We evaluated the relationship between fetal growth in preterm babies using the head circumference (HC)/chest circumference (CC) ratio and other anthropometric parameters at birth and at school age. Data were collected from 187 very low birth weight (VLBW) children born at less than 30 weeks of gestational age (GA) at birth and at 6 years. We assessed the correlation between the HC/CC ratio and body weight (BW), body length (BL), and HC z-scores at birth, and BW, body height (BH), and body mass index (BMI) z-scores at 6 years. Multiple regression analysis showed that BW z-score, BL z-score, and HC z-score at birth were significantly associated with HC/CC at birth. The BMI z-score at 6 years was also significantly associated with HC/CC at birth. The HC/CC ratio at birth is a reliable parameter for evaluating fetal growth restriction and a possible predictor of physical growth in VLBW children. The prognosis of preterm infants has improved dramatically in recent decades. The mortality rate of extremely preterm infants in Japan is shallow compared to that in other developed countries ,2. HowevAnthropometric assessment is essential for monitoring and evaluating the nutritional status and growth of fetuses, newborns, and infants. Fetal growth during pregnancy is indicated by anthropometric criteria at birth, particularly weight. Circumferential dimensions using a tape measure can evaluate nutritional status. For example, mid-upper arm circumference is often measured in children or infants but is rarely assessed at birth. Chest circumference (CC) and head circumference (HC) are simple, reliable, and logistically feasible tools. CC correlates highest with body weight (BW) at birth ,13,14. IIn contrast, cohort studies examining the correlation between SGA and anthropometry among preterm-born children, especially using the HC/CC ratio, are limited. This study aimed to evaluate the relationship between the HC/CC ratio and other anthropometric parameters at birth and 6 years-corrected age (CA) in very-low-birth-weight (VLBW) infants born at less than 30 completed weeks of gestation.This was a multicenter, retrospective study enrolling neonates admitted to neonatal intensive care units (NICUs) in the three affiliated hospitals of Juntendo University  from January 2007 to June 2012. The inclusion criteria of participants were birth weight <1500 g and gestational age (GA) < 30 weeks. GA was determined based on the mother’s last menstrual period and first-trimester ultrasound. According to our nutritional protocol, feeding was typically initiated within the first 8 h after birth (20 mL/kg divided into over 8 feedings per day), and own mother’s breast milk (BM) was the preferred type of feeding. However, when BM was unavailable due to the mother’s unwillingness or inability to provide BM, the infants received preterm formula. Milk intake was increased by about 20 mL/kg daily to 120 mL/kg, at which time the human milk fortifier ) was added to the BM. Typically, we change from preterm formula to general infant formula when the weight of infants exceeds 2000 g.3) at birth or body mass index (BMI) (kg/m2) at 6 years were calculated. Sex- and GA-independent z-scores and percentiles for anthropometric parameters at birth  were calculated according to the Japanese standard curve, estimated using 2003–2005 data from the Japan Society of Obstetrics and Gynecology registry database [We collected the data of BW, body length (BL), HC, CC at birth, BW, and body height (BH) at 6 years of CA (representing the age of the children from the expected date of delivery) from medical records. The ponderal index (PI)  curve and the area under the curve (AUC) were calculated. The best predictive value  was calculated using the Youden index. All statistical analyses were performed using Stata version 15.1 .First, we calculated the mean ± standard deviation (SD) to assess patients’ characteristics. Then, to determine the statistical correlation between HC/CC ratio and GA, BW z-score, BL z-score, HC z-score, and PI at birth and BW z-score, BH z-score, and BMI z-score at 6 years of CA, we used Spearman’s rank correlation coefficient analysis. Furthermore, we examined whether HC/CC, GA, and sex are associated with anthropometric measures at birth and 6 years of CA using regression analysis. First, using a simple univariate regression model, we examined the association between HC/CC, GA, and sex and anthropometric measures, including BW z-score, BL z-score, HC z-score, and PI at birth and BW, BH, BMI z-score at 6 years of CA. Further, we performed a multiple regression analysis using the covariates that showed significant associations in the simple univariate regression analysis. Statistical significance was set at During the study period, 529 VLBW infants with GA < 30 weeks were admitted to the NICU of three hospitals, and 502 preterm infants met the inclusion criteria at birth. Of these, 412 patients were discharged from the NICU. We collected data from 197 children up to 6 years of CA and excluded 10 children who received growth hormone therapy. We analyzed the 187 remaining children, of whom 100 were males and 87 were females. Specific complications were as follows: SGA (19.8% of subjects), intraventricular hemorrhage (3.2%), necrotizing enterocolitis (2.1%), chronic lung disease (68.4%), and home oxygen therapy (18.2%). Spearman’s rank correlation coefficient analysis showed that the HC/CC ratio was significantly correlated with BW z-score, BL z-score, HC z-score, PI at birth, BMI z-score at 6 years, and GA . The relThe simple univariate regression analysis showed that the statistical association between BW z-score, BL z-score, HC z-score, PI, and HC/CC ratio was observed at birth. The associations between BW z-score at birth and GA, HC z-score at birth and sex, and PI at birth and GA were also seen . AlthougThe results of the following multiple regression analysis using covariates that showed statistical significance in the simple regression analysis are presented in The AUC of the HC/CC ratio for the prediction of SGA was 0.851. The HC/CC ratio showed a sensitivity of 86.8% and a specificity of 68.9% at the cut-off value of 1.18 .To the best of our knowledge, this is the first study to evaluate the relationship between the HC/CC ratio and other anthropometric parameters at birth and at 6 years of CA among VLBW children. We demonstrated that the HC/CC ratio was strongly influenced by SGA and was associated with physique at 6 years.The most common fetal biometric parameters were biparietal diameter, HC, abdominal circumference, and femur diaphysis length, as measured by ultrasound. These biometric measurements could help estimate fetal weight using various formulas to evaluate FGR . At birtCircumferential dimensions are noninvasive, reproducible, and low-cost methods that can be performed quickly. HC is strongly correlated with length at birth, as well as later in infancy and early childhood , and witMoreover, the result of the ROC curve in this study showed that the HC/CC ratio of 1.18 is one of the good predictors for SGA in VLBW infants. The rationale behind using the HC/CC ratio is as follows: HC is generally larger than CC at birth. After birth, HC does not increase as rapidly as CC does. In well-nourished children, CC becomes larger than HC between 6 and 12 months of age, producing a mean HC/CC ratio of less than 1 . HC and This study had some limitations. We did not correct potential variables such as parents’ age, parents’ physique, maternal complications during pregnancy, or nutritional management and feeding during infancy. Furthermore, the sample size was small, and the follow-up rate of participants was low (45%). Most of the correlations in this study were not strong due to the small sample size. We assume that study subjects with a good prognosis stopped coming to the hospital for follow-up checkups. We believe that this may not have influenced our results.Our study suggests that the HC/CC ratio is a reliable parameter for evaluating SGA and a possible predictor of physical growth in VLBW children born at <30 weeks of GA. Further research is needed to demonstrate the correlation between the HC/CC ratio and growth and long-term complications in preterm infants.


We present a novel approach of ventilation, using high-frequency oscillation ventilation (HFOV), during neonatal cardiopulmonary resuscitation (CPR) of a very preterm neonate. This case report highlights the importance of adequate lung inflation, which is a current topic, with neonatal resuscitation guidelines recommending a coordinated 3:1 compression:ventilation ratio during CPR. Our patient, a female infant born at 30 weeks gestational age, weighing 970 g, appeared floppy and apneic following birth in the amniotic sac. Lungs were unfolded and white-out in an x-ray done during resuscitation. The aim was to open lungs effectively using HFOV, instead of positive pressure ventilation, which was used unsuccessfully until the 7th minute of life. Heart rate continuously dropped below 60/min 15 min after birth and chest compressions with asynchronous HFOV were started, adrenalin was administered three times and surfactant was instilled endotracheally twice. It was possible to stabilize the patient after 15 min of CPR, following return of spontaneous circulation. HFOV may have enabled an alternative and rescue option of ventilation during neonatal CPR in this case. The case describes the novel use of high-frequency oscillation ventilation (HFOV) during neonatal resuscitation and highlights the controversial topic of the coordination of ventilation and chest compression versus the constant and asynchronous ventilation with continuous and uninterrupted chest compressions. To our knowledge, this is the first time, describing a cardiopulmonary resuscitation (CPR) of a preterm infant using HFOV.At the Medical University of Vienna, a tertiary perinatal center, a neonatal resuscitation team, consisting of at least four healthcare providers, attends deliveries of high-risk infants. During neonatal resuscitation of preterm infants < 32 gestational weeks, heart rate (HR), oxygen saturation on the right wrist, and blood pressure are measured.0/7 weeks postmenstrual age. Pregnancy was complicated by a COVID-19 infection diagnosed in 280/7 weeks’ and no gynecological control appointment had been scheduled during the 14-day quarantine period. Indication for C-section was given following a pathological Doppler ultrasound and intrauterine growth restriction of this twin without a premature rupture of membrane. Prior to delivery, the mother received one dose of antenatal steroids and magnesium sulphate. Our female patient, the first twin, was born with a birth weight of 970 g (14th percentile). The Apgar scores were 1/1/1 at 1, 5, and 10 min and the umbilical cord pH was 7.10. The second twin was not compromised after birth and had a favorable transition, clinical course, and short-term outcome.A 22-year-old primigravida delivered dichorionic diamniotic twins in 30Resuscitation  to a depth of 8.0 cm. ETT placement was confirmed with laryngoscopy by two experienced neonatologists. Due to a loudly audible tube leak, it was changed to a 3.0 uncuffed ETT in minute five. No exhaled CO2 detection was used. Pulmonary auscultation indicated with hardly audible sounds poorly ventilated lungs and peak inflation pressure was increased to 40 cmH2O. Despite PPV and maximal oxygen supply, peripheral oxygen saturation remained unchanged at 50–60%. During resuscitation, the clinical team decided to use HFOV to try to open the lungs, because despite using high pressure levels with PPV, nearly no thorax excursions or breathing sounds were registered. HFOV was initiated at minute seven with the following settings: 12 cmH2O mean airway pressure (MAP), 40 cmH2O amplitude and 12 Hz frequency. Immediately after initiation of HFOV, surfactant  was administrated via the tube. It was decided, as a rescue approach, to continue HFOV, despite the dropping HR, and to open and recruit the lungs of this extremely low birth weight infant. To achieve lung recruitment, MAP was increased up to 24 cmH2O over seven minutes  was started approximately 30 s after birth using a facemask and T-piece device with the local default settings of 8 cmH minutes . MAP was2O MAP, which obviously helped opening the lungs sufficiently to achieve ROSC. Afterwards, a rapid increase in HR was seen, which is considered the best indicator for adequate lung inflation.At minute 11, a peripheral venous catheter was inserted, and the first blood pressure was measured with a mean of 27 mmHg. At minute 15, HR continuously dropped < 60/min and chest compressions were started using the two-thumb encircling technique at a rate of 120/min. Chest compressions were provided continuously, epinephrine (10 µg/kg) was administered at minute 15, 19, and 24, and a fluid bolus with 10 ml/kg isotonic solution was given immediately after the first dose of epinephrine. As shown in The blood pressures measured after CPR were in age-appropriate ranges.2 115 mmHg.The first venous blood gas taken from an umbilical vein catheter at minute 36 showed a pH 6.72, lactate 17 mmol/L, base excess −19.6 mmol/l, and pCOLactate was below 2 mmol/L on the third day of life. Further, the patient was extubated after seven days and weaned of respiratory support on day 24 after birth.On day two after birth, a cranial ultrasound revealed a bilaterally intraventricular hemorrhage grade 3 .The patient had an uneventful further clinical course and was discharged on day 70 of life (40The main cause of cardiovascular collapse in newborn infants is asphyxia due to failure of respiratory adaptation, which makes neonates different from the adult population.The reason for the difficult resuscitation of this 30 weeks’ infant, with a birthweight on the 14th percentile without infection, was potentially lung hypoplasia following intrauterine growth restriction.The infant was intubated in minute two after birth following failure of non-invasive ventilation. A reason for that could have been laryngeal closure after birth.Another continuous form of ventilation, comparable to the principle of sustained inflations, is HFOV, which uses oscillation rates of 8–15 Hz with a more uniform lung inflation and thereby, it might reduce the severity of lung injury caused by intermittent PPV.0/7 weeks gestational age, but had a severe intraventricular hemorrhage, which did not result in any neurological impairments in the first year of life.Until now, no previous research has focused on HFOV during neonatal CPR, following the concept of sustained inflations with asynchronous chest compressions. HFOV adds a lung protective component, explained through low tidal volumes and a constant MAP in conjunction with high respiratory rates, and might help, combined with recruitment maneuvers, to improve gas exchange during CPR.The presented case describes a rescue approach of ventilation during neonatal resuscitation using HFOV as the secondary ventilation mode resulting in ROSC. It highlights the importance of adequate lung inflation during CPR and might offer an alternative option to achieve this.Written informed consent was obtained from the parents for publication of the details of their medical case and any accompanying images.The authors received no funding for the case report.Additional anonymized medical record data are available from the Corresponding Authors upon reasonable requestJulia Buchmayer: Conceptualization, Methodology, Validation, Formal analysis, Resources, Data curation, Writing – original draft, Visualization, Project administration. Lukas Wisgrill: Data curation, Writing – review & editing. Michael Schneider: Data curation, Writing – review & editing. Tobias Werther: Methodology, Validation, Writing – review & editing, Supervision. Katharina Goeral: Writing – review & editing, Supervision. Angelika Berger: Writing – review & editing, Supervision. Georg M. Schmölzer: Conceptualization, Writing – review & editing. Michael Wagner: Conceptualization, Methodology, Validation, Formal analysis, Resources, Writing – review & editing, Project administration, Conceptualization, Methodology, Validation, Formal analysis, Resources, Writing – review & editing, Project administration.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


To construct an individual socioeconomic status index (ISESI) with information available in the Population Information System of the Region of Valencia, Spain, and use it to analyse inequalities in a colorectal cancer screening programme (CRCSP).Cross-sectional study of men and women aged between 50 and 75 at the time of the study (2020) that were selected from the target population of the Region of Valencia CRCSP. . First, a multiple correspondence analysis was performed to aggregate information from the Population Information System of the Region of Valencia into an ISESI. Second, data from the 2016 Region of Valencia Health Survey were used for validation, and finally the relationship between CRCSP participation and the ISESI was analysed by logistic regression models.The variables included in the index were nationality, employment status, disability, healthcare coverage, risk of vulnerability and family size. The most important categories for determining the highest socioeconomic status were being employed and not being at risk of social vulnerability, and being unemployed and at risk of social vulnerability for determining the lowest socioeconomic status. Index validation demonstrated internal and external coherence for measuring socioeconomic status. The relationship between CRCSP participation and the ISESI categorised by quartile (Q) showed that Q4 (the lowest socioeconomic status) was less likely to participate OR = 0.769 (0.757–0.782) than Q1 (the highest socioeconomic status), and the opposite was found for Q2 OR = 1.368 (1.347–1.390) and Q3 OR = 1.156 (1.137–1.175).An ISESI was constructed and validated using Population Information System data and made it possible to evaluate inequalities in colorectal cancer screening. Health equity is defined as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically” . AnalysiColorectal cancer (CRC) screening programmes (CRCSP) is a widely accepted public health policy in Europe. In Spain, CRCSP are population-based and aimed at men and women aged between 50 and 69, in line with the recommendations of European CRC screening guidelines . The EurSES is a multidimensional social determinant of health. The development of SES indicators including different socioeconomic dimensions is important in order to provide evidence-based information on social inequalities in health to support decision-making. Some previous studies in Spain have constructed multidimensional area-level deprivation indexes. The first area-level deprivation index using census data in Spain was developed by the MEDEA project and was applicable to large cities . In 2011Some studies in Spain have analysed inequalities in CRCSP participation by using this type of area-level deprivation indexes , but theThe Population Information System (PIS) of the Region of Valencia, Spain, includes a Segmented, Integrated and Geographic Population Analysis code (SIGPAC) , which cAs it is important to have individual indicators that measure SES in order to identify inequalities in health, the purpose of this study was to construct an individual socioeconomic status index (ISESI) based on information available in the SIGPAC. In addition, this study intends to use the ISESI to evaluate inequalities in CRCSP participation in the Region of Valencia.Cross-sectional study to construct an individual socioeconomic status index (ISESI) based on information available in the Patient Information System (PIS) of the Region of Valencia, Spain.The study population  was composed of men and women aged between 50 and 75 at the time of the study (2020) that were selected from the target population of the most recently completed round in 2020 of the Region of Valencia colorectal cancer screening programme (CRCSP).Individuals with non-updated information in February 2020 in the PIS  were excluded, as well as people with inconsistent date of birth data between the CRCSP information system and the SIGPA (n = 151) and people with unknown date in any of the variables contemplated for the creation of the ISESI . The final study sample comprised 1,150,684 people.The study population was selected from the Region of Valencia CRCSP Information System. It was subsequently crossed with the Population Information System (PIS) of the Regional Ministry of Universal and Public Health of the Region of Valencia and the derived SIGPAC in 2020, thereby obtaining information on healthcare coverage and socioeconomic characteristics. The SIGPAC is updated periodically on the last day of the month including only those people who are registered in the PIS. It is a fixed photo, so the possible variation of a citizen’s data throughout the month is not reflected.To select the candidate SIGPAC variables to be included in the ISESI, first of all their conceptual capacity to measure individual SES was assessed on the basis of their operative definition. The following variables were excluded in this first process: residency status, the assigned healthcare service area and center. Subsequently, variables with a high number of unknown cases were ruled out. Consequently, contribution to prescription charges and annual income were discarded (more than 10% unknown). The rest of the variables included in SIGPAC were analyzed.A multiple correspondence analysis (MCA) was performed to create the ISESI. MCA allows for the analysis of potential relationships between categories of more than two qualitative variables, providing a numerical representation of the relationships between the categories and identifying homogenous subgroups and influences .As a result of MCA, it was decided to take into account the first three dimensions as they accumulated the highest percentage of total variability. The results of each dimension were interpreted to identify whether the categories were grouped based on socioeconomic characteristics. Finally, the first dimension was selected to create the ISESI as it explained the highest percentage of variability and had the strongest conceptual relationship with SES. The results of dimensions 2 and 3 can be seen in a supporting file .The variable categories were represented in a bidimensional space corresponding to dimensions 1 and 2, and the percentage contribution of each category was shown in dimension 1.The variables contemplated for the creation of the ISESI were: Nationality, Migration, Geopolitical groups, Healthcare coverage, Healthcare insurance groups and subgroups, Employment status, Disability, Risk of vulnerability, Family size, Living unity, Family unit composition, Sex, Age at 2020 and Chronicity. Details about these variables and the categories used can be seen in The quantitative ISESI was constructed by combining the coordinate values of the categories included in dimension 1. Additionally, the ISESI was categorized in four groups using quartiles independently for each sex.Firstly, the MCA was applied to the sample stratified by sex. As the coordinates of the first dimension of the MCA model showed very little difference when the sample was separated by sex , the entFinally, the ISESI was composed of 6 variables and 18 categories, resulting from the combination of variables that collected the highest percentage of viability. These are: Nationality; Healthcare coverage, Employment status, Disability, Risk of vulnerability, Family size, Sex was not used as a variable to create the index, but it was subsequently added for categorisation.To confirm the validity of the constructed index, internal coherence was analysed by calculating the distribution of ISESI categories in accordance with each of the variables that make up the categorical ISESI. In addition, external validity was verified with a different population sample. This sample was made up of participants in the 2016 Region of Valencia Health Survey aged between 50 and 69 (n = 779) and with a SIGPAC at the time of the survey. The ISESI was calculated in this population and the relationship with variables related to SES characteristics available in the survey was measured: country of birth, self-declared net monthly household income, self-declared household income, self-declared household ability to make ends meet, employment status, educational level and occupational social class. Each of these variables was described as a percentage as per the categorical ISESI.Finally, with the aim of analysing the ISESI’s capability to assess inequalities in CRC screening, its relationship with participation in the Valencia CRCSP was studied. The population studied in this analysis was the population invited in the last round of the CRCSP carried out in the region of Valencia . Logistic regression models were applied based on the information available in the CRCSP Information System. The response variable was participation, that is to say, whether or not the screening test was carried out. The explanatory variables were the ISESI, age upon being invited to participate in the programme  and type of invitation to participate in the programme . The categorical ISESI was used in the model, It was fitted for the entire sample and for the sample stratified by sex. The model presented significant difference in deviances compared to the null model. Additional logistic regression models were adjusted by each of the variables used to construct the ISESI. A significance level of 0.05 was considered. All of the analyses were carried out using the statistical program R.This study was approved by the Research Ethics Committee of the General Directorate of Public Health and the Advanced Public Health Research Centre (No. 20180928/06). Taking into account the project design, its large sample size, the ethics committee approved carrying out the study without requesting individualized consent from each subject, following the regulations of the Declaration of Helsinki currently in effect . The personal data included in this study was pseudoanonymised to guarantee the confidentiality, privacy and security of the information. The project was developed in accordance with the principles of the Declaration of Helsinki and Spanish confidentiality legislation .A total of 12 dimensions were obtained in the MCA. The first three accumulated 35.24% of total variability, and the first dimension showed the highest percentage of variability at 14.31%, followed by dimension 2 at 11.26% and dimension 3 at 9.67%. (Results not shown in tables)We used the dimension 1 coordinates to condense the information obtained on the involved variables to construct the ISESI. We defined the magnitude of the ISESI for each individual by adding up the coordinates of each category . For exaPerson A: of Spanish nationality, employed, not disabled, social security healthcare coverage, no risk of vulnerability and medium family size.Person B: of Spanish nationality, unemployed, not disabled, social security healthcare coverage, risk due to unemployment and large family size.We can see that the ISESI of person A  considers more favourable conditions than those of person B . A description of the distribution of the continuous ISESI can be seen in additional files, where an uneven distribution can be seen with a concentration of values between -1 and -0.5 .The ISESI was categorised by quartiles (Q). The internal coherence of the ISESI was assessed by analysing the distribution of the category variables that make up the index according to ISESI quartiles . The resMoreover, an external validation was performed. In this study, an individual socioeconomic status index (ISESI) was built and validated for a population aged between 50 and 69 based on information available in the Patient Information System (PIS) of the Region of Valencia, Spain. The ISESI made it possible to analyse inequalities in Valencia colorectal cancer screening programme (CRCSP) participation.A multivariate methodology was used to give a weight to the variable categories that make up the ISESI, representing the statistical relationships between these categories. This methodology made it possible to reduce and combine the wide range of socioeconomic variables that were available in the PIS, including nationality, employment status, disability status, type of healthcare coverage, risk of vulnerability and family size. As a result, a qualitative and quantitative index was built in order to allow and facilitate the analysis of health inequalities.It should be noted that the coefficient of variability explained in the ISESI is low, as shown in the results. This could be due to the fact that the type of information available in the PIS has the purpose of establishing the healthcare coverage rights, type of healthcare coverage and contribution to prescription charges of people registered as living in the region of Valencia. Therefore, as these rights are greatly dependent on employment status and family income, the information available in the PIS and, therefore, the information used to develop the ISESI, is focused on these characteristics. However, despite this, the percentage obtained is greater than the expected variance if random data were used, and therefore they give the ISESI validity and representativity.The ISESI variables with the highest weight were employment status and risk of vulnerability, followed by nationality and healthcare coverage and, lastly, disability and family size. This indicates that the ISESI created in this study mainly characterises the population in accordance with their employment status and how this affects their social, economic, and healthcare vulnerability. Specifically, the nationality variable indicates the possession or absence of Spanish nationality, whose possession recognizes its relationship with the Spanish state and the recognition of a series of rights and duties of citizens in relation to health care. This variable lacks the variability associated with the country of origin, but it should be noted that the ISESI includes other variables that include the situation of social exclusion, such as Vulnerability Risk and health coverage status in the Healthcare coverage variable.By comparing the ISESI with other SES variables and performing external validation with variables such as personal income or household income, in addition to employment status, we confirmed that the ISESI characterises the population according to socioeconomic characteristics, based on their employment and income status. In contrast, it does not appear to be related with variables traditionally used to measure SES, such as educational level or occupational social class . As commThe continuous ISESI has shown an uneven distribution with a higher concentration of cases in certain values, these results are consistent with the distribution of the personal characteristics included in the ISESI, which show an uneven distribution. That is why the results suggest the non-use of the ISESI in a linear way and therefore the categorization of the ISESI.The multidimensional character of the concept of SES and the growing importance of assessing health inequalities has led to the creation of SES indices using information available in various sources. There are several initiatives related to the construction of socioeconomic status indices to measure health inequalities at both the national and international level , 14–16. One limitation is that SIGPAC is automatically updated on the last day of each month, showing a fixed photo at a specific time. Although it should be noted that the PIS is population-based, and the ISESI is available for the entire population of the Region of Valencia registered in the PIS, that is, the entire resident population or that that has come into contact with the health system of the region. Our results show that combining different socioeconomic characteristics in an index to measure inequalities in CRCSP is better than using each of the population’s socioeconomic characteristics independently. These results are in line with other studies that combine several socioeconomic characteristics in a single individual index to analyse health inequalities in the adult population .Some authors state that the type of socioeconomic indicator and its influence on health seems to have a different effect depending on the health problem under analysis –24. One This index has been created to assess inequalities in CRC screening, among other uses. Consequently, it was developed with information on a population group aged between 50 and 69, considering the age of the target population of these programmes. The index can be incorporated to analyse inequalities in CRCSP result indicators or can be used as an SES adjustment variable. Nonetheless, the same methodology could be replicated to create indices adapted to the target populations of other public health programmes in the region of Valencia, such as the early detection of breast and cervical cancer programmes, or programmes for sexual and reproductive health, active ageing or gender violence prevention.An initial approach to using this ISESI to identify inequalities in CRC screening has demonstrated that the population situated in Q1, i.e., with the best socioeconomic conditions, and in Q4, i.e., with the worst socioeconomic conditions, were less likely to participate than those in intermediate quartiles (Q2 and Q3). These results are in line with other studies performed in Spain , 19, 25.Some of the variables used to construct the ISESI, such as employment status, were used to identify inequalities in European CRCSP participation –31. The Analysing social inequalities in CRCSP participation is a complex phenomenon that requires the use of multiple and varied socioeconomic indicators in order to study these inequalities in more detail. The resulting ISESI and its inclusion in the Valencia CRCSP information system could help provide a better understanding of inequalities in CRC screening.If the ISESI created in this study were incorporated into the Valencia CRCSP Population Information System, it would be possible to systematically assess social inequalities in the impact of these programmes. This will ensure that the European Commission’s recommendations  are met S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 TableSES; Socioeconomic Status; ISESI: Individual Socioeconomic Status Index; Q: Quartile.(DOCX)Click here for additional data file.S4 TableSES; Socioeconomic Status; ISESI: Individual Socioeconomic Status Index; Q: Quartile; OR: Odds Ratio; CI: Confidence Interval; AIC: Akaike information criterion. All models adjusted for age, sex and and type of invitation to participate in the programme.(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.


The subjects with less than four prenatal visits had a 2.76-fold higher odds of giving birth to infants weighing less than 2500 g , without relation to maternal and gestational ages. In conclusion, women with less than four prenatal visits had higher odds of giving birth to low birth infants, independently of maternal and gestational ages, and were more likely to give birth to premature babies.The aim of this study is to assess factors associated with the number of prenatal visits of women who delivered in a public maternity hospital in northeastern Brazil. This cross-sectional study focused on 380 puerperal women who gave birth at a public maternity hospital in northeastern Brazil. Prenatal and perinatal data were collected in the immediate postpartum period by interviewing mothers and using medical records. Chi-square/Fisher exact test compared the data, and a logistic regression model estimated the association between birth weight and number of prenatal visits. As a result, the sample was composed of 175 women with <37 weeks of gestational age and 205 women with ≥37 weeks of gestational age. Women with less than four prenatal visits were more likely to give birth to low birth weight (<2500 g) and preterm infants  than those with more than four prenatal visits ( Despite improvements in healthcare, infant morbidity and mortality remain a challenge in Brazil ,2. The iPremature birth complications were the leading cause of neonatal deaths, and the number of preterm births and low birth weight has increased steadily in recent decades ,4. GlobaIn 2020, prematurity led to 76.21% of early neonatal deaths in Brazil [Preterm birth is the result of preconception or gestational issues and interrelated factors, such as social aspects, race, low quality and restricted access to prenatal care, excessive medical interventions during vaginal delivery due to error diagnosing onset of labor, elective cesarean delivery, and inadequate determination of gestational age ,11,12,13Healthcare during pregnancy-puerperal cycle allows monitoring risk factors for infant mortality rate and is critical for improving perinatal outcomes ,15. HealStudies performed in South Africa found that most puerperal women do not receive prenatal care during the first trimester, and its onset is associated with maternal education and parity ,18,19,20This cross-sectional study assessed 380 puerperal women who gave birth in a public maternity hospital in northeastern Brazil  between April 2018 and March 2019. The maternity hospital is located in the city of Parnamirim, in the state of Rio Grande do Norte. This municipality has established the “Stork Network” (Rede Cegonha), a national program that offers 100% prenatal care coverage by the Family Health Strategy for pregnant women with a high-risk pregnancy. The Stork Network is a strategy that aims to structure and organize maternal and child healthcare in Brazil and it is composed of four components: (I)-Prenatal; (II)-Childbirth and birth; (III)-Puerperium and integral child healthcare; and (IV)-Logistics system (sanitary transport and regulation).The study has been approved by the research ethics committee of the Federal University of Rio Grande do Norte (UFRN) (no. 1.047.431/2015) and performed in compliance with the Declaration of Helsinki. All participants signed the informed consent form. Pregnant adolescents were included if they provided assent and had signed consent by legal parent or guardian.Both puerperal women residents in the city of the public maternity hospital and who gave birth there were included. Puerperal women with no record of gestational age or with possible mental disorders were excluded as they could not consent for themselves. Prenatal and perinatal data were collected in the immediate postpartum period (first 24 h postpartum) by interviewing mothers and using medical records.Birth weight, maternal and gestational age were collected from medical records, while information regarding the income and education were collected by interviewing the mother.The primary outcome was the number of prenatal visits and the study variables were distributed into categories as follows:Number of prenatal visits: Less than 4 or equal/higher than 4 visits ,21.Maternal age: This variable was divided into 3: ≤19 years, between 20–34 years, and ≥35 years .Birth weight: This variable was categorized into low birth weight (<2500 g) and birth weight ≥2500 g .Gestational age: Preterm infants were considered those born alive before 37 completed weeks of gestation , while full-term were considered the infants born with ≥37 weeks .Maternal education: The women’s schooling was categorized into < than elementary school or ≥elementary school .Family income: This variable was categorized according to minimum monthly wage: ≥1; 1–2, or 3–5 minimum monthly wages .p < 0.05 was considered as statistically significant. A logistic regression model was adjusted to estimate associations between number of prenatal visits (<4 visits) and variables that presented p < 0.20 in bivariate analysis, i.e., maternal age, birth weight, and gestational age. Since none of the variables considered in the study were associated with the time of the first prenatal visit, logistic regression was performed only for the variable ‘number of prenatal visits’. Statistical analysis was undertaken using SPSS 20 .For data analysis, frequencies distribution and percentages were used for the categorical variables. Chi-square test or Fisher exact test (for the categories with less than 5 cases) compared prenatal/perinatal data and maternal variables. A Three hundred and eighty puerperal women were evaluated: 175 puerperal women with <37 weeks of gestational age and 205 puerperal women with ≥37 weeks of gestational age. Most women (93%) received public prenatal care, and almost 7% received care from the private sector. Only four of the included women (0.019%) did not receive prenatal care.p = 0.001). The trimester of the first prenatal visit  was not associated with the delivery conditions .p = 0.08). Additionally, 72.8% of those who had less than four prenatal visits (n = 33) aged between 20–34 years (n = 24) Preterm birth was more frequent (72.7%) in women with less than four prenatal visits (p < 0.001).Adherence to prenatal care in the first trimester of pregnancy was higher in women aged between 20 and 34 years (60.6) when compared to the other women groups (≤19 years and ≥35 years) However, these results were not statistically significant , independently of maternal and gestational ages.In the studied sample, having less than four prenatal visits is associated with almost 3-fold higher odds of low birth weight. Almost 73% of those who had less than four prenatal visits were aged between 20–34 years. Additionally, preterm birth was more frequent (72.7%) in women with less than four prenatal visits. Prenatal care should ensure a healthy pregnancy for both the mother and infant. Educational and preventive strategies addressing psychosocial aspects of prenatal period, delivery, and postpartum should be introduced by health professionals in the first visits, regardless of trimester of pregnancy .Furthermore, 66% of women completed elementary school or higher education, and 68% had income between one and two minimum monthly wages (~USD 250–500). A study of Angolan women found that inadequate prenatal care was more likely among young women with low levels of education and income .Insufficient visit frequency increased almost 3-fold the odds of low birth weight, an important indicator of infant health status . Low birHowever, no study has linked the number of prenatal consultations to the risk of low birth weight, emphasizing the importance and innovation of our study for maternal and infant care. Our results show that low birth weight was associated with the number of prenatal visits regardless of maternal and gestational ages. This backs the importance of following the recommendations of the number of prenatal visits, since the infant mortality rate is higher in low birth weight ,24. BecaTaking into account the well-qualified healthcare needed to decrease the number of deaths among high-risk factor groups, maternal age is an important variable that should be controlled, since adolescent childbirth is related to higher odds of low birth weight, and, consequently, to mortality . In our This study presents some strengths: to identify the factors that may be related to low birth weight and premature birth, which are causes of mortality, and then address the necessary healthcare. Regrettably, we did not address associations between content and quality of prenatal visits and birth outcomes, highlighting the limitations for this study. Limited access to prenatal care, including issues related to medical records, may hinder favorable birth outcomes. Inadequate educational and prevention strategies during prenatal care compromise pregnant women’s health and child development . In nortIn the studied sample from northeastern Brazil, women with fewer than four prenatal visits had higher odds of giving birth to low birth babies (<2500 g) when compared to women who had four or more visits, regardless of maternal and gestational ages. Furthermore, women with fewer than four prenatal visits were more likely to give birth to premature infants  than those with more than four prenatal visits.


Background: Prematurity is a leading cause of neonatal morbidity and mortality and is associated with insufficient development of multiple body structures, including neurovascular and retinal tissues. Retinopathy of prematurity (ROP) is an abnormal vaso proliferation of the neonatal retina that results from an arrest in the normal development of the retinal nerve and blood supply. Incidence has been increasing due to advancements in intensive care and survival of preterm neonates, as well as improvements in screening methods for ROP.Objectives: The objective is to assess the initial clinical and laboratory characteristics of preterm infants at the time of birth to identify population-specific risk factors for the development of ROP in a tertiary care center in western Saudi Arabia.Methods and materials: This was a retrospective record review conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. The study included 37 patients diagnosed with ROP. Their ROP staging, complete blood count, appearance, pulse, grimace, activity and respiration (APGAR) score, and birth characteristics were all analyzed.Results: Thirty-seven neonates diagnosed with ROP and who met the study inclusion criteria were included. our results showed a female predominance of 51.4%, the mean age of the pregnancy was 27.18 ± 2.29 weeks, the mean birth weight was 0.8 ± 0.26, and 66.7% of our sample was delivered by the cesarean section. A significant association was found between the birth weight and the development of ROP in the right eye (p = 0.026); another significance was found between gestational age and the development of ROP in the same eye (p = 0.016).Conclusions: A low birth weight and gestational age show a significant association with the development of ROP. Early identification and treatment of ROP are important to preserve a neonate's eyesight. Preterm birth, defined as a delivery that occurs before the completion of 37 weeks of gestation, occurs more frequently than once in every 10 live births ,5. RetinThis single-center retrospective record review was conducted at King Abdulaziz University Hospital (KAUH), a tertiary care center in Jeddah, Saudi Arabia. This research was authorized by the Institutional Review Board of KAUH (Ref: 603-21). The procedures used were under the responsible committee's ethical standards based on the Good Clinical Practice Guidelines. Due to the study's retrospective nature, informed consent was waived. We collected and analyzed the data of 1,000 preterms born between January 2010 and January 2021. The number of preterms who fulfilled the inclusion criteria was 37; we included all preterms with documented follow-up visits and a diagnosis of ROP. Preterms with poor documentation, not classified according to the international classification of ROP (ICROP), and infants with congenital malformations were excluded. The clinical data of patients obtained from the medical records included demographic data such as gestational age, Gender, mode of delivery , and birth weight. Furthermore, 1, 5-minute APGAR score, and Complete Blood Count values: hemoglobin level (Hb), hematocrit value (Hct), leucocyte count (WBC), mean corpuscular hemoglobin (MCH), mean corpuscular volume (MCV), red cell distribution width (RDW) and platelet count were collected.StagingROP was staged for each eye individually by an experienced ophthalmologist. The right eye was referred to as oculus dextrus (OD) and the left eye as oculus sinister (OS) and classified according to the ICROP; Stage 1: demarcation line, stage 2: ridge, stage 3: extraretinal fibrovascular proliferation, stage 4: partial retinal detachment, and stage 5: total retinal detachment .Statistical analysisExcel sheet was used to collect data, and Social Science Package Statistical (SPSS) version 21 was used for statistical analysis. Categorical variables were described as frequencies and percentages, while Mean and standard deviation (SD) were calculated to be reported as continuous variables. Chi-square and student t-test were applied to assess between categorical and continuous variables, respectively. Furthermore, a p-value less than 0.05 was considered significant.Our results showed a Female predominance of 51.4%, the mean age of the pregnancy was 27.18 ± 2.29 weeks, the mean birth weight was 0.8 ± 0.26, and 66.7% of our sample was delivered by Cesarean section (Table A significant association was found between birth weight and the development of ROP in the right eye (p = 0.026) Table . AnotherBoth eyes of preterms were classified according to the ICROP for the development of ROP and showed a stage 1 predominance with 18 for OD and 21 for OS, respectively. Stage 2 was recorded for 11 of OD and 12 of OS. 5 OD and 4 OS were recorded for stage 3, and stage 4 was the least with 1 for OD , but this was not applicable to the OS. this partially agrees with Lazo et al., which also found low birth weight is a risk factor for ROP . AnotherAnother significant association was found between gestational age and the severity of ROP in the OD . This finding broadly supports the work of other studies in this area linking the gestational age of newborns with the development and severity of ROP ,23-25. AContrary to expectations, this study did not find a significant difference between 1- or 5-minute APGAR scores and the development of ROP. This is in contrast to Al Qahtani et al., who found 1-minute APGAR scores to be significantly associated with the development of ROP, but not a 5-minute score . ConsideFurthermore, a retrospective study by Englert et al. found that anemia was not identified as an independent risk factor for the severity of ROP in preterm infants. However, the number of blood transfusions did affect the severity of ROP in a directly proportional relation. This study goes in parallel with our findings which showed no significance between anemia in preterm neonates at the time of birth and the development of ROP. This reveals that close monitoring of those preterms is better than leaving an anemic child without transfusion .Our study showed no significance between platelet count and the development of ROP in either eye. This goes against a review by Seliniotaki et al., which concluded that platelet deficiency was associated with severe forms of ROP . This coOur study was limited by being a single study location, a small sample size, and poor documentation of data for some patients. A multicenter and multiethnicity study is recommended to understand better the factors related to ROP.This research aim was to study and analyze the laboratory and birth characteristics of preterm infants diagnosed with ROP. Birth weight was found to be a significant risk factor in the development of ROP. Furthermore, Gestational age was also found to be significantly associated with ROP severity. As ROP prevalence is increasing every decade, it is important to point out what may contribute to its development and development; these findings help to reinforce the importance of proper screening and follow-up with such neonates. Therefore, we recommend future studies to analyze other aspects of a neonate at the time of birth that could contribute to the development of ROP.


Pericardial cysts are rare, with the most common etiology being congenital. Ventricular septal defect is the most common congenital heart disease in children. However, the combination of pericardial cyst, ventricular septal defect, and patent ductus arteriosus is extremely rare.A one-year-old boy with ventricular septal defect and patent ductus arteriosus was planned for surgical correction. Intraoperatively, we made an additional diagnosis of a large pericardial cyst; and the cyst was excised along with ventricular septal defect closure and patent ductus arteriosus ligation.Pericardial cysts can sometimes be missed with transthoracic echocardiography. Excision of the cyst can safely be done during concomitant cardiac surgery.The online version contains supplementary material available at 10.1186/s43044-022-00278-6. Pericardial cysts are rare, with incidence of 1:100,000 . VentricA one-year-old boy weighing 10 kg was brought to us with repeated lower respiratory tract infections since birth. On examination, he was a playful boy with stable vital signs. Systemic oxygen saturation (SpO2) was 96% in room air. He did not have cyanosis, clubbing, edema, pallor, icterus, or jugular venous distension. Respiratory system examination was unremarkable. Cardiovascular examination revealed normal first and loud second heart sounds with systolic murmur in left lower sternal border.Baseline hematologic and biochemical profiles were within normal limits. Electrocardiogram showed sinus rhythm with heart rate of 113 beats/min. Chest X-ray showed cardiothoracic ratio (CTR) of 0.55 with plethoric lung fields. Transthoracic echocardiography revealed dilated left ventricle (3.6/2.1 cm) with ejection fraction (EF) of 60%, anterior malaligned perimembranous VSD measuring 1 cm with left to right shunt, 3 mm PDA with left to right shunt, and severe pulmonary artery hypertension (tricuspid regurgitation pressure gradient (TRPG): 50 mmHg). With this diagnosis, VSD closure and PDA ligation was planned.nd postoperative day; and discharged home on 5th postoperative day. The histopathology of the resected specimen showed fibro-collagenous wall with mild inflammation and mesothelial lining consistent with pericardial cyst  in the inferior surface of heart, which was attached by a stalk to the posterior pericardium near the atrioventricular groove on the left side. Fig. . Right a × 4 cm i. We believe ours is one of the rarest reports of a one-year-old child with associated VSD and PDA.Pericardial cysts are rare, with most common etiology being congenital . Most peMost of the cysts are diagnosed by transthoracic echocardiography; however, in our case, we missed to detect during preoperative echocardiography. Echocardiography is operator-dependent; and most of the times, we look for intracardiac lesions; and extracardiac lesions could be overlooked. Also, chest X-ray would show cardiomegaly or abnormal shaped cardiac silhouette;  however,Immediately after opening the chest, we were not sure about the content of the cyst. Keeping in mind the rare possibility of hydatid cyst, we deferred to excise the cyst until after the intracardiac procedure was completed and cardiac chambers were closed to avoid spillage of the cyst contents inside the heart itself. We do not believe that the management would have been significantly different from ours in any other cardiac center. We also do not believe that we have done a marvellous job by resecting a pericardial cyst in a child with VSD and PDA. However, we do believe that reporting our case would definitely add to the available literature given that this is a rare entity.We encountered pericardial cyst as an incidental finding during cardiac surgery and we have successfully resected a pericardial cyst as a concomitant operation during VSD closure and PDA ligation in a very young child.Additional file 1: Video 1. The cyst is seen freely mobile, which appears and disappears with cardiac contractility. Pump sucker tip is used to bring the cyst to our field of vision.Additional file 2: Video 2. Cyst is seen all the time unlike in supplementary video 1.


Nutrition in the first 1000 days of life is essential to ensure appropriate growth rates, prevent adverse short- and long-term outcomes, and allow physiologic neurocognitive development. Appropriate management of early nutritional needs is particularly crucial for preterm infants. Although the impact of early nutrition on health outcomes in preterm infants is well established, evidence-based recommendations on complementary feeding for preterm neonates and especially extremely low birth weight and extremely low gestational age neonates are still lacking. In the present position paper we performed a narrative review to summarize current evidence regarding complementary feeding in preterm neonates and draw recommendation shared by joint societies  for paediatricians, healthcare providers and families with the final aim to reduce the variability of attitude and timing among professionals. Nutrition in the first 1000 days of life can help ensure appropriate growth rates and prevent adverse short- and long-term outcomes in infants –4. ApproAlthough the impact of early nutrition on health outcomes in preterm infants is well established, evidence-based recommendations on complementary feeding (CF) for preterm neonates and especially for extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGAN) are still lacking. CF  is defined by the World Health Organization as “the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants” so that “other foods and liquids are needed, along with breast milk” . It playWhat is known is that guidelines for CF in term infants , 15 are The objective of this position paper is to summarize current evidence regarding CF in preterm neonates and provide recommendation shared by joint societies  for paediatricians, healthcare providers and families with the final aim to reduce the variability of attitude  and timiPaediatricians and healthcare providers involved in the care of preterm neonates and preterm infantsParents and carers of preterm neonates and preterm infantsA recommendation development committee was created including neonatologists, paediatricians and nutrition experts. Parent representatives were also surveyed at multiple points during the process.The target population was determined to be preterm neonates (GA < 37 weeks) and committee members were assigned topics based on expertise.For each topic, screening was performed according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines . The folThe timing for introduction of solid foods in preterm infants is still a matter of debate. Different timeframes were suggested in the past such as 3–6 months of postnatal age (PA) , 71, 5–8The majority of data on CF in preterm infants were derived from observational studies, thus reducing the robustness of the recommendations. Only few randomized controlled trials have assessed differences between timings of CF introduction Table . MarriotConversely, an RCT conducted in India to compare two different timings of CF (4 vs. 6 months CA) in ex preterm neonates with GA < 34 weeks revealed that weight-for-age z score at 12 months CA did not differ between groups, but the 4-month CA group experienced a higher rate of hospital admission primarily due to infectious disease . Hence aSimilarly, a pooled analysis of prospective studies by Morgan et al.  showed nWhat is known is that preterm infants are usually weaned early (before 4 months of age) compared to their term counterpart , 54–57. However, also late preterm infants are often weaned early, at a mean postnatal age of 5.7 months and a mean CA of 4.6 months .The early introduction of solid foods in preterm infants has been linked to a higher risk of rapid weight gain , allergyIt is noticeable not only that preterm infants are introduced early to CF, but also that the attitude of primary care paediatricians is widely variable in terms of timing of introduction and type of suggested foods .This is partly due to the lack of specific guidelines on CF introduction for preterm infants . The COMAlthough critical, neurodevelopmental readiness is not the only aspect to take into consideration. Difficult transition to complementary food may also be related to comorbidities, or even behavioural issues, which should be carefully assessed with the aid of a multidisciplinary team. Indeed, the multiple and unpleasant procedures undergone during hospital admission  may lead to a negative attitude towards CF. Furthermore, parental emotional factors should not be underestimated, particularly in growth-restricted infants, whose growth rate is often concerning for parents , 60.Currently, there is insufficient evidence to draw final conclusions regarding a specific timing for starting CF in preterm infants, due to their extreme variability in achieving neurodevelopmental and oral skills. Hence, we suggest an individualized approach based on the accurate evaluation of the infant development and attitude towards semi-solid foods, employing corrected or postnatal age as an indicative reference rather than a mandatory schedule.Recommendations/StatementsCF in preterm infants should be started between 5 and 8 months of chronological age.Consider also the limit of 3 months CA to ensure the acquisition of developmental skills which allow the consumption of solid foods.Certainty of evidence: Moderate.Grade of recommendation: Strong.Oral dysfunction is not uncommon among infants born preterm, due to the higher occurrence of comorbidities  or neurodevelopmental impairment , 37. RepHowever, guidelines regarding CF for preterm infants with oral dysfunction or major comorbidities are still lacking, hence the nutritional strategy for these infants should be tailored and revised regularly Table . SeemingImportantly, preterm infants with oral dysfunctions or comorbidities require a multidisciplinary follow up encompassing nutrition experts, speech therapists, and a behavioural psychologist , 29, 69:Complete foods based on amino-acid mixtures concentrate in small volumes a high macronutrients content: they may be an option to meet the high nutritional requirements of infants with comorbidities or of those infants unable to ingest large quantities of food .Recommendations/StatementsPreterm infants with oral dysfunctions or comorbidities may require a multidisciplinary assessment to evaluate when and how CF should be started.Certainty of evidence: Low.Grade of recommendation: Weak.When it comes to solid foods for preterm infants, two critical aspects should be taken in consideration. Firstly, if the acceptance and consumption of semi-solid food is still inadequate, attention should be paid to the intake of micronutrients. In this respect, supplementation with iron and multivitamin products are helpful to ensure the correct supply of micronutrients. Secondly, if catch-up growth has not been reached by the time of weaning, a high protein and energy intake should be promoted by means of the correct formula or specific foods to propose. The choice of the right formula milk  is also dependent on the milk tolerance of the infant, since less mature preterm infants may have immature feeding skills but higher energy requirements , 30.Importantly, several figures are involved in the process of weaning a preterm infant: families, primary care paediatricians and nutrition experts. Each figure plays an important role. The family is pivotal since it represents the main support for the babies and their parents. According to a recent systematic review, nutrition education for families may decrease the risk of undernutrition in term infants , hence wMore specific recommendations for preterm infants regarding type of foods to choose, sequence and speed of introduction are lacking, hence guidelines for term infants currently remain the gold standard . ImportaRecently, Salvatori et al.  suggesteAs for micronutrients, iron supply is a matter of concern due to its essential role for brain development. Iron supplementation is recommended for preterm infants until at least 6–12 months of age . HoweverRecommendations/StatementsRecommendations for preterm infants regarding type of foods to choose, sequence and speed of introduction may be considered the same as for term infants currently.Consider starting CF encompassing sources of carbohydrates, proteins and vegetable fats (extra-virgin olive oil) and paying special attention to the intake of micronutrients .Certainty of evidence: Low.Grade of recommendation: Weak.p = 0.01). Fasting 32–33 split proinsulin levels were also associated with greater weight gain in the first two weeks of life, suggesting that early relative undernutrition in children born preterm may have beneficial effects on insulin resistance [Extrauterine growth retardation is very frequent in preterm infants that usually weigh significantly less than expected at hospital discharge and often remain small throughout infancy and childhood. However, an excessive protein supply in the first stages of life and the early introduction of CF have been linked to increased concentrations of insulin and insulin-like growth factor-1 (IGF-1), which in turn cause higher weight gain and body fat deposition leading to an increased risk of obesity. Singhal et al. demonstrated that ex-preterm patients aged 13–16 years featured higher fasting 32–33 split proinsulin concentrations if fed with a nutrient-enriched diet in early childhood  in preterm infants Table . Gupta eA recent study showed that half of preterm infants featured an early adiposity rebound (≤ 4 years of age) irrespective of timing of CF introduction , hence aRecommendations/StatementsTiming of CF start in preterm infants is unlikely to influence the incidence of overweight and obesity in childhood and adulthood.The start of CF in preterm infants should not be delayed with the aim to prevent overweight and obesity.Certainty of evidence: Moderate.Grade of recommendation: Strong.The retrospective case-control study by Yrjänä and coll. showed that very early introduction of CF does not affect the incidence of allergy or atopic manifestations among preterm infants, suggesting that their gut-associated lymphoid tissue is ready for CF within 3 to 6 months of chronological age, regardless of GA at birth .Conversely, Morgan et al. showed that preterm infants introduced early (within 17 weeks' CA) to at least four solid foods featured a higher risk of eczema in infancy  Table 55. DespitRecommendations/StatementsThe introduction of allergenic foods  may not be delayed in preterm infants.Certainty of evidence: Very Low.Grade of recommendation: Weak.Vegetarian and vegan diets are increasingly popular  also amoDue to the shortage of consistent data supporting the safety and feasibility of alternative weaning regimens Table , they shConsumption of foods low in fibre and rich in calcium, iron, zinc, iodine, and DHA together with the supplementation of vitamin D and B12 (in case of vegan diet) are recommended . InfantsRecommendations/StatementsVegetarian and vegan weaning may be carefully planned in preterm infants.Certainty of evidence: Very Low.Grade of recommendation: Weak.Similarly to in-hospital nutrition, also at home the main options are human milk (HM), raw or fortified, and formula milk adapted for preterm infants. Despite the fact that fortified HM may help ensure adequate growth , 53, theAccording to ESPGHAN, exclusive breastfeeding, mixed feeding (in case of insufficient amounts of breast milk) or standard infant formula enriched with LCPUFA should be preferred for infants without EUGR. In contrast, in case of EUGR or high risk of long-term growth failure, infants should be fed up to 40 (but possibly 52) weeks' postmenstrual age with fortified HM or formula milk adapted for preterm infants featuring high protein contents, calcium, phosphorus, zinc, and LCPUFA .RecommendationsInfants without EUGR may be fed with exclusive breastfeeding, mixed feeding (in case of insufficient amounts of breast milk) or standard infant formula enriched with LCPUFA.Infants with EUGR or at high risk of long-term growth failure may be fed with fortified HM or formula milk adapted for preterm infants as long as necessary to gain an optimal weight for CA.Evidence quality: Low.Grade of recommendation: Weak.To the best of our knowledge, the present position paper by joint societies  is the first to draw tailored guidance regarding nutrition and complementary feeding of preterm infants.We suggest that CF in preterm infants should be started between 5 and 8 months of chronological age, taking also into account the limit of 3 months CA to ensure the acquisition of crucial neurodevelopmental skills which allow the consumption of solid foods. As for type of foods to choose, sequence and speed of introduction, the same guidelines available for term infants should be applied also for ex-preemies. CF should be started encompassing sources of carbohydrates, proteins and vegetable fats . Attention should be paid to the intake of micronutrients .A multidisciplinary assessment to evaluate when and how CF should be started is recommended for preterm infants with oral dysfunctions or comorbidities.According to current knowledge, the timing of CF in preterm infants is unlikely to influence the incidence of overweight and obesity in childhood and adulthood. Thus, it is not necessary to delay the start of CF in preterm infants to prevent overweight and obesity. Similarly, the introduction of allergenic foods  should not be delayed in preterm infants.Vegetarian and vegan weaning should be carefully planned in preterm infants, in order to prevent detrimental effects due to nutritional deficiencies.Future research should also aim at providing tailored recommendations for subgroups of preterm infants, such as late preterm neonates, that feature higher risk of lower weight and height during childhood, insulin resistance, glucose intolerance, and high blood pressure compared to term neonates, and whose nutritional requirements are still matter of debate .


We examined whether and how birth outcomes and prenatal care utilization among Latina mothers changed over time across years associated with the Trump sociopolitical environment, using restricted-use birth records from the National Center for Health Statistics (NCHS). To assess potential variation among subpopulations, we disaggregated the analyses by maternal nativity and country/region of origin. Our results indicate that both US- and foreign-born Latina mothers experienced increasingly higher risks of delivering low birthweight (LBW) and preterm birth (PTB) infants over the years associated with Trump’s political career. Among foreign-born Latinas, adverse birth outcomes increased significantly among mothers from Mexico and Central America but not among mothers from Puerto Rico, Cuba, and South America. Levels of inadequate prenatal care utilization remained largely unchanged among groups who saw increases in LBW and PTB, suggesting that changes in prenatal care did not generally explain the observed worsening of birth outcomes among Latina mothers during the Trump era. Results from this study draw attention to the possibility that the Trump era may have represented a source of chronic stress among the Latinx population in the US and add to the growing body of literature linking racism and xenophobia in the sociopolitical environment to declines in health among Latinx people, especially among targeted groups from Mexico and Central America. A growing body of evidence suggests that the political career of Donald Trump has generated harmful consequences for the health and wellbeing of Latinx people in the United States. Throughout his 2016 presidential campaign and subsequent presidency, Trump prioritized an immigration platform that included explicit and implicit anti-immigrant and anti-Latinx policies and rhetoric –9. This Sociopolitical stressors during pregnancy have been linked to adverse birth outcomes, including low birthweight (LBW) and preterm birth (PTB) –15, whicSeveral studies have documented adverse birth outcomes among Latina mothers after discrete anti-immigrant events. One study found a 24% greater risk in LBW among births to both US- and foreign-born Latina mothers in Postville, Iowa following a federal immigration raid that took place there in 2008, compared with births prior to the raid . AnotherTwo recent studies have investigated potential changes in birth outcomes among Latina mothers as a result of anti-immigrant policy and rhetoric in the Trump sociopolitical environment, specifically. One study compared the risk of PTB between periods before and after Trump’s presidential inauguration using birth records in New York City and found a significant increase in the rate of PTB among Latina mothers, with the greatest increase among foreign-born Latinas . In the While these studies provide valuable contributions to our understanding of how birth outcomes among Latina mothers in the US are affected by structural racism, in general, and by Trump’s political career, specifically, key gaps in our knowledge remain. First, surprisingly little work has considered how racist and anti-immigrant sociopolitical events serve as chronic sources of stress. Discrete events can be linked to specific dates with accuracy, and researchers tend to measure potential effects of stress in a period of a few weeks or months after an event. Stress caused by a discrete event, however, likely persists well beyond a few weeks or months. Indeed, racist and anti-immigrant events have the capacity to fully reshape the sociopolitical environment, creating a chronic experience of stress for long periods of time .Second, most studies in this area have focused on birth outcomes among women who are encompassed by the broad umbrella terms of “Hispanic” or “Latina.” In terms of research in the Trump era specifically, no study has examined how national-level changes in birth outcomes among infants born to Latina mothers differ by nativity or country/region of origin. There are important reasons to expect, however, that the health effects of racist and xenophobic policies and rhetoric would vary within the Latinx population –27. PeopThird, more attention is needed on the potential mechanisms that could explain the observed link between sociopolitical stress and adverse birth outcomes among Latina mothers, such as changes in the use of prenatal care. Existing literature finds that racist, anti-immigrant events can lead to “chilling effects,” whereby feelings of fear, anxiety, and mistrust prevent immigrants from seeking needed healthcare services –35. A reTo address these important and timely gaps in the literature, we examined the associations between the Trump sociopolitical environment and birth outcomes and prenatal care utilization among Latina women over a six-year period. While these associations are temporal and not causal, our analyses nevertheless allow us to document whether and how racist, anti-immigrant events associated with the Trump sociopolitical environment may have represented chronic sources of stress for the Latinx population in the United States. To assess potential heterogeneity within the Latina immigrant population, we leveraged information in the restricted-use birth records from the National Center for Health Statistics (NCHS) that allowed us to disaggregate results by maternal country/region of origin. Given Trump’s specific targeting of and scrutiny against people from Mexico and Central America –7, we hyWe conceptualized the entirety of Trump’s presidential campaign and subsequent administration as a period of chronic stress for Latinx people in the United States. At the same time, we also expected that stress levels affected by this sociopolitical environment may have varied over time as Trump’s racist, anti-immigrant rhetoric and policy agenda became increasingly threatening over the course of his political career. Accordingly, we designed this study to compare birth outcomes and levels of prenatal care across each year of Trump’s political career, including his presidential campaign, election, and administration, relative to a “pre-Trump” period. Descriptions of these periods are provided in We considered the formal launching of Trump’s presidential campaign as the primary marker of time when we might expect to observe negative changes in adverse birth outcomes and prenatal care utilization among Latina mothers, owing to experiences of racism and discrimination during pregnancy. In the June 2015 speech announcing his candidacy, Trump established the racist and anti-immigrant tone of his campaign by referring to Mexican immigrants as “criminals” and “rapists” and promising to build a “great wall” along the US-Mexico border. His campaign speech also went on to disparage all Latinx people, stating that crime is “…probably coming from more than Mexico. It’s coming from all over South and Latin America…”. Trump’s racist and xenophobic speech toward Mexicans and other Latinx groups continued in his speeches, interviews, and were prominent on his Twitter account throughout his campaign ,37, we uOur analyses are based on restricted-use natality data for the years 2014–2019, collected by the National Center for Health Statistics (NCHS) as part of the National Vital Statistics System –41. We rst through December 31st of each study year. Among these cases, we restricted our analysis to singleton live-births to Latina mothers who were residents of one of the 50 US states and who had complete information on maternal country/region of birth, age, formal schooling, parity, infant birthweight, and infant gestational age. Cases removed due to missing information made up less than 1% of all birth records in our study years.In line with our study design, we limited our analytic dataset to include only births that occurred from July 1The Institutional Review Board of the University of North Carolina at Chapel Hill approved the study protocol. All data was fully anonymized before we accessed them. All analyses and reporting of results were conducted in accordance with our data use agreement with NCHS/NAPHSIS.We examined two sets of outcomes: infant health at birth and maternal use of prenatal care. The infant health outcomes we considered were low birthweight  and preterm birth  . MaternaTo estimate exposure to the Trump sociopolitical environment, the key independent variable distinguished the pre- and post-Trump study periods . The control variables included in the analysis were maternal age , formal schooling , and parity (first live birth or not).z-tests.We performed a multistep analysis. First, we conducted preliminary and descriptive analyses to evaluate the distributions and temporal variability of study variables. In these analyses, we estimated univariate frequencies of the control variables  as well as the outcome variables  as proportions across each of the study periods. We assessed whether the proportions in the post-Trump periods differed from the pre-Trump period using two-tailed Second, we estimated multivariable logistic regression models to identify the temporal associations between exposure to the Trump treatment periods and each outcome of interest: LBW, PTB, and inadequate prenatal care utilization. Rather than comparing outcomes to a reference group with the lowest risk of the outcome , we stratified the models for each population group of interest: US-born Latinas, foreign-born Latinas (aggregated), foreign-born Mexicans, foreign-born Central Americans, foreign-born South Americans, foreign-born Puerto Ricans, and foreign-born Cubans. By analyzing within-group variation over time, each ethnic population in essence serves as its own control group, providing a clearer assessment of how the exposure-outcome association differs across Latina mothers by nativity and maternal country/region of birth . All modThird, we tested the sensitivity of our results by accounting for potential sources of bias. One potential source of bias in our statistical models in the exclusion of maternal marital status, which is a well-documented predictor of infant birth outcomes and use of prenatal care –51. DespP < .05. All analyses were conducted using Stata 15 SE software.For all analyses, statistical significance was assessed at 2-sided P < .05) in the rates of births by mothers who were less than 20 years old and who had less than a high school level of formal schooling.Despite having no significant changes in their levels of LBW and PTB, mothers from South America, Puerto Rico, and Cuba saw some significant increases in their levels of inadequate prenatal care utilization. Among mothers from South America, the odds of using inadequate levels of prenatal care increased significantly during the 2016, 2017, 2018, and 2019 post-Trump periods, with their largest increase occurring in 2019 . Mothers from Puerto Rico saw significant increases in their odds of using inadequate levels of prenatal care in the 2015 and 2016 post-Trump study periods, and mothers from Cuba saw significant increases in their odds of using inadequate levels of prenatal care during the 2016, 2017, and 2019 post-Trump study periods see . SimilarOur sensitivity testing produced essentially the same results as the primary analyses. Results of our imputation models controlling for maternal marital status in addition to maternal age, formal schooling, and parity are available upon request.The Latinx population in the United States was targeted by racist and xenophobic rhetoric and policy during the entirety of Trump’s political career, from his presidential campaign through his administration, and people from Mexico and Central America were particularly threatened –7. The sAddressing this important gap in the literature, we examined temporal associations between the Trump sociopolitical environment and birth outcomes among Latina mothers over a six-year period and investigated potential heterogeneity in outcomes by nativity and country/region of origin. Our results indicate that both US- and foreign-born Latina mothers experienced increasingly higher risks of adverse birth outcomes over the course of Trump’s political career from 2015 to 2019. For US-born Latina mothers, the odds of delivering a low birthweight infant increased by 3.1–7.2% and the odds of delivering a preterm infant increased by 0.1–13.7% across the observed years of Trump’s political career , in comparison to a pre-Trump period (2014). These changes in birth outcomes suggest that there were approximately 3,700 more low birthweight infants and approximately 5,300 more preterm infants delivered by US-born mothers during the Trump era, compared to the counterfactual scenario in which the pre-Trump levels of LBW and PTB had continued. Among foreign-born Latina mothers, the odds of delivering a low birthweight infant increased by 2.1–8.9% and the odds of delivering a preterm infant increased by 1.0–16.5% during 2015–2019. These results imply that the population of immigrant Latina mothers in the US delivered approximately 3,300 more low birthweight infants and nearly 6,300 more preterm infants during the Trump era than what would have been expected based on the pre-Trump data.In our analysis examining heterogeneity in birth outcomes among immigrant Latina mothers, we find notable variation across nativity and nationality. Consistent with our hypotheses, our results indicate that the Trump sociopolitical environment was associated with significant increases in the risk of adverse birth outcomes among foreign-born Mexican and Central American mothers, but not among mothers from South America, Puerto Rico, and Cuba. These findings may reflect important differences in stress and anxiety among Latina mothers due to variations in migration experiences, citizenship status, and racism experienced by people from different Latin American countries. People from Mexico and Central America may have experienced greater levels of stress and anxiety because they are more likely to be undocumented, to have undocumented family members, or to be suspected as being undocumented , and theIncreases in adverse birth outcomes were most severe among foreign-born Mexican mothers. For this group, the odds of delivering a low birthweight infant increased by 3.7–12.5% and the odds of delivering a preterm infant increased by 1.0–21.1% across 2015–2019, implying that immigrant mothers from Mexico delivered approximately 2,300 more low birthweight infants and roughly 3,800 more preterm infants during the Trump era, in comparison to what would have been expected based on the pre-Trump data. Together with the results among the aggregate population of foreign-born Latina mothers, these findings suggest that low birthweight and preterm deliveries were disproportionately concentrated among foreign-born Mexican mothers during the years associated with Trump’s political career. Despite making up about 55% of all births to foreign-born Latina mothers during the study period  in their levels of inadequate prenatal care during the 2019 post-Trump period. We find that immigrant mothers from South America, Puerto Rico, and Cuba also saw significant increases in their levels of inadequate prenatal care, although they experienced no significant increases in their levels of LBW and PTB. These worsening trends in prenatal care among South American, Puerto Rican, and Cuban mothers were not associated with observable changes in the data, such as changes over time in demographic composition or in the geography of where births took place. Future research should investigate these surprising and troubling increases in inadequate prenatal care, more deeply.Taken together, the unexpected findings on prenatal care suggest that the worsening of adverse birth outcomes among Mexican and Central American mothers are not generally explained by a co-occurring decline in prenatal care. However, because our results illustrate patterns at the national level, more research is needed on the extent to which changes in the use of prenatal care may have varied geographically. Given previous research that found significant declines in prenatal visits among expectant immigrant Latina mothers from Mexico and Central America in Houston, Texas following the initiation of Trump’s presidential campaign , there aDespite the strengths of this study, we acknowledge several limitations. First, although we controlled for important maternal factors associated with birthweight, it remains possible that there are unmeasured and unobserved confounding variables that were not considered in our analysis. Further, although existing studies show that Latinx people have experienced increased stress and anxiety due the ways that Trump has influenced the sociopolitical environment –9, our aSecond, our results may be subject to selection biases from changes in the composition of mothers giving birth in the US. Declines in the number of births among more advantaged and healthier mothers would cause us to overestimate the potential true effect of the Trump treatment periods on birth and prenatal care outcomes. Our analysis of maternal sociodemographic characteristics over time, however, shows that traditional risk factors associated with LBW, PTB, and inadequate use of prenatal care were generally less prevalent in the post-Trump periods compared with the pre-Trump period.Third, our analysis examining temporal changes in birth and prenatal care outcomes over time uses one year of data for the pre-Trump study period. Using more pre-Trump years extending into the past can be important to evaluate and rule-out pre-treatment trends as a potential source of confounding. In our early analyses for this study, we examined birth and prenatal care outcomes using the restricted-use birth records from as far back as 2010 and found that trends in these outcomes were generally stable or declining prior to 2015 (2010–2014). Accordingly, the 2010–2019 data generated results that were statistically and substantively identical to those presented here. We opted to restrict the analysis to the 2014–2019 data, however, for two reasons. First, because the results from the 2014–2019 data were more conservative, given that they do not account for some declines in the outcomes prior to 2014. Second, and most importantly, because some measures used in our analysis were only available for certain states prior to 2014. In 2003, the NCHS adopted a revision to birth certificates that changed the standard reporting of information in the natality data, and these revisions were implemented across states over time. In 2014, all states fully transitioned to the revised birth certificate for the measures used in our analysis. Thus, we considered the data prior to 2014 as incomplete and found no statistical or substantive value in adding these years to our analysis.Fourth, the analysis excludes information on maternal health status, which may have important implications for our observed results. The NCHS birth records data includes a select few measures on maternal health, including pre-pregnancy diabetes, gestational diabetes, pre-pregnancy hypertension, gestational hypertension, and eclampsia, which are all strongly associated with adverse birth outcomes . In addiFifth, the restricted data files we used enabled us to identify foreign-born Latina mothers by country/region of origin but lacked information that would allow us to identify US-born Latina mothers across nationalities. Understanding temporal changes in birth and prenatal care outcomes among these groups of mothers is important because Trump’s attacks against immigrants from Latin American countries create negative health implications that extend beyond intended targets, affecting US-born co-ethnic groups.Lastly, we could not identify the mechanisms that account for the temporal relationships between the Trump study periods and the observed birth outcomes. Although potentially flawed (as mentioned above), we considered Trump’s political career as an environmental stressor for expectant Latina mothers, given existing evidence indicating that Latinx people have experienced increased stress and anxiety due to Trump’s sociopolitical influence –9. EnvirOur findings add important and timely updates to the growing literature on the temporal linkages between the Trump sociopolitical environment and adverse birth outcomes among Latina mothers in the US ,14. In tA growing body of literature emphasizes the embodied stress that Latinx people in the US experienced during Trump’s political career, due to his racist and anti-immigrant rhetoric and policy –9. BuildS1 File(DOCX)Click here for additional data file.