’s abilities, limitations, and need for assistive technologies ,19. In t4. The mohttp://links.lww.com/MPG/D51). Additionally, we wanted to examine the extent of interventions, and therefore included possible interventions related to feeding problems, also presented in Table 1, Supplemental Digital Content 1, http://links.lww.com/MPG/D51. Since all children with feeding problems may not have received a diagnosis, we decided to also include those with underweight [below −2 standard deviation (SD)] at 2.5 years in a composite outcome variable “feeding problems and/or underweight,” henceforth abbreviated as FPUW.In this study, feeding problems were defined as having 1 or more of a number of diagnoses from the International Statistical Classification of Diseases and Related Health Problems – Tenth Revision (ICD-10). In order to cover all relevant ICD-10 codes, we included codes related to feeding behavior (R63.3 and F98.2), failure to thrive and malnutrition (R62 and E43), dysphagia (R13.9), and need of nutritional support (nasogastric tube >6 months and percutaneous endoscopic gastrostomy) . Aggregated diagnosed data from the whole Swedish population during the same period were also obtained from the National Patient Register.Growth data were collected at birth, 36 weeks postmenstrual age (PMA) and at 2.5 years of age. Data was retrieved from hospital records and from the EXPRESS cohort database. A Swedish gender-specific growth reference was used to calculate the standard deviation scores (SDS) for weight and length . For datSmall for gestational age (SGA) was defined as a birth weight more than 2 SD below mean. Underweight was defined as weight-for-age <−2 SD. Stunting was defined as length/height-for-age <−2 SD. A weight and length/height between −2 SD and +2 SD were considered to be appropriate for age (AGA).Data on perinatal and morbidity data included Apgar-scores, Clinical Risk Index for Babies (CRIB)-score, antenatal steroids, respiratory support, postnatal steroids, and treatment with antibiotics. Exact time intervals for neonatal treatments were collected prospectively.http://links.lww.com/MPG/D51 after discharge and before the age of 2 years uncorrected age or having a weight below −2 SD at 2.5 years.The primary composite outcome, FPUW, was a combination of post-discharge diagnoses/interventions (up to 2 years of age) and underweight at 2.5 years. FPUW was defined as having at least 1 of the diagnoses or interventions listed in Table 1, Supplemental Digital Content 1, We included the following variables as potential risk factors for FPUW: birth weight, birth weight SDS, CRIB-score, Apgar score at 10 minutes, days on mechanical ventilation, severe bronchopulmonary dysplasia (BPD), treatment with postnatal steroids, and treatment with antibiotics.First, we analyzed the associations between these risk factors and FPUW in univariable binary logistic regressions. Finally, the significant variables from the univariable analyses were entered into a binary logistic regression model using a stepwise approach. A receiver operating characteristic (ROC) analysis was performed to assess the number of days with mechanical ventilation as a predictor for the risk of later feeding problems. As a final step we redid the multivariable analysis using only the diagnosed feeding problems as the outcome.P value of less than 0.05 was considered statistically significant. The Regional Ethical Review Board in Umeå, Sweden, approved the study (Dnr 2017/425-31).The statistical analyses were performed by using SPSS Statistical software version 25.0 . A http://links.lww.com/MPG/D52. All infants had a recorded birth weight, whereas birth length was available for 80% of the infants. The mean duration of mechanical ventilation was 11.97 days, mean CRIB-score 5.7, and 25% of the included infants received postnatal steroids (for a mean 3.48 days). Severe BPD was diagnosed in 28% of the infants. Apgar-scores at 1, 5, and 10 minutes in mean were 5.53, 7.44, and 8.46, respectively.Of the 432 infants that took part in the follow up program, 347 were included in the analyses Fig. . Of the http://links.lww.com/MPG/D51 regarding feeding problems. Furthermore, 48 of the 66 infants (81%) had been given at least 1 of the diagnoses after discharge but were not underweight at 2.5 years of age. Of all infants, 19 (28.8%) had been given at least 2 of the listed diagnoses in Table 1, Supplemental Digital Content 1, http://links.lww.com/MPG/D51. The most common diagnosis was R62 which includes failure to thrive and stunting with 5.8% (n = 20) of the infants in the cohort. The most frequent intervention was the use of nasogastric tube with a duration of more than 6 months . Table In this cohort, 66 infants 19%) had the composite outcome FPUW between discharge and 2 years and/or underweight at 2.5 years , with an odds ratio (OR) of 193.1 (95% CI 137.6–270.9).P ≤ 0.001). Being treated with postnatal steroids was also significantly associated with the risk of FPUW for all the first 8 postnatal weeks, except week 1, and was also significant when considering the whole period of 8 weeks (P ≤ 0.001). Treatment with antibiotics was not significantly associated with later outcome for any of the first 8 postnatal weeks. Severe BPD was significantly associated with the composite outcome FPUW (P ≤ 0.001), as well as lower gestational age at birth (P ≤ 0.001). A low Apgar score at 10 minutes and a high CRIB-score was significantly associated with FPUW .Associations between neonatal risk factors and FPUW were first investigated using univariable linear analyses Table . The numP ≤ 0.001) and CRIB-score . The risk of having FPUW increased by 4.8% for each day treated with mechanical ventilation during the first 8 postnatal weeks. The significant association between days on mechanical ventilation and later feeding problems remained when using only diagnosed feeding problems as the outcome .In the multivariable analysis, variables that were significant in univariable analysis were included. Two significant variables remained in the multivariable analysis; the number of days treated with mechanical ventilation between birth and 8 weeks of age . The cut-off with the highest combination of sensitivity and specificity was 10 days on mechanical ventilation, which had a sensitivity of 71% (0.712) and a specificity of 67% (0.665).P = 0.140) were found.No significant interaction between FPUW and the method of intubation during the first 2 postnatal weeks (P ≤ 0.001) or stunting  at 2.5 years of age remained.When children with diagnosed feeding problems were removed from the multivariable analysis, thus only examining the children with underweight at 2.5 years, a significant association between days on mechanical ventilation and either underweight  in 278 (80%) infants regarding weight, and 180 (52%) infants regarding length/height.The proportions of infants with normal weight (–2 SD to +2 SD) and underweight at the different ages are illustrated in Figure A majority (87%) of the infants had a weight appropriate for gestational age at birth. However, at the age 36 weeks PMA, 42% of the infants born AGA were underweight (below −2 SD). Almost all of these infants showed a progress in weight gain at 2.5 years where 93% of the children had a weight above −2 SD.The same pattern, but even more pronounced, was present when observing the change in SDS regarding length/height, 72% of the infants had a normal birth length (above −2 SD), but at 36 weeks PMA, 81% were stunted (below −2 SD). At 2.5 years of age, 92% of the children had a normal height (above −2 SD).In this cohort of extremely preterm infants, the incidence of feeding problems after discharge from neonatal intensive care units (NICUs) was 19%, using our composite outcome, FPUW, including feeding problem diagnosis and/or underweight up to 2.5 years of age. This incidence is similar compared with other studies on premature infants using various definitions of feeding problems, which have found incidences ranging between 20% and 38% ,22,23. FSanchez et al  examinedA Dutch study by Hoogewerf et al  comparedThe incidence of post-discharge feeding problems in our study is likely an underestimation since it is based on register data and a single anthropometric measurement at 2.5 years of age. Thus, the true incidence in our cohort is likely to be at least 19%.Our study shows that a large proportion of extremely preterm infants have postnatal growth impairments leading to underweight during the hospital stay, results similar with Horbar et al . At 2.5 In the univariable analysis we found associations between CRIB-score, postnatal steroid treatment, severe BPD, and low Apgar at 10 minutes. A common factor for these is that they all in some way reflect general neonatal morbidity and respiratory challenges in particular. CRIB-score is calculated based on gestational week at birth and birth weight as well as oxygen treatment and maximum base excess during the first 12 hours and the presence of congenital malformations. The total CRIB-score is therefore strongly influenced by the gestational age at birth and reflects general morbidity associated with extremely preterm birth. We found that the number of days treated with mechanical ventilation was the strongest predictor of later feeding problems after discharge, and the risk increased by 4.8% for each day of treatment. The risk factor of being treated more than 10 days on mechanical ventilation had a sensitivity of 71% and a specificity of 73% of predicting later feeding problems. Our results agree with Poore et al (Enomoto et al reported a correlation between oral endotracheal intubation and the development of acquired palatal grooves in extremely and very low birth weight infants in Japan . Their rProlonged use of feeding tubes is crucial for supplying nutrition to extremely preterm infants. However, it has been suggested that the presence of feeding tubes might hinder oral feeding attempts and affect the suck-swallow-breath coordination . One stuOur finding of a significant and strong correlation between days with treatment of mechanical ventilation and the post-discharge feeding problems is of potentially great significance for the development of post-discharge follow-up programs of extremely preterm infants. Infants who are treated with mechanical ventilation for a longer period than 10 days might benefit from planned early visits with speech therapists and dietitians to identify and treat feeding problems early. This could also help prevent later stunting or underweight in this vulnerable patient group that is already at risk for poor growth .The strengths of this study were the prospective inclusion of all infants born before 27 gestational weeks in Sweden. Also, the data on diagnoses were collected from the Swedish National Board of Health and Welfare from the National Patient Register which undergoes ongoing quality controls and has been shown to be of high data quality . HoweverThis study shows that the risk of being diagnosed with feeding problems, or being underweight at 2.5 years, is significantly associated with the number of days treated with mechanical ventilation during the first 8 postnatal weeks. We propose that all infants who are discharged from NICUs and have spent more than 10 days intubated could potentially benefit from a follow-up program involving for example physicians, dietitians, and speech therapists to intervene early and help these children avoid later growth restrictions and morbidities.


There is a need for novel methods to determine preventable causes of racial health disparities. This need has been met with the development of improved methods for mediation modeling. Current mediational analysis methods call for an evaluation of statistical interaction or effect modification between the investigated cause and mediator. For racial disparity, this approach facilitates the estimation of racially specific risks for infant mortality. However, current methods for evaluating multiple interacting mediators are inadequate. The first objective of the study was to compare Bayesian estimation of potential outcomes to other approaches to mediation analysis that included interaction. The second objective was to evaluate three potentially interacting mediators of racial disparity for infant mortality by modeling the large dataset from the National Natality Database using Bayesian estimation of potential outcomes.A random sample of observations from the 2003 National Natality Database was used to compare the currently promoted methods for mediation modeling. Racial disparity was modeled as a separate function for each of three potential mediators, (i) maternal smoking, (ii) low birth weight and (iii) teenage maternity. As a second objective, direct Bayesian estimation of potential outcomes modeled infant mortality as function of the interactions among the three mediators and race using the full National Natality Database for the years 2016 to 2018.The counterfactual model was inaccurate in estimating the proportion of racial disparity that was attributable to either maternal smoking or teenage maternity. The counterfactual approach did not accurately estimate the probabilities defined by counterfactual definitions. The error was a result of modeling the excess relative risk instead of the risk probabilities. Bayesian approaches did estimate the probabilities of the counterfactual definitions. Results showed that 73% of the racial disparity for infant mortality was attributed to infants born with low birth weight.Bayesian estimation of potential outcomes could evaluate whether proposed public health programs would affect races differently and decisions could include consideration of the causal effect the program may have on racial disparity. The large contribution of low birth weight to racial disparity for infant mortality should be further investigated to identify preventable factors for low birth weight. In United States, compared to white infants, Black infants are twice as likely to die in their first year of life. While the overall rate of infant mortality has been decreasing over several decades, the racial disparity, defined as the difference between races, has increased . RecentlConsiderable methodological development on mediation analysis within the causal-inference literature has been reported over the last ten years and may provide the novel methods called for by the NIHMD . The advThis study’s objective was to evaluate three potential mediators of racial disparity for infant mortality, including maternal smoking, low birthweight, and teenage maternity. The study implements direct Bayesian estimation of potential outcomes using aggregated counts of observations for each level of race and potential mediators. To illustrate the novel approach, results from direct Bayesian estimation of potential outcomes will be compared to the mediation approach based on a counterfactual model and a Bayesian SEM approach with both models including the estimation of interaction effects. Models will be compared using a smaller database with 100,000 random observations taken from 2003 national U.S. natality database birth records. The direct Bayesian model will then be applied to approximately 11 million observations from the U.S. natality database for the years 2016 to 2018.https://www.cdc.gov/nchs/nvss/births.htm). In the United States, State laws require birth certificates to be completed for all births, and federal law mandates national collection and publication of births and other vital statistics data. The National Vital Statistics System, the federal compilation of these data, is the result of the cooperation between the National Center for Health Statistics (NCHS) and the states to provide access to statistical information from birth certificates.The source of data was the National Vital Statistics System who provide the data online  and mediator .For all models, proportion attributable Model 1 was a counterfactual method known as a four-way decomposition . This apThe approach uses the regression parameters algebraically to partition components of risk as a portion of the total risk, estimated as the portion of relative risk that exceeds 1.Model 2 was a Bayesian Structural Equation Model . For i=1The logit of Total effect Models 3 and 4 estimated the rates for potential outcomes under Bayesian implementations. Race In model 3, for The four rate parameters are the potential outcomes had The total effect The controlled direct effect For model 4, the rates for potential outcomes were estimated using direct Bayesian estimation on tabulated data and a Binomial prior. Data were aggregated into four rows with each row identified by unique values for The four rate parameters are the potential outcomes and were given The total effect (TE) was the rate of The controlled direct effect For the second objective, Model 5 estimated rates for potential outcomes using direct Bayesian estimation on tabulated data and a Binomial prior. Data were aggregated into 16 rows with each row identified by unique values for The The standard counterfactual definition was used as The To estimate controlled direct effect For all Bayesian modeling, estimation was performed using Multibugs 1.0 . A burn-For objective 1, the models produced very similar results for the mediation effect of low birth weight including both the mean effect and the variability of the effect. For the counterfactual model, the estimates for PA for maternal smoking and teenage maternity were different than for the other models . The conParameters from regression modeling showed that estimates for both the counterfactual model  and the Births from the U.S. natality database for the three years, 2016 to 2018 were followed for one year, including until December 31, 2019, for the incidence of infant mortality. The records identified 11,226,394 singleton births for analyses.The Deviance Information Criterion (DIC) was estimated to evaluate goodness of fit among the models. The best fitting model included all interactions among race and the three mediators. The four-way interaction model was shown to be far superior to reduced models .The modeling results are based on the 16 outcome probabilities, defined by combinations of race, smoking, low birth weight and teenage maternity .The public health benefit is the population’s reduction in racial disparity for mediating (completely preventing) one or more of the alterable risk factors. The mediated proportion estimated using the Bayesian model showed virtually no mediation of racial disparity for maternal smoking and teenage maternity and maternal smoking combined with teenage maternity. The proportion mediated by low birth weight was 73.0  and the proportion mediated by low birth weight combined with maternal smoking and by low birth weight combined with teenage maternity was slightly higher but very similar to the mediation of low birth weight, alone . MaternaCounterfactual modeling was developed and promoted to estimate causal effects. The causal effect evaluated in this study is racial disparity defined as the effect of race on infant mortality. A patient’s race cannot be altered but, the current study aims to evaluate whether three known causes of infant mortality cause all or part of the racial disparity. Counterfactual or potential outcome modeling has addressed the limitation that a modeler cannot know a patient’s alternative outcome that would have occurred if the facts had changed and the mediator under consideration had been different. In Bayesian modeling, the directly estimated potential outcome applies to all individuals in the strata defined by approach .Proponents of counterfactual modeling propose definitions of the target probabilities . For exaMediation of causal effects when the cause and mediator interact should be consistent with a structural causal model and must be representable by a directed acyclic graph (DAG) , 17. FacWith race With direct estimation of potential outcomes, the single cause and single mediatior DAG can readily be expanded to multiple mediators and single cause with both interaction and mediation. The DAG used to guide the second objective of the current study proposed a 16 level interaction node. This prior belief is also consistent with estimation equations and counterfactual definitions defined previously for multiple mediators interacting among themselves and with a cause . The 16  effects .The assumption of exchangebility when data are tabulated is essentially that there are no other variables identifying the probability of infant mortality within any spsecific stratum. This can be tested by entering the variable into the interaction and evaluating the DIC. When the variable enters as an interaction and the model fit is superior, the conclusion is that the previous data were not conditionally exchangeable. Bayesian proponents often claim that the condition of exchangeablity is more relaxed than the comparable frequentist assumpions. In the proposed application, the assumption is not less restrictive. The results from this study showed that the best fitting model included interactions among all three mediators which confirms that the data for three single mediator interactions with race were not exchangeable. Further, it can be expected that more variables can be entered thus nullifying the three mediator model. The assumption of exchangeablity is not more relaxed – it is merely simpler to move forward in the modeling process. The modeling showed that the three mediator model was superior to the single mediator model with LBW mediating racial disparity but the superior models do little to change the estimate of the proportion of racial disparity attributable to LBW. The conclusion is that approximately 75% of the racial disparity for infant mortality was due to low birth weight but the proportion varied a small amount with maternal smoking and teenage maternity.Investigators committed to a Bayesian approach should recognize that the probability is near certain that at least one cause of missing infant mortality is missing from at least one stratum and these missing variables provide a modeling limitation. Under the modeling proposed here, these missing variables should be considered potential effect modifiers of racial disparity rather than confounders contributing to bias. For example, the pre-submission reviewers rejected the results, presented here, because low birth weight could have been confounded with premature delivery. Certainly the two factors will interact because low birth weight is either caused by intrauterine growth restriction or preterm birth. Intrauterine growth restriction can cause preterm birth and subsequent infant mortality and preterm birth can cause low birth weight and subsequent infant mortality. Thus, low birth weight and preterm birth will interact in causing infant mortality and the current model should be expanded to include preterm birth. Following the proposed methodology, not knowing the causal ordering between LBW and preterm birth is no longer limiting the mediation analysis. The proportion of racial disparity attributable to either or both can be estimated. The overall average effect of LBW on racial disparity will remain the same but the extent of racial disparity can be expected to vary along with gestation length.As more causes of racial disparity are identified, the complexity of models will become a limitation. Evaluating DIC as more variables are evaluated will show that each additional variable adds an increasing number of effective parameters. Frequentists will recognize this as a similarity to increasing degrees of freedom for interaction models. In the reported modeling, race plus intercept has two effective parameters. Adding the first mediator increased effective parameters to four and adding the second mediator increased the effective parameters to eight and the third mediator to 16 effective parameters. The current study had over 11 million observations, but most studies will model many fewer data. There are at least two reasonable responses. The first is to reduce the number of levels of interaction. For example, in a hypothetical model, it is possible that a single combination of three mediators could be the cause of 100% racial disparity. Such a model could be reduced to two effective parameters (intercept and a single combination of race, The racial disparity for infant mortality in the U.S. from three years of observations was largely mediated by low birth weight. The mediation model predicts that if low birth weight could be prevented, nearly 75% of the racial disparity for infant mortality would be alleviated. Besides different rates between the two race groups for both prevalence of mediators and race-specific risks there also exists a difference in acceptance of public health programs. A legacy of racial discrimination in medical research and the health care system has been linked to a low level of trust in medical research and medical care among African Americans . This miThe causes of racial disparity for infant mortality need more research. A Bayesian mediation modeling approach has shown remarkable potential for identifying the mediating causes.


The prevalence of high birth weight or large for gestational age (LGA) infants is increasing, with increasing evidence of pregnancy-related factors that may have long-term impacts on the health of the mother and baby. We aimed to determine the association between excessive fetal growth, specifically LGA and macrosomia, and subsequent maternal cancer by performing a prospective population-based cohort study. The data set was based on the Shanghai Birth Registry and Shanghai Cancer Registry, with medical records from the Shanghai Health Information Network as a supplement. Macrosomia and LGA prevalence was higher in women who developed cancer than in women who did not. Having an LGA child in the first delivery was associated with a subsequently increased risk of maternal cancer . Additionally, in the last and heaviest deliveries, there were similar associations between LGA births and maternal cancer rates . Furthermore, a substantially increased trend in the risk of maternal cancer was associated with birth weights exceeding 2500 g. Our study supports the association between LGA births and increased risks of maternal cancer, but this risk requires further investigation. There is increasing evidence that pregnancy-related factors may have a long-term impact on the health of mother and offspring, with multiparity established as a protective factor for breast, ovarian, and endometrial cancer3. However, other studies have shown that excessive fetal growth (EFG) is associated with an increased risk of developing hormone-related cancers in mothers, such as breast, thyroid and ovarian cancer6. Moreover, a large cohort study in Sweden found that EFG was independently associated with a higher risk of colorectal cancer7. The potential etiology of the different types of cancer may be due to the different influences of rapidly increasing levels of estrogen, progesterone, insulin-like growth factor-1 (IGF-1), and leptin during pregnancy. However, few studies have evaluated the association between fetal growth and the total risk of all cancers in mothers.During pregnancy, significant anatomical and physiological changes occur in pregnant women to nurture and accommodate the development of the fetus9 and the complex relationship between pregnancy characteristics and different types of cancer grows, it is urgent to investigate the influence of birth weight on the total risk of all cancers. Using a large population-based, data-linked cohort, we aimed to assess the association between the birth weight of infants and the long-term risk of cancers in mothers, ultimately aiming to discover a birth weight that may reduce future maternal cancer risks.We hypothesized that fetal growth levels may serve as an indicator of estrogen and progesterone levels, and that birth weight and large for gestational age (LGA) weights could be used to indicate fetal growth levels. As the average worldwide birth weight increases11.We performed a population-based, prospective cohort study to explore the associations between EFG, specifically LGA and macrosomia, during pregnancy and maternal cancer after childbirth. The birth data was set as the basic database, and the mother’s national identification number (ID) was used to link maternal cancer information from the cancer registry information and medical records in the Shanghai Health Information Network (SHIN). This method and its application in similar studies in Shanghai has been commended for its excellent performance in managing and analyzing an extensive databaseBirth data was obtained from the Shanghai Birth Registry (SBR) of the Shanghai Municipal Center for Disease Control and Prevention (SCDC), which is a legislated population-based surveillance system that was established in 2003. The SBR registers all live births with no limitations to birth weight or gestational age at birth. Birth information included date of birth, infant’s sex, weight and length at birth, gestational age at birth, birth defects, embryo number, mode of delivery, gravidity, parity, and socio-demographic characteristics of the infant’s parents. Between January 1, 2005 and December 31, 2020, 1,168,684 live births born to household-registered women in Shanghai were registered in this system  and a statutory population-based cancer registry, the SCR covers all registered permanent Shanghai residents12. For each patient, the following data were collected: basic demographics, primary site of cancer , incidence date, basis of cancer diagnosis, and reporting hospital. More than 75% of cancer diagnoses were verified using pathology, and more than 90% were confirmed as the primary diagnosis.Cancer data were verified from multiple sources according to the registry data from the Shanghai Cancer Registry (SCR) of the SCDC and medical records in SHIN. As a member of the International Association of Cancer Registries .Cancers, identified by registered cancer cases and all diagnoses of malignant cancer (ICD-10 codes: C00-C97) and benign tumors (ICD-10 codes: D00-D48) reported in SHIN for the first time, were linked to 1,153,429 live births born to 1,010,154 mothers by maternal ID. Mothers with a history of tumors before delivery and with a history of benign tumors were excluded. In the end, 33,221 mothers  identified with maternal malignant cancer diagnoses were included, compared with 825,654 mothers  without maternal tumors  the first delivery, including the first birth records of the mothers; (2) the last delivery, including the last birth records of the mothers; and (3) the heaviest delivery, including the birth records of the heaviest child of the mothers. As more than 85% of the mothers had one child only, the overlap between the first and second groups exceeded 85%.The birth characteristics among mothers who did and did not develop cancer were described in the first, last, and heaviest deliveries. Chi-square tests were used to compare the differences in birth characteristics, and Fisher’s exact tests were used to assess the significance of the differences when the expected number of any of the cells was below five. However, no analyses on the interactions between birth characteristics were conducted.Cox proportional hazard models were used to estimate the association between the birth of an LGA or macrosomia infant and the maternal risk of cancer by calculating hazard ratios (HR) and the 95% confidence interval (95% CI), adjusting for potential confounders. The following pregnancy factors were included in the model as covariates : year of childbirth, maternal age, education level, number of childbirths, history of abortion (including both induced abortion and spontaneous abortion), and number of embryos. Additionally, the time until cancer during follow-up was the dependent variable. To assess heterogeneity effects by maternal age, we used a stratified analysis with each maternal age group. The results were similar to those obtained using an analysis with maternal age serving as a covariate, reported herein. The maternal age and birth weight were set as classification variables in the Cox proportional hazard models for estimating the maternal cancer risk in each group, but were set as continuous variables for estimating the trend.p values were < 0.05. Data preparation and analyses were performed using SAS version 9.4.All tests were two-tailed, and the hypothesis was considered statistically significant if This population-based cohort included 858,875 women from 2005 to 2020, of which 33,221 (3.87%) developed cancer. At the end of follow-up, the average age of the women who did not develop cancer was 37.67 years , and the average age at cancer diagnosis was 35.82 years  compared with women who did not develop cancer (85.85%). More often, women who developed cancer had a previous abortion or caesarean section. In the first, last, and heaviest deliveries, the prevalence of macrosomia and LGA infants was higher in women who developed cancer compared with women who did not develop cancer. A Kaplan–Meier plot of the incidence of maternal cancer after delivery was analyzed; it can be seen in Fig. In all three groups, with increasing childbearing age, the risk of cancer after delivery dramatically increased  per 1000 person-years, while those who did give birth to LGA infants in the first delivery had a 4.66 (95% CI 4.52–4.80) per 1000 person-years incidence  was reported as a protective factor for maternal breast and ovarian cancer, and high birth weight increased the risk of maternal cancerAdditionally, our study confirmed that low birth weight, which was strongly associated with premature births, was also associated with subsequent maternal cancer, as we unexpectedly observed that the risk of maternal cancer was highest in the group with birth weights of 1500–1999 g. Although this finding requires verification, it suggests that controlling birth weight and avoiding premature birth is crucial to reducing the risk of subsequent maternal cancer. This may be achieved by determining the factors of preterm births and low birth weights, including eclampsia and gestational diabetes mellitus.32 showed that reporting LGA, using standardized regional growth charts, would better capture the incidence of high birth weight and allow for the comparison and identification of contributing factors. From 2016 to 2017, the prevalence of macrosomia in China was 7.37%, while the prevalence of LGA was double, at 15.5%19. Our study added LGA as another indicator to show the extent of fetal growth. Compared with macrosomia, LGA may be a more comprehensive and sensitive index reflecting fetal growth, by considering gestational age and gender factors. LGA can reflect EFG in each period of gestation, instead of macrosomia, which may only reflect the infant's weight at birth. For example, a preterm birth who has overgrown at early gestation can be an LGA birth, but may not indicate fetal macrosomia, with normal birth weight. Consequently, it is better for us to analyze both indices—macrosomia and LGA. The association between LGA and maternal cancer was statistically significant, indicating that the gestational age-specific weight along with the duration of the pregnancy is crucial, instead of controlling the birth weight within a specific span only.Most former studies have always included only macrosomia as an indicator of fetal growth level. Macrosomia, usually defined as infant birth weight of ≥ 4000 g, does not consider gestational age, gender, or region-specific differences in mean birth weight and maternal body weight. One study among Asian population33. Moreover, delivery before the age of 24 years decreased long-term cancer risk, while delivery after the age of 26 years increased long-term cancer risk, indicating that conceiving earlier may reduce the risk of subsequent cancer.Apart from the fetal growth results, our study also found that women who gave birth at a relatively later age were more likely to develop subsequent cancers; this outcome was confirmed by further analysis which supported this findingOur findings from a large, population-based cohort contribute to the existing evidence regarding the role of EFG on subsequent malignancy risk in the mother. Previous studies appeared to focus on hormone-related cancers, except one large cohort study in Sweden, which found that EFG was independently associated with a higher risk of colorectal cancer. Our study included all types of maternal cancers. In addition, we included the variable LGA, a more accurate and proper index, to study the association between fetal growth and maternal cancer. Furthermore, no study has been able to find a more appropriate birth weight to reduce the future maternal cancer risk, whereas we determined the optimal birth weight to be approximately 2500 g for the lowest risk of all maternal cancers.Limitations included a lack of information for certain other exposures that may be associated with maternal malignancies, including alcohol use, smoking, and diet. Hence, we were unable to examine their potential influences on our findings. This cohort was also relatively young, with a median age of 37 years (maximum 65 years) at the end of follow-up. Additional follow-up is required to examine our observed associations at older ages, when malignancy is more common. Studies with more specific types of cancer would be useful to examine the associations reported in this study. Although the cases in our model were independent, as we divided birth records into three groups as “the first group, the last group and the heaviest group”, the births from the same women were not studied separately, and this should be analyzed in the future.In conclusion, the association between LGA birth and increased risk of maternal malignancy was statistically significant and plausible in our study. This potential link should be further examined in a different population. The results of this study may provide a basis for future research on the link between fetal growth and the risk of maternal malignancy.


Orbital conjunctival epithelial cysts have traditionally been excised, with the risk of leaving behind remnants that may result in recurrences. We present an 18-year-old male who complained of a poorly retained prosthesis three years after a primary evisceration and polymethylmethacrylate (PMMA) ball implant. We performed cyst aspiration and injection foam sclerotherapy for the cyst, which resolved completely in six weeks, allowing the prosthesis to be retained comfortably. Aspiration and injection of sclerosing agents may result in the collapse of the cyst along with fibrosis of their walls with obliteration of the lumen, resulting in complete resolution. Conjunctival epithelial inclusion cysts of the orbit following evisceration are uncommon; however, there have been several modalities of treatment used to manage them. In an anophthalmic socket, these cysts can result in an ill-fitting ocular prosthesis due to the rise in surface area or migration of the orbital implant. The patient might suffer from the inability to retain the prosthesis, and this is usually when the patient presents, resulting in poor cosmesis . These cAn 18-year-old Indian male presented to us with complaints of displacement of his custom ocular prosthesis Figure  and occaCT of the orbit revealed an orbital fluid-filled cyst that had shifted the PMMA implant upward Figure , 2b and We then proceeded to perform injection sclerotherapy for the patient. In the supine position, with topical anesthetic instilled, the area was painted and draped, and a speculum was placed on the side of the anophthalmic socket Figure . With thIn the first 48 hours after the procedure, the patient may experience minimal discomfort due to transient inflammation prior to the onset of fibrosis. The patient preferred the option of prosthesis modification for the management of his left upper lid ptosis.Foam sclerotherapy is an inexpensive and easily performed procedure that has been used for periorbital dermoid cysts  and venoTo summarize, this is a rare presentation of a conjunctival epithelial cyst after primary orbital implantation following evisceration. Imaging can help to localize the exact position and depth of the posterior wall of the cyst to plan cyst aspiration. STS is an effective treatment as a foam sclerosant for a minimally invasive solution for the management of these cysts.


The onset of manual reaching allows the expansion of the infant’s interaction with the environment. When born preterm, infants become vulnerable to problems in the development of reaching. However, it is still unknown whether there are differences in reaching according to the degree of prematurity.This study aimed to explore the differences in reaching acquisition and behavior between late preterm and very preterm infants, as well as whether age and clinical variables influence the results.This is an exploratory, comparative, observational study. In total, 24 infants were included soon after reaching onset; 12 infants were born late preterm  and 12 very preterm . Infants were placed in a baby seat, and a toy was placed at a reachable distance for 2 min. Reaching behavior was the primary variable; birth weight and length of hospital stay were secondary variables.The age of reaching onset was higher in the very preterm group. The proportion of reaches with grasping was higher in the late preterm group. These differences were affected by the lower birth weight and longer length of hospital stay in the very preterm group. The proportions of proximal and distal adjustments did not differ between groups.Very preterm infants presented disadvantages in the acquisition time and the number of reaches with grasping, but not in the proportions of proximal and distal adjustments of reaching, relative to late preterm infants. Group differences were influenced by clinical variables. If hospOne of the motor skills commonly affected by preterm birth is manual reaching. The onset of reaching typically occurs at 3–5 months of age and requires the ability to locate the object in space and move one or both hands to finally touch it . It is cCompared with typically developing full-term infants, very preterm infants (28 to 31/6-week gestation) with low birth weight delay the acquisition of reaching  and use Despite the clinical importance of assessing reaching behavior as a potential strategy to monitor developmental problems in preterm infants, no studies that have investigated whether delays and early changes in reaching behavior are different according to degrees of prematurity were found. Furthermore, it is not known whether these problems are influenced by other clinical features. The objective of this study was to explore differences in early reaching behavior between two groups of infants with different degrees of prematurity. The following question guided this study: (a) Do very preterm infants (higher degree of prematurity) differ from late preterm infants (lower degree of prematurity) in the age of acquisition of reaching and in the reaching behavior at this period? (b) Do age and clinical variables, such as birth weight and length of hospital stay, affect the results? The results can expand the knowledge of the impact of preterm birth on early manual skills and guide further research.2.2.1.This is an exploratory observational study with a comparative analytical cross-section.2.2.Participants were 30 preterm infants, recruited from the Neonatal Intermediate Care Unit (NICU) of the University Hospital of the Federal University of Mato Grosso do Sul, Brazil. The infants were assessed between 2016 and 2018. The final sample consisted of 24 infants (12 late preterm and 12 very preterm infants). Infants were assessed immediately after the emergence of reaching .For inclusion in the study, infants had to be born preterm, with a gestational age of 34 to 36/6 weeks (late preterm) and 28 to 31/6 weeks (very preterm), regardless of birth weight or length of hospital stay in neonatal units. All infants should be under maternal home care. Diagnosis of anoxia, signs of neurological complications, hyperbilirubinemia, congenital malformations, genetic syndromes, progressive neuromuscular conditions, and orthopedic, sensory , or cardiorespiratory problems were exclusion criteria.The study was approved by the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (protocol number 2355473/2017). All parents signed the informed consent form authorizing their infants’ participation.2.3.To follow up on the emergence of reaching, home visits were carried out by the researcher twice a week from the 12th week of the chronological age of the infants . During 2 in size and varied in shape and texture ; the goal was to offer varied opportunities for infants to reach and grasp, thus mimicking the actual environment. The toys were presented always in the same sequence for all infants. No verbal or physical encouragement was provided for the infant during the assessments. If the infant was fussy or crying, the assessment was interrupted, the infant calmed down and the assessment restarted.Reaching assessment was performed on a single day. Infants should be in an active alert state. The infant was placed in the baby seat, and a toy was presented for 2 min . During 2.4.Clinical variables considered were birth weight  and length of hospital stay. These data were collected from the hospital discharge reports provided by the parents. The length of hospital stay was considered the total number of days the infant remained hospitalized in the NICU. The age of emergence of reaching (age at reaching onset) was considered as the one in which the infant was able to perform three to five reaches in 1 min.The reaching outcomes considered were the total number of reaches, proximal adjustments, distal adjustments, and grasping outcome.The total number of reaches was considered as the number of valid reaches performed by the infant. A reach was considered valid when the infant performed the movement with one or both upper limbs toward the object until touching it, with or without grasping .Proximal adjustments were considered as the initiative to direct one or both upper limbs to the presented toys and were categorized as follows: (a) unimanual reaching, when the infant moved only one of the upper limbs toward the object until touching it  or (b) bDistal adjustments were considered as the hand configuration at the object touch, as follows: (a) open hand, when the fingers were fully extended or slightly flexed; (b) closed hand, when all the fingers were completely flexed or, in a few cases, when all the fingers were completely flexed and only one finger was extended; or (c) semi-open hand, when the fingers were in an intermediate position between open and closed .The outcome of reaching in terms of grasping was also considered: (a) reaching with grasping, when the infant was able to hold the object or part of it using the hand or fingers of one or both hands after a valid reaching; and (b) reaching without grasping, when the infant reached the object without grasping it .2.5.Statistical analysis was performed using SPSS 23.0. The Shapiro–Wilk test was used to evaluate data distribution. Clinical variables and age were described using mean and standard deviation; median, minimum, and maximum were used to describe reaching outcomes. The total number of reaches were analyzed considering the frequency of their occurrence, and the proximal and distal adjustments and grasping were analyzed considering their proportions in relation to the total number of reaches.t-tests were applied for clinical variables and age. The Mann–Whitney U-test was applied to reach outcomes. Non-parametric ANCOVA (Quade’s test) was used to examine the effect of clinical variables and age as intervening variables on reaching outcomes, considering birth weight, length of hospitalization stay, and age at reaching onset as covariable. The adjusted R2 was used to determine the effect size; the stronger its value, the stronger the strength of the association between the dependent variable and the intervening variable (For comparisons between groups (late preterm × very preterm), independent variable . An α si3.t = 8.91; p < 0.01). The very preterm group had a longer hospital stay at the NICU (34.67 ± 13.80 days) than the late preterm group ; late preterm infants were not admitted to the NICU.With respect to clinical variables, birth weight was higher in the late preterm group (2.510 ± 0.34 grams) than in the very preterm group  and corrected  ages.The age at reaching onset was higher in the very preterm group  than in the late preterm group  for both chronological (p = 0.35). Bimanual reaches  and reaches with semi-open hand  were the most adopted proximal and distal adjustments, retrospectively, but there were no differences between the groups for those variables , which indicated this variable did not affect the result. The group difference was not maintained when birth weight  and length of hospital stay were analyzed as covariates , which indicated that despite the small association, these variables affected the variance in the proportions of grasping.There was a difference between the groups for grasping. The proportion of reaches with grasping was higher in the late preterm group than in the very preterm group , birth weight , and length of hospital stay  and indicated small associations between these independent variables and the dependent reaching outcomes.The other reaching outcomes remained similar between the groups in the covariance analysis after adjusting the values for age at reaching onset ’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.AF: Methodology, Writing – review & editing, Data curation, Writing – original draft. PT: Data curation, Writing – original draft, Writing – review & editing. AO: Formal Analysis, Writing – review & editing. ET: Writing – review & editing. DS-M: Conceptualization, Formal Analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – review & editing.


Low birth weight has been shown to increase the risk of mortality in feline species. Thus, it is important to provide pet professionals with weight thresholds in order to enable them to make the best use of this simple and inexpensive, but essential, management practice, i.e., weighing kittens at birth. Based on data collected from 194 French catteries, this study defined birth weight thresholds which allow for the identification of kittens at higher risk of 0–2 months mortality in 15 breeds (5596 kittens). Two thresholds were identified, classifying kittens into three groups: normal, low, and very low birth weight, characterized by low, moderate, and high risk of 0–2 months mortality, respectively. Values defining very low birth weight kittens varied between 60 g and 78 g depending on the breed and the values defining low birth weight kittens were between 74 g and 104 g. When used as alarm thresholds, these values will facilitate the detection of kittens requiring specific nursing.In many species, low birth weight is identified as a major determinant for neonatal survival. The objectives of the present study were (i) to assess, in a large feline purebred population, the impact of birth weight on 0–2 months mortality in kittens, and (ii) if such mortality occurs, to define cut-off values for birth weight to identify at-risk kittens. Data from 5596 kittens from 15 breeds and provided by 194 French breeders were analysed. A logistic mixed model was used to identify low birth weight, being a male, and being born in a large litter as significant risk factors for kitten mortality during the first two months after birth. Classification and regression tree analysis was used to define the thresholds, first at the species level and, when possible, at the breed level. Two thresholds were defined to group kittens into three categories: low, moderate, or high risk of 0–2 months mortality . In our population, 19.7% of the kittens were classified as low birth weight and 1.9% as very low birth weight. Critical thresholds may differ between breeds with similar birth weight distributions and equivalent mortality rates . These critical birth weight thresholds, established in 15 breeds, could be used to identify kittens requiring more intensive nursing to improve survival. Kitten mortalities during the first two months after birth impacts the welfare of the animals, affects the emotional state of breeders, and impacts the financial stability of their facilities. Despite its interest for veterinarians, breeders, and pet owners, feline neonatalogy remains poorly explored and neglected , especiaIn many mammalian species, birth weight has been identified as a major determinant for neonatal survival . The relThe first objective of the present study was to assess the impact of birth weight on 0–2 months mortality in kittens in a large feline purebred population with multiple breeds. Since weighing at birth is an easy action to implement in the field, it is necessary to determine decisional birth weight thresholds: in the second part of this work, cut-off values for birth weight to identify at-risk kittens were determined by breed.This study was constructed from the same data collection presented in Mugnier et al. . BrieflyFrom the total database, several exclusion criteria were applied to select the study population for the current study. All stillborn neonates, kittens born before 2000, and/or with no birth weight provided and/or with unknown status regarding mortality at two months of age were excluded. Finally, only kittens from breeds with at least 100 individuals were included in the final dataset.p-values less than 0.05 were considered significant. Statistical uncertainty was assessed by calculating 95% binomial confidence intervals (95%CI).All statistical analyses were performed using R software version 4.2.1 . Resultsp < 0.001, Kruskal–Wallis rank sum test) using breed-specific quartiles. For each breed and each parameter, kittens were divided into four groups based on the calculated quartiles: Q1 for kittens with a value in the lowest 25% of the study population (lower than the first quartile); Q2, with a value between the first quartile and the median; Q3, with a value between the median and the third quartile, and Q4, a value in the highest 25% (higher than the third quartile).A logistic mixed model was fitted using the package lme4  to deterperformance , for NBW kittens (203/4486), 16.5%, 95% CI , for LBW kittens (166/1004), and 50.9%, 95% CI , for VLBW kittens 54/106; .This work describes a national scale study on feline neonatalogy. The size of the population (1507 litters) was higher than in the previous studies on this topic , was similar to that in a previous study in France (7.9%) , but lowThe interest in birth weight for better controlling neonatal mortality has been demonstrated in numerous species , but stuFor the other factors explored, contrary to a previous study , litter Data was collected through questionnaire. In order to limit memory bias and the length of the questionnaire , not allThe main objective of this study was to provide, as in other mammalian species , cat breThese thresholds vary depending on the breed (from 60 g to 78 g for Threshold 1 and from 74 g to 104 g for Threshold 2). This variation cannot be explained only by breed variation of birth weight ,12,36 siMoreover, the population of (very) low birth weight is probably non homogeneous ,38: someEarly detection of at-risk kittens is essential to reduce the mortality rate in catteries. This study could help pet professionals  build awareness of the issue of LBW. It also provides objective birth weight thresholds, making the identification of at-risk newborns practical. Weighing at birth requires no specific skills but allows for easy identification of kittens that will require care with an inexpensive tool . Beyond the neonatal period, further research is required to study the mid- and long-term consequences of reduced intrauterine growth and low birth weight. In addition, it would be interesting to explore, in depth, the postnatal growth of kittens, the monitoring of which could also be an interesting tool in the field.


We developed a facile method to produce a uniform chromate conversion (CC) coating on zinc alloy-plated steel substrates (ZS). When an acidic CC solution is applied to ZS (C-ZS), zinc is dissolved and chromium ions are reduced to form a chromate coating. In localized areas where zinc is excessively dissolved, zinc hydroxide particles are formed, which hinders the formation of a uniform chromate film, leaving the areas vulnerable to further corrosion  when exposed to high humidity conditions. To suppress the excessive dissolution of zinc, the ZS surface was pretreated with thiolated polyethylene oxide to form a hydrophilic self-assembled monolayer. A more uniform protective CC coating was obtained on the pretreated ZS, resulting in superior corrosion resistance under high humidity conditions. To improve the corrosion resistance of ZS further, an acidic chromate conversion (CC) coating is often used as a post-treatment process4. When an acidic CC solution is applied to ZS, the anodic dissolution of zinc leads to the cathodic precipitation of chromium oxide, which acts as a barrier to protect the underlying zinc alloy from corrosive environments6.Zinc alloy-plated steel (ZS) is widely used in various industrial applications because of its excellent resistance to corrosion8. These dark spots are caused by zinc corrosion products, such as zinc oxide and zinc hydroxides. Although zinc oxide and zinc hydroxides are usually white in color, they can appear dark due to variations in the optical properties of the corrosion products and the underlying zinc7. Once dark spots appear, they can induce the peeling of an applied organic film, such as paint, and can lead to the development of larger white corrosion products9. Therefore, the development of a method to suppress dark spot formation during the CC coating process is needed.While CC coatings have proven effective in preventing general corrosion, studies have reported the appearance of small dark spots on CC-coated ZS (C-ZS) under high humidity conditions12, to the best of our knowledge, this is the first attempt to utilize a hydrophilic SAM to achieve a uniform CC coating on ZS. The surface of C-ZS treated with an interlayer of PEO-SH (CP-ZS) showed minimal damage and effectively prevented the formation of dark spots during CC coating treatment. The resulting CP-ZS demonstrated superior corrosion resistance to C-ZS under high humidity environments.In this study, it was revealed that the appearance of dark spots on the C-ZS surface was initiated by the localized damage inflicted on ZS during the application of the acidic CC coating. The regions that were left without adequate coverage were prone to developing into dark spots when exposed to high humidity. To mitigate surface damage, the ZS surface was pretreated with a thiolated polyethylene oxide (PEO-SH) self-assembled monolayer (SAM) before applying the CC coating. While hydrophobic SAMs have been employed to protect metal substrates from aggressive water and acid molecules3)3 and ethanol (absolute) were purchased from UNICOH (Korea) and Sigma-Aldrich , respectively. Due to the carcinogenic nature of hexavalent chromium, we utilized trivalent chromium for the conversion coating process. Thiolated polyethylene oxide  was procured from Polypure . Nitric acid (60%) and methyl ethyl ketone were obtained from SAMCHUN (Korea) and DAE JUNG (Korea), respectively. Deionized (DI) water (18.3 MΩ·cm) was obtained using a reverse osmosis water system .Hot-dipped Zn alloy-plated steel was obtained from POSCO (Korea). The zinc alloy layer comprises 97% Zn, 1.5% Mg, and 1.5% Al. Cr(NO3)3 in 7:3 (v:v) DI water and ethanol was prepared as the CC coating solution. Following typical commercial processes14, the pH of the CC coating solution as adjusted to 1.6 using 20 wt.% nitric acid. Ethanol was employed to enhance the wettability of the solution on ZS. It is worth noting that the use of volatile organic compounds in industrial production is limited to a low amount. The PEO-thiol solution was prepared by dissolving PEO-SH in absolute ethanol to a final concentration of 10 mM. ZS samples were cut into 3.7 × 3.7 cm squares, degreased in methyl ethyl ketone, and then sonicated in ethanol for 3 min. Thereafter, ZS squares were immersed in the PEO-thiol solution for 24 h to obtain P-ZS. The CC solution was then applied to ZS and P-ZS using a bar coater to create C-ZS and CP-ZS, respectively. C-ZS and CP-ZS samples were then dried in a 100 °C oven at a peak metal temperature of 60 °C.A 3 wt.% solution of Cr set to 40 °C and 95% RH for 72 h. The surface and cross-section of the CC coatings were then examined using optical microscopy  and scanning electron microscopy equipped with energy dispersive X-ray spectroscopy . Cross-section pieces were polished using an ion beam cross-section polisher (Leica model EM TIC 3X) and a 60 nm thick Pt layer was sputtered on to distinguish the CC coating from the layer deposited during ion beam milling.16. The surface morphology of C-ZS was similar to that of ZS, indicating that the very thin (~ 100 nm) CC coating did not substantially alter the surface morphology. After exposure to high humidity, only negligible morphological changes were observed on the ZS sample; however, dark spots appeared on the C-ZS sample, indicating that the dark spots were associated with the CC coating process.Figure Figure 10.If a uniform and dense CC coating is applied to ZS, it should effectively protect the underlying zinc layer from corrosion. Therefore, the formation of dark spots on C-ZS is believed to be caused by surface damage during the CC coating under acidic conditions. To test this hypothesis, a hydrophilic PEO-SH layer was applied to the surface of ZS before the CC coating was applied. After coating with PEO-SH, the water contact angles of ZS changed from 79° to 43°, indicating the formation of a hydrophilic PEO layer on P-ZS Fig. . Figure 3 in ethanol solution, using the same pH (1.6) as the CC coating solution, a significant increase in oxygen content was observed on ZS, while only a negligible change in oxygen content was seen on P-ZS . Utilization of a PEO-SH surface modifier in the CC coating process effectively reduced the formation of dark spots on ZS, indicative of corrosion, when exposed to high humidity conditions. As PEO-SH spontaneously forms on zinc surfaces via covalent bonding under ambient conditions, the developed method has the potential for improving the corrosion resistance of ZS in a wide range of applications.Supplementary Figures.


N = 29) and term (N = 28) infants, we found that the maturation of the aperiodic EEG component was accelerated in the preterm cohort, with a significantly flatter 1/f slope when compared to the term infants. The flatter slope was a result of decreased spectral power in the theta and alpha bands and was correlated with the degree of prematurity. To determine the circuit and cellular changes that potentially mediate the changes in 1/f slope after preterm birth, we used in vivo electrophysiology in preterm mice and found that, similar to infants, preterm birth results in a flattened 1/f slope. We analyzed neuronal activity in the visual cortex of preterm (N = 6) and term (N = 9) mice and found suppressed spontaneous firing of neurons. Using immunohistochemistry, we further found an accelerated maturation of inhibitory circuits. In both preterm mice and infants, the functional maturation of the cortex was accelerated, underscoring birth as a critical checkpoint in cortical maturation. Our study points to a potential mechanism of preterm birth-related changes in resting neural activity, highlighting the utility of a cross-species approach in studying the neural circuit mechanisms of preterm birth-related neurodevelopmental conditions.Prematurity is among the leading risks for poor neurocognitive outcomes. The brains of preterm infants show alterations in structure and electrical activity, but the underlying circuit mechanisms are unclear. To address this, we performed a cross-species study of the electrophysiological activity in the visual cortices of prematurely born infants and mice. Using electroencephalography (EEG) in a sample of healthy preterm ( Preterm infants born < 37 weeks’ gestation currently represent a tenth of the infant population, with rising prevalence. Risks for prematurity include multiple gestations and pregnancy complications, with health outcomes positively correlated with increasing age at birth . As the in utero fetuses of the same gestational age, suggesting that preterm birth alters developmental trajectories in a circuit-specific manner  has been increasingly used in the clinical setting both for prognostic and diagnostic purposes . EEG is Increasing use of animal models that replicate electrophysiological signatures of preterm birth-related brain injury, such as hypoxia, has aided in identifying the cellular and circuit changes after preterm birth . Very eain vivo electrophysiology in preterm mice to identify changes in periodic and aperiodic neural activity associated with prematurity. We focused our study on the visual cortex for three reasons: (1) it is well characterized anatomically and functionally in both humans and mice  preand mice , and (3)Sixty-eight preterm infants recruited from the University of Virginia neonatal intensive care unit (NICU) and 75 term infants recruited from the greater Charlottesville area completed a resting-state EEG paradigm as part of a larger, ongoing study. Inclusion criteria for the preterm sample were birth prior to 37 weeks’ gestation, corrected age 0–4 months at testing, English-speaking legal guardian, no known uncorrectable severe auditory or visual deficit, and health condition deemed sufficiently stable for participation by the neonatology care team. Inclusion criteria for the term sample were birth after 37 weeks’ gestation, age 0–4 months at testing, English-speaking legal guardian, no known family history of neurodevelopmental disorder, and no known uncorrectable auditory or visual deficit. All data were collected at the onset of the critical period for the development of binocularity (after birth) , a visuaFull scalp resting-state EEG  was recoad libitum. Animals from both sexes were used during the 4th week after birth. Preterm mice were generated through timed breedings, where the day after the pairing was considered as gestational day (GD) 0. Once the pregnancy was confirmed (>1.5 g increase in weight at GD 10), pregnant dams were habituated to handlers by daily handling. Mifepristone  was dissolved in DMSO and 150 μg was injected subcutaneously on GD 17  on standard 12:12 light:dark cycle, with food and water on GD 17 . Pretermon GD 17 , and incon GD 17 . Pretermon GD 17 . Controlon GD 17 . AnimalsN = 9) and preterm (N = 6) female and male mice, ages 21–28 days after birth, using a treadmill and blank screen as described in V1 recordings were performed on awake term  were sectioned into 40 μm, stained, and mounted on glass slides. Images were acquired from 4 to 6 sections/mouse (minimum 20 images/mouse). Quantification was performed on background subtracted images using ImageJ. See Brains from term and preterm mice , unless stated otherwise. Spectral analysis was performed with Spike2 on 60 s of data at 500 Hz for both infant and mouse datasets. Power was normalized to the power in high frequency band (150–250 Hz). For infant data, power between 58 and 62 Hz was excluded to eliminate contamination from line noise which was present in some samples. Power spectral density values were averaged across channels of interest  using nested interest . 1/f sloNeurocognitive and visual deficits of unclear origin are common in preterm children , and theF = 2.55, p = 0.039; Sidak’s multiple comparison test delta p = 0.43, theta p < 0.0001, alpha p = 0.02, beta p = 0.95, gamma p = 0.99].We first used EEG in infants to measure resting state activity in the occipital and parietal visual areas within the first 4 months of life. While the preterm infants had a typical distribution of high power in low frequencies and low power in high frequencies , power iF = 137.00, p < 0.0001], despite preterm infants being significantly younger in postmenstrual age  and equivalent in chronological age  between slope values and the degree of prematurity, with extremely  and very  preterm infants showing the flattest 1/f slopes. We found no effects of mode of delivery on 1/f slope values in either term or preterm cohort , nor of respiratory issues reported in both cohorts . Within the preterm cohort, we further found no relationship between the 1/f slope values and retinopathy of prematurity , or between 1/f slope values and administration of antenatal steroids , two most common complications in our cohort  in layer 2/3 of the primary visual cortex (V1) of awake, young term and preterm mice  = 2.93, p = 0.03], and post-hoc tests revealed a significant reduction of power in the delta band . However, preterm mice also had a significantly flatter 1/f slope , indicating accelerated maturation of the primary visual cortex and suggesting the relative conservation of the effects of prematurity on neural activity in mice and humans.To confirm whether electrophysiological activity of visual areas in a mouse model of preterm birth recapitulates changes seen in preterm infants , we usederm mice . There wt-test t(9) = 2.42, p = 0.030; 239 isolated neurons from 5 term and 6 preterm mice].The fourth postnatal week represents a critical transition toward visually-driven activity in mice, reflected in increased suppression of spontaneous neuronal activity by rising levels of inhibitory neurotransmission . Given tp < 0.0001, D = 0.38), with no changes in their density . Cortical perisomatic inhibition is mediated by fast-spiking, Parvalbumin-expressing interneurons , without any changes in the overall density of PV interneurons . Altogether, these results demonstrate accelerated maturation of the visual cortex after preterm birth and suggest a central role of inhibition in this process.Suppressed spontaneous firing could be a result of increased inhibition in the developing cortex . To testrneurons . As prevrneurons , we thenrneurons , with lorneurons . In agreDespite extensive research, effects of premature birth on cortical activity in the early postnatal period remain unclear. Through a comparative approach, our study identified accelerated maturation of neural activity in the visual cortex of preterm infants and mice driven by elevated levels of inhibition.Cortical oscillatory activity shows distinct developmental patterns, with a reduction in the relative power of low frequencies and an increase in high frequencies with increasing age . Such diFast-spiking, Parvalbumin interneurons are central for the maturation of cortical circuits . Their fAnother potential cause of divergence between our findings in preterm mice and previously published findings on interneuronal populations , 2021 inTerm-born mouse pups in the first postnatal week are commonly compared to preterm newborns, based on cortical development milestones . While dThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the University of Virginia Institutional Review Board for Health Sciences Research. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. This animal study was reviewed and approved by the University of Virginia Animal Care and Use Committee.AR and MP conceived and designed the study. AR acquired and analyzed mice data, analyzed infant data, and wrote the manuscript with input from all authors. MP, MN, WC, AB, and AD acquired infant data. MP analyzed infant data. EM analyzed infant and mice data. IW, TH, and CS collected and analyzed the immunohistochemistry data. All authors contributed to the article and approved the submitted version.


The majority of nasopharyngeal cysts are asymptomatic and rare. Nevertheless, these lesions are rarely discovered during regular endoscopies and imaging tests. An upper nasopharyngeal Thornwaldt cyst is a benign, mucosal congenital cyst. Even less frequently, they can cause unexplained sinonasal symptoms such as rhinorrhea, vision problems, and nasal blockage. Here, we report a case with new-onset hearing loss after the coronavirus infection, in which his imaging investigation showed a nasopharyngeal mass.After covid-19 infection we should consider branchial Cyst and Thornwaldt Cyst in a high-risk patients. On the other hand, the progressive hearing loss after covid-19 can occur due to activation of this kind of cysts. Tinnitus, balance abnormalities, smell and taste disorders, as well as other otoneurological symptoms, are all signs that SARS-CoV-2 may be involved. However, research on Hearing Loss in COVID-19 patients is still in its infancy. It may be possible to address therapeutic options to enhance clinical recovery and prevent side effects by looking into the function of SARS-CoV-2 as an aetiological cause of Sudden Sensorineural Hearing Loss (SSNHL). Nasal endoscopy showed a well-defined smooth surfaced cystic mass in his posterior lateral and midline nasopharynx . MRI with gadolinium showed a high signal intensity lesion at the nasopharynx's right posterolateral wall, suggestive of complicated or high protein-containing brachial cleft cyst type 2 based on its place . It also showed a high signal intensity cyst with ring enhancement at the central part of the nasopharynx's posterior wall, suggestive of a complicated or high protein-containing thornwaldt cyst .  He underwent surgery with the diagnosis of a branchial cyst, and marsupialization was performed under general anesthesia; Cyst was full of Brawny discharge. Biopsy was taken, and pathology showed fragments of cyst-like structure lined by stratified squamous and respiratory ciliated epithelium with underlying chronic inflammation lymphoid aggregation and fibrosis .  It was compatible with the branchial cleft cyst. After one year of follow-up, there is no recurrence, and the patient is asymptomatic.The nasopharynx should unquestionably be assessed before administering any medicinal therapy to patients who complain of nasal blockage and have no neurological symptoms. This case is the first reported case of a tornwaldt Cyst and nasopharyngeal branchial cleft cyst simultaneously. They both are rare diseases, and their management is surgical in both. When the bursa's entry to the nasopharynx is blocked by an infection, an adenoidectomy, or radiation therapy, a Thornwaldt cyst forms. On the other hand, Depending on their infectious status, bronchogenic cysts may present with symptoms. In this patient, we suggest that the covid-19 infection had a role in Thornwaldt cyst formation and bronchial cyst presentation due to the lack of symptoms before infection.Histopathologically, branchial cysts are lined by various types of epithelium, mostly stratified squamous and ciliated columnar epithelium . We haveClinical presentation varies based on the size and extension of the Cysts. These cysts are primarily small and asymptomatic. in symptomatic cases, Ear fullness, serous otitis media, and conductive hearing loss are common . Nasal oUnfortunately, the occurrence has not been reported till now. There are different techniques to treat, including aspiration, excision, or marsupialization. These recent years there has been a tendency to use endoscopic/robotic approaches in rich countries ,18. HoweBefore administering any medical treatments to individuals who simply have the complaint of new onset hearing loss and have no neurological signs or active infection, the nasopharynx could be thoroughly examined. After covid-19 infection we should consider branchial Cyst and Thornwaldt Cyst in a patient with risks. On the other hand, the progressive hearing loss after covid-19 can occur due to activation of this kind of cysts.


Around the world, caesarean section rates have steadily increased over the past few decades. The World Health Organization (WHO) guidelines on nonclinical interventions to reduce caesarean section rates emphasize educational interventions and support programs.In this study, we have determined factors associated with adolescents’ intention regarding childbirth options using the Theory of Planned Behavior (TPB). The sample was comprised of 480 high school students in Greece who were invited to complete a questionnaire consisting of three sections: a section on sociodemographic data; a section featuring the Adolescents’ Intentions towards Birth Options (AIBO) scale, a recently developed instrument that accesses attitudes and intentions regarding vaginal birth and caesarean section; and a section detailing participants’ awareness regarding reproduction and birth.Multiple logistic regression found that participants’ impressions of vaginal birth and the TPB constructs were significantly associated with intention towards caesarean section. In particular, participants with a negative impression of vaginal birth had a 2.20-fold higher probability of reporting their preference for caesarean section, compared to participants with neither a negative nor a positive impression. Furthermore, participants with higher scores on the “Attitudes towards vaginal birth,” “Subjective norms,” and “Perceived behavior control over vaginal birth” subscales had a significantly lower probability of reporting preference for caesarean section.Our study demonstrates the effectiveness of the TPB to identify factors that influence adolescents’ preference for childbirth. We highlight the necessity to implement nonclinical interventions to reduce the preference for caesarean section, providing evidence for developing school-based educational programs for a timely and consistency implementation. Around the world, caesarean section (CS) rates have steadily increased over recent decades . CaesareThe rise in caesarean section rates can be explained through a complex multivariate analysis of the following contributing factors: changes regarding both the distinguishing characteristics of the mother (with pregnancies being increased in elderly nulliparous women) and professional practice styles; personalized medicine instead of team obstetric care; increased malpractice pressure (defensive medicine); and economic, organizational, social, and cultural factors ,4,5,6. AWhile the debate for interventional approaches is ongoing, the World Health Organization (WHO) guidelines on nonclinical interventions attempt to provide evidence-based recommendations specifically designed to reduce caesarean section rates. The WHO has emphasized educational interventions and support programs, such as childbirth training workshops that include sessions about childbirth fear and pain, non-pharmacological pain-relief methods, and the advantages and disadvantages of caesarean section and vaginal delivery .Social cognitive theory models indicating that attitudes directly affect behaviors are currently being tested to predict the preferred birth approaches , 11, 12.In this study, we have determined the factors associated with young adolescents’ preference and intention regarding vaginal birth and caesarean section using the TPB. In order to estimate adolescents’ awareness in regard to reproduction and birth, we also consulted various sources of information on these issues.A cross-sectional study was conducted in 14 vocational high schools in Greece, with ten school units being in the Athens area and four school units being in the countryside. Data was collected via a questionnaire between October 2019 and April 2021. The study protocol was reviewed and approved by the Ιnstitute of Educational Policy, which is the scientific agency that provides support to the Minister of Education and Religious Affairs on issues regarding secondary education (No Φ12/124243/Δ4 1/8/2019). Eligible participants were ensured confidentiality and anonymity in their responses. Written consent was received from all participants and their parents before filling in the questionnaire. Due to the specialized nature of the project, we provided instructions in every school unit and additional clarifications were available in classrooms for each of the students during questionnaire completion.The sample was comprised of 480 students (54.2% girls) aged 14–17 years, with a mean age of 15.5 years (SD = 0.6). The sample characteristics are presented in This phase was designed for scale development. In order to access students’ preference and intention towards vaginal birth and caesarean section, a multidimensional instrument was developed to access the three main dimensions of the Theory of Planned Behavior .Through an extensive literature review, we identified data that examined attitudes towards birth decisions among men and women (pregnant and nonpregnant). A focus group of six experts from different fields evaluated the face validity and the content validity index (CVI) of the developed scale.The scale was prepared in Greek, and the psychometric evaluation assessed reliability, exploring the factor structure of the instrument and the internal consistency by using Cronbach’s alpha coefficient, and assessed the stability of the tool by evaluating the test-retest reliability via intraclass correlation coefficient (ICC) and the discriminant and construct validity by using known groups method testing.The test-retest reliability of the scale was calculated for 30 out of 480 students who agreed to repeat the scale two weeks after the first administration. Significant agreement in all factors emerged from the test-retest assessment.The results of the exploratory factor analysis suggested that discriminative capacity existed among the initial items and that a five-factor solution was the most appropriate. The factors were interpreted by the authors, and the attitude constructs were labeled as follows in accordance with the TPB: “Cognitive component of vaginal birth” for knowledge and beliefs about vaginal birth, “Affective component of vaginal birth” for emotions regarding vaginal birth, “Cognitive component of caesarean section” for knowledge and beliefs for caesarean section, “Subjective norms-significant others” for family’s and health professionals’ beliefs about delivery mode, and “Perceived behavior control” for participants’ perception of their control over a hypothetic vaginal birth. Every question was answered by a 5-item Likert scale ranging from “strongly disagree = 1” to “strongly agree = 5”. Lower scores indicated negative attitudes and higher scores indicated positive attitudes. The scale was named “Adolescents’ Intentions towards Birth Options Scale” (AIBOS) (Appendix).The overall Cronbach’s alpha coefficient was 0.76, indicating acceptable internal consistency of the scale.Discriminant construct validity was evaluated by analysing the association between the factors of the questionnaire and gender, field of study, and preference for a specific type of labor using students’ t-tests. Statistical significance was set at p<0.05 and analyses were conducted using IBM SPSS Statistics for Windows, Version 24.0 . It was found that girls had significantly greater mean scores in all factors, except in “Knowledge on caesarian section,” compared to boys. Teenagers who would study health sciences in the future had significantly greater scores in “Knowledge on vaginal labor,” “Affective attitude,” and “Subjective norms,” and significantly lower scores in “Knowledge on caesarian section” in comparison to teenagers who would study non-medical sciences. Moreover, teenagers who would prefer to have a vaginal birth for themselves or their partner had significantly greater scores in “Knowledge on vaginal labor,” “Affective attitude,” “Subjective norms,” and “Perceived behavior control,” and significantly lower scores in “Knowledge on caesarian section,” in comparison to teenagers who would prefer to have a caesarian section .All students of the first grade were invited to complete a questionnaire consisting of three sections. In section A, sociodemographic variables such as age, gender, parents’ level of education and students’ field of study were assessed. In section Β, attitudes, subjective norms, and perceived behavior control were examined via the AIBO scale. Section C, in order to survey students’ awareness in regard to birth and reproductive health, assessed sources of information, impressions towards pregnancy and birth, and students’ reported knowledge gaps about the afore mentioned issues.It is worth mentioning that the instructions requested the participants to keep in mind their role: a girl who will manage a future healthy pregnancy, or a boy who will support a pregnant woman.t-tests were used for comparison of mean values between the two groups. Logistic regression analysis was used to find independent factors associated with the intention to select caesarean section. Adjusted odds ratio (OR) and 95% confidence interval (95% CI) were computed from the results of the logistic regression analyses. The Hosmer–Lemeshow statistic was used to check the goodness of fit of the logistic regression models. The betas and standard errors are not provided; since it’ was a logistic and not a linear regression analysis, the betas are not interpretable and could not directly provide likelihood comparisons. Instead, we have provided odds ratios along with a 95% confidence interval. With odds ratios (Exp(b)) we can directly understand the effect of the independent variables. All reported p-values are two-tailed. Statistical significance was set at p < 0.05 and analyses were conducted using IBM SPSS Statistics for Windows, Version 22.0 .Quantitative variables were expressed as means and standard deviations, whereas qualitative variables were expressed as absolute and relative frequencies. For comparison of proportions, chi-square and Fisher exact tests were used. Independently sampled students’ Participants’ intentions towards vaginal birth and their associations with sources of information are presented in Participants who could imagine having children at some point in the future tended to prefer vaginal birth by a significantly larger percentage than participants who did not imagine having children at some point in the future . FurtherMultiple logistic regression found that participants’ impressions of vaginal birth and all the TPB constructs were significantly associated with intention towards caesarean section . More spBirth-related attitudes during pregnancy are frequently considered and analysed. Strategies to raise awareness about the benefits of vaginal birth, to promote women’s confidence in their ability to deliver naturally, are being updated. For young populations, although research indicates that developing and supporting evidence-based education programs is vital, the availability of data regarding adolescents’ attitudes towards birth options is scarce , 16.In our study, most participants would prefer a vaginal birth for them or their partner in a hypothetical healthy future pregnancy. In accordance with this, studies in similar populations indicate that, regardless of the recorded rise in the rate of caesarean sections, young students who are introduced into a medicalized birth culture report a vaginal birth preference for a healthy future pregnancy , 18, 19.Regarding the factors on the AIBO scale related to participants’ preference for mode of birth, we found that all subscales were significantly associated with the intention for caesarean section. More specifically, participants with higher scores on the “Cognitive component of vaginal birth,” “Affective component of vaginal birth,” “Subjective norms,” and “Perceived behavior control” subscales had a significantly lower probability of selecting caesarean section. In contrast, a higher score on the “Cognitive component of caesarean section” subscale was significantly associated with a higher probability of selecting caesarean section. This outcome is consistent with the effectiveness of the TPB to predict and explain the correlation between factors and intention.Taking into consideration the significant association between intention and the AIBO scale constructs, we indicate the necessity to modify the negative attitudes towards vaginal birth and educate young populations about the benefits and risks of different modes of delivery. In line with recent WHO guidelines for nonclinical interventions to reduce caesarean section rates, such as childbirth preparation workshops, we suggest introducing health and reproduction education programs into the school curricula in primary schools and most certainly in high schools. The fact that only 13% of our sample reported school-based education programs as a source of information in birth issues indicates the educational inadequacy in Greece. Furthermore, our study showed that significant others, obstetricians, and midwifes can affect adolescents’ intention towards a particular mode of delivery; thus, they could, and should, be involved with providing information from a more scientific perspective.Perceived behavior control over childbirth seems to be another factor related to delivery preference. A recent study suggests that increased self-efficacy in childbirth is associated with a wide variety of improved perinatal outcomes and that self-efficacy is a psychosocial factor that can be modified through various efficacy-enhancing interventions . This ouA more recent study examined stakeholders’ views on the barriers and facilitators of nonclinical interventions to reduce unnecessary caesarean sections, targeted at organizations, facilities, and systems. The authors reported that these interventions were strongly mediated by organizational power differentials and stakeholder commitment. The study also indicated that the barriers are greatest where the implementation plans contradict both system and cultural norms .This study’s results need to be interpreted by taking into consideration its limitations. First, convenience sampling was used, although this was not planned. The research protocol had anticipated the participation of schools from various geographical departments; however, the emergence of the COVID-19 pandemic made all school communities wary of face-to-face activities. Additionally, the sample of students was drawn only from vocational high schools due to the limitations of the responsible National Educational Institute stating that any surveys should be integrated in the relevant courses. It is also worth mentioning that, ideally, the researchers would have wanted to have collected data about the emotional state of the participants, but this was prevented due to the low average age of the sample.Thus, this study may have introduced selection bias and produced a non-representative sample of students; therefore, the results may not be generalizable to other populations.In conclusion, in our study, we assessed sources of information and TPB constructs to identify factors influencing adolescents’ preference and intention towards vaginal birth and caesarean sections. To the best of our knowledge, this is the first such study in Greece with such a low average age of participants, and it indicated that adolescents’ birth preferences were significantly associated with sources of information, attitudes towards the delivery mode, subjective norms, and childbirth perceived behavior control. The findings highlight the necessity to implement nonclinical interventions to reduce the preference for caesarean section, providing evidence for developing school-based educational programs. We propose that these interventions should be implemented both consistently and in a timely manner. Our study also purports that the rise in caesarean section rates should be approached through a multivariable model that involves individuals, families, educational systems, health professionals, and communities.