About three – quarters of all neonatal deaths occur during the first week of life, with over half of these occurring within the first 24 h after birth. The first minutes after birth are critical to reducing neonatal mortality. Successful neonatal resuscitation (NR) has the potential to prevent these perinatal mortalities related to birth asphyxia. This study described the practice of NR and outcomes of newborns with birth asphyxia in a busy referral hospital.Direct observations of 138 NRs by 28 healthcare providers (HCPs) were conducted using a predetermined checklist adapted from the national pediatric resuscitation protocol. Descriptive statistics were computed and chi – square tests were used to test associations between the newborn outcome at 1 h and the NR processes for the observed newborns. Logistic regression models assessed the relationship between the survival status at 1 h versus the NR processes and newborn characteristics.P = 0.035, OR = 2.90, CI = 1.08–7.76), keeping baby warm , meconium in airway  and gestation age  were associated with newborn outcome at 1 h.Nurses performed 72.5% of the NRs. A warm environment was maintained in 71% of the resuscitations. Airway was checked for almost all newborns (98%) who did not initiate spontaneous breathing after stimulation. However, only 40% of newborns were correctly cared for in case of meconium presence in airway. Bag and mask ventilation (BMV) was initiated in 100% of newborns who did not respond to stimulation and airway maintenance. About 86.2% of resuscitated newborns survived after 1 h. Removing wet cloth  contains supplementary material, which is available to authorized users. Globally, approximately 4 million deaths occur in neonates with 99% of them occurring in low and middle income countries . Birth aEvidence around the world also show that the risk of death increases by 16% for every 30 s delay in initiating ventilation up to six minutes and every 6% for every minute of delay of applied bag and mask ventilation . TherefoNeonatal mortality in Kenya is still high at 21 per 1000 live births . Birth aHowever, despite the HCPs’ pre – service and in – service training, guidelines and job aids with adequate equipment in NR, practices of HCPs with regard to NR are still reported to be poor –17. InefThis was a cross - sectional study employing direct observations of NR in labour ward and maternity theatre between April and June 2016 at the regional Kakamega County General Hospital. This method is non – intrusive, where the HCPs do what they normally do (resuscitation) without being interrupted or disturbed by the observer , 22. Thin = Z2pq/e2) for cross – sectional studies was used to calculate the sample size of the NRs to be observed , airway maintenance [four items], bag and mask ventilation [seven items] including the optional cardiopulmonary resuscitation [two items]  and the primary outcome . However, since the NR steps are dependent, the regression was done independently for each NR step performed. Newborn characteristics that were significant in the bivariate analysis were retained as predictors in the final model. With a 95% confidence interval, n = 17, 60.7%) of the HCPs had attended the Basic Emergency Obstetrics and Neonatal Care (BEmONC) training that has a component on NR with at least half  of them completing the training within the past six months prior to the study. Support supervision in NR was reported by most HCPs (89.3%). Over half of the HCPs (60%) reported having received the supervision within the past year prior to this study by the maternity unit manager and/or the labour ward in – charge.Twenty eight HCPs with a median age of 30 years (range 24–50) participated in the study. Nurses/midwives were the majority cadre (71.4%) providing newborn resuscitation. Two thirds of nurses/midwives (65%) were registered diploma holders and one third (35%) were bachelor degree nurses. Most of the HCPs (89.3%) had worked in the maternity ward providing NR care for more than a year. Eighteen HCPs (64.3%) reported ever attending a NR training. Most HCPs (66.7%) had such trainings over 12 months prior to this study. Importantly, all the HCPs who participated in the study had at least undergone either a formal NR training or a non – specific NR induction training . More than half (Nurses provided NR for the majority of the newborn babies (72.5%). Majority of the newborn babies (63.8%) were cared for by HCPs who had undergone a NR training. The HCPs with over a year experience working in maternity performed most of the NRs 89.1%) (See Table % (See TaHelping Babies Breathe (HBB) NR action plans and guidelines were displayed at the resuscitation area. No immediate newborn care and warm chain charts were observed in the unit. All the basic NR equipment: two resuscitaires equipped with electric warmers; oxygen source ; suction devices (electric suction machine & colored suction bulbs); ambubags; term face masks (size 1) and the wall clock were available, functional and accessible at the common resuscitation station. However, only one functional preterm mask (size 0) was available and occasionally shareable between the labor ward and the newborn unit. A clean dry towel for drying the newborn was present in each delivery pack.n = 135) resuscitation cases, equipment used (suction devices and face masks) were well processed with the HCPs adhering to recommended infection prevention practices. These were cleaning of ventilating face mask and the suction device, decontamination in 0.5% sodium hypochlorite solution for 10 min , washing with soap and water and rinsed well and aired to dry until next use.In 97.8%  were by spontaneous vertex delivery (SVD) and cesarean section . The mean birth weight was 3211.2 g (SD ± 936.0); lowest had 900 g and highest had 5000 g. Thirty (21.7%) newborns had low birth weight (< 2500 g) while 51 (37.0%) of the newborns were preterm births with gestational ages less than 37 weeks. Fifty seven (41.3%) newborns had meconium present in their airway at delivery  the newborns were dried gently by rubbing the back with the dry towel. However, the wet towel was not removed in a third of the newborns (31%) resuscitated. A few inappropriate stimulation practices observed during the resuscitations included: vigorously rubbing the baby’s back and chest , flicking the baby’s feet  and patting the baby’s back .Nearly all (n = 123) newborns who did not respond to stimulation with any form of airway secretions. Meconium was present in the airway in 57 (46%) of the newborns. Suctioning of airway before stimulation in presence of meconium as per the national guidelines was only correctly done in 23 (40%) of the newborns. Inappropriate head positioning  to clear the airway was observed in 21 (17%) cases and 11 (7.2%) of the newborns were turned upside down and back patted. A few  newborns required prolonged suctioning with a bulb suction device for over 10 min to open the airway.The airway was checked and cleared for all . Ventilation was initiated within the Golden minute in just over half  of the newborns who required help. The mean time for initiation of bag valve and mask ventilation was 69.2 s (SD ± 19.6). Less than half  of the newborns did not respond after the initial BMV for a minute and required advanced/subsequent BMV. Chest compressions with effective breaths and supplemental oxygen were provided for the newborns who did not initiate spontaneous breathing after the advanced BMV as per the national guidelines (See Table Bag and mask ventilation (BMV) was initiated for all the newborns who did not initiate breathing after airway clearance  resuscitated were followed up from 1, 5, 10 min and at 1 h. The mean APGAR scores were 5.9 (SD ±1.3) at 1 min, 6.9 (SD ± 2.0) at 5 min and 8.1 (SD ± 2.9) at 10 min for the 138 newborns resuscitated. More than half  of the newborns had APGAR scores less than 6 at 1 min with the remainder  having APGAR scores of 7 at 1 min. Overall, majority of the neonates  survived. Of the 19 (13.8%) who died, a third  died before 10 min after birth with the remaining deaths  occurring within the first hour of life.All the newborns  of the newborns initiated spontaneous breathing after the initial drying and airway suction stimulation. Less than half  of the newborns required bag and mask ventilation to initiate spontaneous breathing  were under normal routine care with the mother and the remaining 34 28.6%) were in special newborn care unit for supportive oxygen and/or other specific management for the newborns at risk after birth , keeping the baby warm , meconium presence in airway , suctioning before stimulation in meconium presence  and chest movements with each bag and mask ventilation  showed statistically significant associations with the neonate’s survival at 1 h. In addition, neonate’s gestation age  and birth weight  were significantly associated with the neonate’s survival or death  and keeping the baby warm after stimulation  were significantly associated with survival of the newborn. Newborns with meconium presence in airway were 66% more likely not to survive past 1 h after resuscitation . Gestation age ≥ 37 weeks was significantly associated with increased survival at 1 h post NR  . Our study finding show that HCPs clearly recognize the indication for bag and ventilation in newborns without or gasping respirations as recommended , 24. HowThere is evidence that most resuscitated newborns will initiate spontaneous breathing after simple stimulation with very few going through the advanced NR steps involving chest compressions and drugs . This imSecretions obstruct the airway worsening the asphyxia. Our findings showed that newborns born with meconium – stained amniotic fluid in the airway who did not start breathing on their own had reduced chances of survival in the first hour after birth. Similarly, HCPs’ NR skills were poor in airway clearance in presence of meconium in babies who did not start breathing on their own. Healthcare providers dried/stimulated newborns before airway clearance in presence of meconium in non – breathing newborns contrary to both the international and national guidelines on the management of meconium presence in the airway , 14, 24.Bag and mask ventilation with room air and subsequent transfer to positive pressure ventilation using the nasal cannulae for unstable newborns was the standard practice on oxygen use during resuscitation. This is to ensure that asphyxiated newborns are given the highest quality of care to improve their chances of survival as recommended . This isPotentially harmful/inappropriate NR practices are still prevalent in the labor wards. This finding is widely reported in the most recent studies on adherence of HCPs to the national NR guidelines in Kenya , 28, 30.Prematurity is among the top three causes of neonatal mortality in Kenya  and the This study did not consider possible maternal factors that could have led to the deaths of the resuscitated newborns. The Hawthorn’s effect is a major drawback in direct observation studies; however, this helps to observe the ‘where’ and ‘when’ of the ongoing process/situation/behavior wanted. Multiple resuscitations per HCP were observed on the assumption that after a few minutes, the HCP would become accustomed to our presence and function in a more natural fashion. The small number of observations for the NR steps after failed initial stimulation and airway maintenance entails that our results should be interpreted in light of the small sample size.The hospital is prepared with the basic equipment to provide NR with nurses/midwives being the primary providers of NR services. In addition, training in neonatal resuscitation for HCPs is poorly spaced allowing deterioration of key skills. Nurses/midwives and other HCPs providing NR need regular cost – effective NR trainings with focus on maintaining the warm chain for the newborns, airway clearance in meconium – stained amniotic fluid in airways of newborns not breathing, bag and mask ventilation and care for premature babies focusing on the knowledge and practical skills at least after every 6 months. Besides, mentorship programs for the new HCPs in the maternity unit by the more experienced HCPs in the maternity can help to pass knowledge and skills to the new staff joining the unit .Additional file 1:Structured observational checklist. (PDF 561 kb)


The Lao People’s Democratic Republic (Lao PDR) is a lower-middle income country making steady progress improving maternal and child health outcomes. We sought to ascertain if there have been improvements in three specific birth outcomes  over the last decade.We retrospectively reviewed birth records between 2004 and 2013 at the Mother and Child Health (MCH) hospital in Vientiane. We defined preterm birth as gestation <37 weeks and low birth weight as <2,500 g. We calculated small for gestational age (SGA). We describe birth outcomes over time and compare proportions using Chi square.p < 0.02) or preterm  than those aged >18. There was no difference in the frequency of babies born SGA by age .Between 2004 and 2013, the annual average number of newborns delivered each year was 4,322 and the frequency of low birth weight ranged from 9.5 to 12%, preterm births from 6.3 to 10%, and infants born SGA from 25 to 35%. There were no improvements in these frequencies over time. Women <18 years at delivery had a statistically significantly higher frequency of babies born with a low birth weight (15.3 vs. 10.8%, At the largest maternal and child hospital in Lao PDR, we found a high frequency of poor birth outcomes with no improvements over the last decade. Improving maternal and child health are priorities for the United Nation’s Millennium Development Goals (MDG), and the World Health Organization (WHO) recommends various measures, including antenatal care, delivery in health facilities with skilled attendants, malaria chemoprophylaxis and tetanus toxoid vaccine during pregnancy, and childhood vaccination to achieve targets in key health indicators. The Lao People’s Democratic Republic (Lao PDR) is a lower-middle income country in Southeast Asia that has made numerous investments in child and maternal health over the last decade that have yielded substantial gains in key health indicators . MaternaWhile these improvements are significant and bring Lao PDR closer to reaching MDG targets, Lao PDR still has one of the highest <5 mortality in the region, and infant and maternal mortality rates remain among the highest in the region. Furthermore, there is no information on whether there have been improvements in birth outcomes such as the proportion of infants born low birth weight, preterm or small for gestational age. To ascertain if there were improvements in birth outcomes over time we reviewed historical data from the largest maternal hospital in Lao PDR between 2004 and 2013. Reviewing these data may help us better understand birth outcomes patterns in the context of a country going through substantial economic development striving to reach their MDG goals.The Mother and Child Health (MCH) hospital is a 70-bed referral hospital located in Vientiane, Lao PDR. There are five large delivery hospitals in Vientiane and approximately one third of all hospital deliveries are in MCH . We condth percentile of birth weights of the same sex and same gestational age in weeks, and is expressed as a percentage of live births with gestational ages from 22 to 43 weeks. LGA was defined as a live birth with a birth weight more than the 90th percentile of birth weights of the same sex and the same gestational, expressed as a percentage of live births with gestational ages from 22 to 43 weeks. For each individual newborn record in 2004–2010, there was no indication on whether it was a singleton or part of a multiple birth so all births were assumed to be singletons for the calculation of SGA and LGA. We used three month moving averages to smooth the curves for the proportion of birth outcomes small for gestational age, low birth weight and preterm. To compare proportions we used Chi-square and for multiple samples we used the Mantel-Haenszel test of linear association; to compare continuous variables we used the Mann-Whitney test for two independent samples and the Kruskal-Wallis test for k independent samples. A p < 0.05 was considered significant.Data were entered into Excel (Microsoft Office 2010) and Access (Microsoft Office 2010) and imported into SPSS  for analysis. In 196 (1.4%) newborn records, gestational age was recorded as a two-week range; we selected the earlier week. We defined preterm birth as gestation <37 weeks and low birth weight as <2,500 g. We calculated small for gestational age (SGA) and large for gestation age (LGA) using the Kramer method [Between 2004 and 2013, the total number of recorded deliveries at MCH Hospital was 38,906 , but birth weight was 40 g more in the years that only included singleton births . The frequency of low birth weight  ranged from 9.5% in 2013 to 12% in 2005 and 2009; there was no linear association with delivery year (p = 0.08). The annual mean gestational age was 38.8 weeks, and the frequency of preterm births ranged from 6.3% in 2004 to 10% in 2012; the linear association with delivery year was statistically significant (p = 0.002). The proportion of infants born SGA ranged from 25% in 2009, 2012 and 2013 to 35% in 2005 and 2006; the linear association with delivery year was statistically significant (p < 0.001).Data on infants were available for all years 2004–2013 (Table p < 0.02) or preterm  than those aged ≥18 old. There was no difference in the frequency of babies born small for gestational age by age . In years 2011–2013, we had monthly data on birth outcomes and observed an annual increase in the number of births in September through November in 2011 and 2012 but not in 2013  per capita increased from $390 to $1,490, and Lao PDR is now considered a lower-middle income country . If geneMany factors, including maternal insults during pregnancy, contribute to poor birth outcomes such as infants being born small for gestational age. Infections, including influenza, in pregnant women are associated with higher risks of severe outcomes,  and mateThese data have several limitations. First, data were abstracted from hard-copy logbooks, some of which had gone missing over the years. However, missing logbooks were unlikely to be drastically different from those we analyzed. Second, for all but the three most recent years of data, we lacked individual-level data on whether each newborn was a singleton or part of a multiple birth. Newborns that are part of multiple births are smaller and weigh less so inclusion in the calculation of SGA may have exaggerated the number of SGA infants. It may be that our population reference for calculating small for gestational age is not appropriate for Asian populations and overestimates the proportion of infants born small for gestational age. Nevertheless, with the consistent application of the methodology each year, any oberserved change was likely real. Finally, the hospital from which data were reviewed is the largest maternity hospital in Lao PDR located in Vientiane, a major urban city. It is likely that the women using this hospital may have better access to care than those from rural Lao PDR, and therefore the results may not be generalizable to rural Laos. Despite these limitations, the findings are consistent with data from other Southeast Asian nations, suggesting that our data may be fairly representative , 18.In Lao PDR, prenatal health care, proper maternal health and nutrition and maternal education have all been demonstrated to be important factors to improve outcomes of infants . Other fAn analysis of 10-years of data on live births from the largest maternal and child hospital in Lao PDR found a consistent, high frequency of poor birth outcomes. Furthermore, we found increases in the proportions of infants born preterm and SGA. These results highlight the critical need for evidence-based interventions such as prenatal health care, proper maternal health and nutrition and maternal education.


Nausea and vomiting during pregnancy (NVP) is considered to be associated with favorable fetal outcomes, such as a decreased risk for spontaneous abortion. However, the relationship between NVP and preterm births remains unknown. This study was conducted to evaluate the association between NVP and the risk of preterm births.The dataset of a birth cohort study, the Japan Environment and Children’s Study (JECS), was retrospectively reviewed. Participants’ experience of NVP prior to 12 gestational weeks were evaluated by a questionnaire administered from 22 weeks of pregnancy to 1 month before delivery. NVP responses were elicited against four choices based on which the study population was divided into four subcohorts. Preterm birth was the main study outcome. Logistic regression analysis was used to quantify an association between NVP and risk of preterm birth.Of 96,056 women, 79,460 (82.7%) experienced some symptoms of NVP and 10,518 (10.9%) experienced severe NVP. Compared to those who did not experience NVP, women with severe NVP had lower odds for preterm birth . An even lower OR was found among very preterm birth and extremely preterm birth .An inverse association exists between NVP and preterm births, especially, very preterm births and extremely preterm births. Nausea and vomiting during pregnancy (NVP) is among the most common clinical complaints in the first trimester of pregnancy. NVP affects up to 70% of pregnant women, but there is considerable variation among reported frequencies 35–91%) [% [1]. NVIn the context of these hypotheses, NVP is associated with favorable fetal outcomes , 10. A nWe retrospectively analyzed the dataset of the JECS, a long-term birth cohort study to elucidate the influence of chemical exposures during the fetal period and early childhood on children’s health with follow-up until age 13. The protocol and baseline data of this study are available elsewhere .For the JECS, pregnant women were recruited between January 31, 2011 and March 31, 2014. Eligibility criteria for study participants (expectant mothers) were as follows: 1) residing in the study areas at the time of recruitment and attending collaborating healthcare providers; 2) expected delivery date after August 1, 2011; and 3) capable of comprehending Japanese and completing self-administered questionnaires. Details of the JECS project have been described in a previous article [With regards to exposure measurement, lifestyle and other background information was collected using a self-administered questionnaire distributed to participating pregnant women from the first trimester up to 21 weeks and 6 days of pregnancy (M-T1) and from 22 weeks of pregnancy to 1 month before delivery (M-T2). Medical histories of past and present pregnancies, and physical status of participants and their offspring, were collected from an obstetrician’s medical chart at registration (Dr-T1) and at delivery (Dr-0 m). Study analyses were based on M-T2, Dr-T1, and Dr-0 m.n = 1250) and multiple births (n = 1929). We also excluded women who had delivered before 26 weeks of gestation because they may have delivered before the M-T2 questionnaire was provided (n = 271). Moreover, we excluded cases with missing data on gestational age (n = 2323), and cases with missing data on NVP (n = 2273). In total, 96,056 births were included in the final study sample .Information on parity, maternal height, and pre-pregnancy weight was obtained from Dr-T1, and data on maternal age, gestational age, birth outcomes, and prenatal complications were obtained from Dr-0 m. Participants underwent ultrasound examinations during the first trimester, and these results were used to determine the expected date of delivery if there was more than a 7-day difference between this date and the date calculated from the last menstrual period.2), normal (18.5–24.9 kg/m2) and overweight (≥25 kg/m2). Maternal smoking habits were categorized into smoking during pregnancy and others.Maternal age was categorized into six groups: younger than 20 years, 20–24 years, 25–29 years, 30–34 years, 35–39 years, and 40 years or older. By data on parity, the cohort was classified into nullipara and multipara. A proxy for socioeconomic status, maternal length of education, was categorized into ≤12 years and > 12 years. Body mass index (BMI) was calculated from the information on pre-pregnancy height and weight and categorized into three groups: underweight , term (37–41 weeks) and preterm (< 37 weeks). Further, preterm birth was subdivided into moderately preterm (32–36 weeks), very preterm (28–31 weeks), and extremely preterm (26–27 weeks) .P-values < 0.05 indicated statistical significance.The study population was divided into four groups, based on the answers to the questionnaire for NVP symptoms as follows: those who did not experience NVP (no NVP); those who experienced nausea only (mild NVP); those who experienced NVP but could have meals (moderate NVP); and those who experienced NVP and could not have meals (severe NVP). Maternal characteristics and pregnancy outcomes were compared among the four NVP groups. Gestational age was compared employing Kruskal–Wallis test for non-normally distributed data. Categorical variables were compared using a chi-squared test. Logistic regression analysis was used to estimate the association between NVP and the risk of preterm birth. For analysis of the odds ratio (OR) of preterm birth, we used a dichotomized outcome variable: preterm birth (< 37 weeks) and others (≥37 weeks). For analysis of OR of very preterm birth and extremely preterm birth, we used another dichotomized outcome variable: very preterm birth and extremely preterm birth (born at < 32 weeks of gestation) and others (born at ≥32 weeks). ORs were adjusted for maternal age, parity, maternal education, maternal pre-pregnancy BMI, and smoking habits during pregnancy. Results are presented as crude odds ratios (cOR) and adjusted odds ratios (aOR), or as mean differences with 95% confidence intervals (95% CI). All analyses were conducted using Stata 13.1 .n = 16,596; 17.3%), mild NVP , moderate NVP , and severe NVP . Higher rates of no symptoms of NVP were seen among women with older age, nullipara, higher education, low pre-pregnancy BMI, and smoking during pregnancy.As shown in Table The prevalence of pregnancy-related complications possibly causing preterm birth were also significantly different among the four groups. In women without NVP, the prevalence of threatened abortion and threatened premature labor were lowest, whereas rates of preterm rupture of membrane and pregnancy-induced hypertension were highest Table .The overall rate of preterm births < 37 weeks) was 4.6% . Rates of extremely (26–27 weeks), very (28–31 weeks), and moderately (32–36 weeks) preterm births were 0.09% , 0.38% , and 4.1% , respectively. Median gestational age was not statistically influenced by NVP status. However, the prevalence of preterm birth was slightly higher in women without NVP (Table 7 weeks wIn our nationwide cohort study of approximately 100,000 births, we found that NVP symptoms were associated with decreased risk of preterm birth. An even lower OR was found for very preterm birth and extremely preterm birth. Furthermore, pregnancy complications such as preterm rupture of membrane and pregnancy-induced hypertension were less frequent in women who experienced at least some symptoms of NVP than in women with no NVP.These findings are similar to the results of a Norwegian large cohort study showing higher prevalence of preterm births in women who did not experience NVP than in women who did experience NVP . CzeizelAs Czeizel indicated, these previous inconsistent results may be attributed to the difference in the definition/classification of NVP . VariousOther possible reasons for previous inconsistent results may be the mild effect of NVP on gestational age and the difference of sample size . In thisThe etiopathogenesis of NVP, although unclear, is likely to be multifactorial, including placenta-mediated mechanisms . Niebyl Several limitations pertaining to this study should be considered. Information on the duration of NVP, treatment of NVP and late onset NVP could not be obtained. Therefore, we could not assess prolonged NVP and late onset NVP. The fact that information on maternal characteristics and NVP were missing in some cases was also a limitation. Some women who delivered preterm babies before 26 weeks may have failed to answer the questionnaire because they may have delivered before the questionnaire was provided. Therefore, we excluded women who had delivered before 26 weeks of gestation.The strengths of our study are that it is a large population-based cohort study. To our knowledge, our study is the largest study to date on this topic and the first study to evaluate the association between NVP and preterm births in the Asian population. These data enabled us to analyze risks of subgroups that experienced preterm birth against a range of confounding factors, including maternal characteristics and prenatal risk factors. The fact that information on NVP were obtained before delivery is another strength of this study. Besides the adjustment for confounders, the standardized healthcare system in Japan and the relatively homogeneous Japanese pregnant population should limit possibilities of residual confounding.NVP was inversely associated with preterm births, especially for very preterm births and extremely preterm births. Further investigation of the association between severity of NVP and placental characteristics or hormonal milieu is needed.


Admissions of infants in England have increased substantially but there is little evidence whether this is across the first year or predominately in neonates; and for all or for specific causes. We aimed to characterise this increase, especially those admissions that may be avoidable in the context of postnatal care provision.A cross sectional analysis of 1,387,677 infants up to age one admitted to English hospitals between April 2008 and April 2014 using Hospital Episode Statistics and live birth denominators for England from Office for National Statistics. Potentially avoidable conditions were defined through a staged process with a panel.The rate of hospital admission in the first year of life for physiological jaundice, feeding difficulties and gastroenteritis, the three conditions identified as potentially preventable in the context of postnatal care provision, increased by 39% (39.55 to 55.33 per 1000 live births) relative to an overall increase of 6% (334.97 to 354.55 per 1000 live births). Over the first year the biggest increase in admissions occurred in the first 0–6 days  and 85% of the increase (12.36 to 18.23 per 1000 live births) in this period was for the three potentially preventable conditions.Most of the increase in infant hospital admissions was in the early neonatal period, the great majority being accounted for by three potentially avoidable conditions especially jaundice and feeding difficulties. This may indicate missed opportunities within the postnatal care pathway and given the enormous NHS cost and parental distress from hospital admission of infants, requires urgent attention.The online version of this article (10.1186/s12887-018-1360-z) contains supplementary material, which is available to authorized users. Hospital admissions, especially emergency ones place a huge cost on health services , 2 and tOver the last 30 years, the postnatal length of stay in hospital in the UK has reduced considerably: in 1989–90, only 44% women were discharged within two days of giving birth compared to 81% women in 2016–17 .We wanted to know whether the changes to postnatal care provision coincided with the increase in infant admissions which in some cases may have been potentially avoided. We sought to investigate whether the increase in infant admissions was predominantly in the early neonatal period and whether it was confined to a sub-group of conditions more sensitive to the quantity and quality of postnatal care, and therefore amenable to intervention earlier in the care pathway. If findings showed this to be the case, the current five year national maternity review programme in England  would prData on all admissions to hospital in the first year of life across England from 1st April 2008 to 31st March 2014 from Hospital Episode Statistics (HES) were included. We developed clinical definitions of potentially avoidable conditions. Admission rates were calculated with denominator data on all live births from Office for National Statistics (ONS). Main outcomes were admissions to hospitals for potentially preventable conditions across different ages within the first year and overall admissions.An anonymised extract of inpatient data from Hospital Episode Statistics (HES) for all NHS hospitals in England from 1st April 2008 to 31st March 2014 was obtained. HES collects routine demographic data, administrative information and clinical information based on World Health Organisation (WHO) ICD 10  and OPCS4 and is suitable for research purposes . All admTo avoid capturing routine admissions to the postnatal ward which frequently occur with a hospital birth, based on the HES data dictionary  cases wiThe data recorded in HES for each admission included a code for infant age category on admission. Codes for gender, region of admission and ethnicity were also included and a score for social deprivation was assigned, allowing exploration of rate variations by these characteristics. Ethnicity within HES is self-reported and the 16 Census ethnic groups  were merEach infant admitted was assigned a Local Authority District and Government Office Region (GOR) of residence based on their lower super output area (LSOA) of residence. A LSOA is a small unit of United Kingdom census geography  and contDenominator data on all live births across England was provided by Office for National Statistics (ONS), providing frequencies of live births by financial year of birth, Region , gender, ethnicity  and IMD quintile.Pre-specified definitions of ICD-10 codes of potentially avoidable admissions were produced before analysis of admission rates. The definition of potentially avoidable in this context was a condition or illness which could have been identified before postnatal discharge from hospital or in the community and adequately treated during birth hospitalisation or through community care services. The process for identifying conditions/illness that could be considered potentially avoidable within the HES dataset was undertaken with an advisory panel comprising a consultant general paediatrician, a consultant community paediatrician/professor of child health and a clinical coding manager at a specialist children’s hospital. The selection of conditions/illnesses and corresponding coding framework was developed in a four stage approach Fig. . ConditiPatient involvement was via the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands Patient and Public Involvement Supervisory Committee.SPSS (V.22) was used to analyse all infant admissions. Summary statistics were used to describe the proportion of avoidable infant admissions in 0–6 days and 7–28 days, 1 to under 3 months, 3 to under 6 months, 6 to under 9 months and 9 to 12 months after birth by condition/illness, ethnicity, deprivation indices, region in England and year of admission. Frequency of admissions by hospital trust was also explored in addition to exploring readmission rates. Unadjusted annual infant admission rates and annual rates for specific conditions and 95% confidence intervals were calculated by (N admissions for each year/N live births 2008–09) × 100. Change in admission rates were calculated as follows: (rate in 2013–14/rate in 2008–09) × 100. Where appropriate, Cochrane Armitage tests for trend were conducted to assess significance of the year on year trend over the 6 year period. A sample size calculation was not necessary due to the exploratory and descriptive nature of the study. The following sensitivity analyses were conducted: comparison of the rates of admissions by episodes of care versus spells of care and selecting the primary diagnosis code versus all diagnostic codes.P < 0.0001). Infants born in 2013/14 had 1·26 times the risk of being admitted within the first 6 days of life compared with infants born in 2008/09   to 354·6 (95% CI 353·6–355·9) per 1000 live births  compared to 216·85 per 1000 live births (95% CI 215·11–218·60) in the Black ethnicity category.potentially avoidable conditions increased by 39% from 39·79 to 55·33 per 1000 live births  to 22·35 (95% CI 21·99–22·70) admissions per 1000 live births (P < 0.0001)  were admitted over the period compared to 29,251 female infants (14·77 per 1000 live births (95% CI 14·63–14·92). The infant admission rate for physiological jaundice varied by IMD quintile (Table feeding difficulties rose from 11·35 (95% CI 11·10–11·60) per 1000 live births in 2008/09 to 13·12 (12·85–13·40) in 2013/14 (P < 0.0001). The age specific admission rate for feeding difficulties varied considerably over the period. The largest increase in risk of admission over the period was in the 0–6 day age category where there was a 46% increase in 2013/14 compared with 2008/09  (P < 0.0001). Admissions to hospital for feeding difficulties after one month of age were much less common and the rate consistently decreased with age up to one year  compared to 12·37 per 1000 live births (95% CI 12·22–12·53) for females. There was a small but significant difference in the admission rate for feeding difficulties by IMD quintile with the lowest rate in the most deprived quintile 11·31 per 1000 live births, (95% CI 11·11–11·50). The lowest rate of admission was observed for black infants  compared to 16·69 in the ‘not stated’ ethnicity category (95% CI 16·10–17·28).gastroenteritis the rate of infant admission per 1000 live births rose from 12·14 in 2008/09 (95% CI 11·88–12·40) to 19.86 (95% CI 19·52–20·19) (P < 0.0001). The rate of admission for gastroenteritis significantly increased across all age categories but admission was least frequent in infants in the first 28 days. It was greatest in the 9–12 month age category, although infants aged 1–3 months had the largest relative increase in risk of admission  from 2008/09–2013/14  and 14.07 (95% CI 13·90–14·23) for female infants. The highest rate was noted in the most deprived IMD quintile  . It is reassuring that the incidence of admissions for physiological jaundice and feeding difficulties over the age of 3 months was very small, suggesting that the selection of codes for these conditions was accurate. Although a systematic review of coding accuracy studies suggested that HES data has improved significantly over time , it is uHES is widely accepted as a database for health research and suitable for studies identifying trends in healthcare , althougUse of age specific admission rates for infants under one year showed that the increase in admission over the period 2008 to 2014 only existed within the first 6 months of life, and had increased most in the 0–6 day category. The admission rate for infants from 6 to 12 months remained stable over the period. Our findings are consistent with those of other studies that explore unplanned infant admissions to hospital . The oveThe change in infant admission rates we observed over the period was concentrated in those under 7 days of age and for the potentially avoidable conditions, particularly jaundice and feeding difficulties. In England over a similar period of time women and infants have had less routine contact with health professionals as the length of stay in hospital after birth and the median community visits following discharge from birth has reduced , 10. OveOur findings show that most of the increase in the rate of admission to hospital for infants up to age one over the period 2008–2014 was in the early neonatal period; and the great majority of this increase is explained by the three conditions, physiological jaundice, feeding difficulties and gastroenteritis, predominantly the former two. Potential missed opportunities within the postnatal care pathway require urgent modification given current NHS capacity and resource issues.Additional file 1:Flow chart of the process for identifying infant admissions under the age of 1 year unrelated to birth admissions in Hospital Episode Statistics. (DOCX 43 kb)Additional file 2:Coding framework for potentially avoidable infant admissions. (DOCX 17 kb)


Birth spacing is the time gaps between two consecutive life births. Optimal spacing until the next pregnancy is the resting period that allows the mother time to recover from pregnancy, and labor. Birth interval of 3 to 5 years increases maternal health and child survival and family planning programs have advocated this birth interval.To assess prevalence of Suboptimal Child spacing practice and its associated factors among Women of Child bearing age in Serbo town, Jimma Zone Southwest Ethiopia.p-value < 0.05 with the outcome variable.Community based cross sectional study was conducted on a total of 314 women of child bearing age from March to April 2017 who were selected by simple random sampling. A semi structured questionnaire which was pretested was used to collect the data. Data was checked for completeness and analyzed using SPSS V.20. Bi-variable logistic regression and multi- variable regression were done for predictor variables associated at The prevalence of short birth interval in this study was 59.9%. Independent predictors like age at first marriage , sex of index child , educational status , duration of breastfeeding  and use of modern contraceptives  were found to be statistically associated with short birth interval.Majority of the study respondents were practicing short birth interval. Education level, age at first marriage, having female child, short duration of breastfeeding and not using of modern contraceptives were factors associated with the outcome variable. Therefore awareness about modern contraceptive utilization, importance of breastfeeding as birth spacing mechanism and impact of early marriage are recommended. Birth spacing is the time gaps between two consecutive life births also known as the inter-pregnancy interval . OptimalThree to five years birth interval is safer for both the mother and child. Globally, a birth interval of less than 18 months is associated with increased risk for Neonatal mortality AOR =3.17), Infant mortality (AOR = 3.16), and Under-five mortality AOR = 2.81). Birth interval, less than 15 month is associated with increased risk for the mother like; third trimester bleeding (AOR = 1.7), Premature rupture of membranes (AOR = 1.7), Anemia (AOR = 1.3) and Puerperal endometritis (AOR = 1.3) .17, Infa.Short birth spacing has been continued to be a problem of both developed and developing countries like; Uganda and Zimbabwe, resulting in negative infant, child, and maternal health outcomes . In USA,Beyond the health implications, closely spaced birth intervals accelerate population growth and undermining development efforts. It makes difficult for women to become productive members of society, thereby limiting their contribution to economic development .Determinant for the occurrence of short birth interval includes; maternal education, maternal age, early marriage, lack of optimal breastfeeding practice and inadequate knowledge, Attitude and practice towards modern contraceptives use and different socio-demographic factors , 10.Even though interventions such as promoting female education and empowerment, awareness creation and enhancing breastfeeding practice and modern contraception utilization has been done, problem of birth spacing is still evident in most parts of African countries including Ethiopia. For instance, a previous study in southern Ethiopia showed that about more than half of 57.5%) women practicing shorter birth interval with the median birth interval length of 33 months .5% women–15. OptiCommunity based cross - sectional study was conducted from March to April 2017 in Serbo Town Jimma Zone, Oromia Regional state, South - West Ethiopia. Serbo town is located in kersa district, Jimma Zone of Oromia regional state with an attitude of 1640 km above sea level. The town is located 345 km far from Addis Ababa, Capital city of Ethiopia and about 18 km from Jimma town. The study was conducted in two kebeles , namely Omaticha kebele and Wayu kebele. The town has two kebeles with total populations of 7450, of this 3650 were females. There were a total of 1649 Child bearing age mothers in the town.The source populations were all women’s of child bearing age groups (15–49) in Serbo town. And all randomly selected women of child bearing age group in Serbo town were the study population.All women of child bearing age group (15–49) having at least two children were included in the study.Sample size was calculated by using the formula for single population proportion and by considering, 35.8% proportion of optimal birth interval in Lemo District, Southern Ethiopia  95% leve5  for both kebele’s and the first house hold to be started from was selected by lottery method.The sample was taken from two kebele’s  in Serbo town, namely Omoticha kebele and Wayu Kebele and the study was conducted in these two kebele’s. The calculated sample size was allocated proportionally to the size of populations in each kebeles. Household was selected with an interval of K for each kebele, where K was the total number of household in each kebeles divided by the total number of study subjects in each kebele’s which was found to be Data was collected using a semi-structured questionnaire which was adopted and modified from different literature . The queThe questionnaire were prepared in English version and translated into local languages (Amharic and Afan Oromo) and then back translated into English to maintain its consistency. Three days orientation training was given on the process of data collection for data collectors and supervisors. A pretest was done by 5 % of the study population three weeks before the actual data collection to evaluate the clarity of questions and validity of the instrument and reaction of respondents to the questions.Suboptimal birth spacingSocio-demographic variables , fertility history, contraceptive utilization, inconsistent breastfeeding.it denotes to 3–5 years’ birth interval (including 3 and 5 years) between the birth of the child under study and the immediately preceding live and surviving birth to the mother.it refers to less than 3 years’ birth interval between the birth of the child under study and the immediately preceding live and surviving birth to the mother.it refers greater than 5 years’ birth interval between the birth of the child under study and the immediately preceding live and surviving birth to the mother.p - value < 0.20. Variables which had significant association with the outcome variable during bi-variable logistic regression analysis was introduced in to multivariable binary logistic regression and finally, predictors of suboptimal child spacing were identified at p – value < 0.05, 95% CI.The data was cleaned manually, coded and entered into Epi data version 3.1 and exported to SPSS version 22.0 software for further analysis. Bi-variable logistic regression analysis was used to see significance of association between dependent and each independent variable. Candidate variables for the final model (multivariate binary logistic regressions) were identified at  were in the age group of 25–29 with mean age of 30.84 (SD ± 5.956) years. Most, 292 (93.0%) of the respondents were married. Majority of the respondents 215 (68.5%) age at first marriage was 18 years and above with mean of 18.38 (SD ± 2.41) years of age. Two hundred and thirty five (74.8%) were Muslim religious followers. Almost one third of 115(36.6%) respondents were illiterate and majority of them 209 (66.6%) were housewives. More than half, 171 (54.5%) of the study participants had monthly income of less than 1000 Ethiopian birr (37 US Dollar) Most of the respondents 286 (91.1%) were informed about modern contraceptives methods used by male and female to space and limit child birth. Majority 265 (84.4%) of the study respondents agreed that an optimal birth interval has health advantages both for the mother and child. Of the total respondents 47 (15.0%) did not know the health disadvantages of short birth interval for the mother and the child. Concerning with the preference of birth interval among mothers; more than half, 163 (51.9%) prefer an optimal birth interval. Almost half of the respondents 159 (50.6%) have three to four children and about thirty eight (12.1%) mothers reported child death soon after birth. Two hundred and eighty three (90.1%) of mothers have breastfed their last child, but about 31(9.9%) of them have not yet breastfed their last child due to different reasons. Among those who breastfed their last child, above three forth, 217(76.4%) breastfed their last child for 24 months and above whereas18 (6.3%) for less than 24 months  of the mothers were practicing short birth interval less than 36 months, followed by 112 (35.7%), and 14(4.5%) practicing optimal and long birth interval between their last two children respectively.Two hundred and sixty six (84.7%) of the study respondents had information about modern contraceptives used to space and limit birth. Nearly two third (62.7%) of the study respondents had used those methods before the last child, 162(82.2%) for spacing purpose. One hundred fifty three (89.5%) of them were getting the service from health center and fifty one 35.7%) of those who did not use modern contraceptive mentioned religion as the main reason for not using  followed by pills 233 (87.7%). Injectable was also the most frequently used 116 (58.9%) and more than half, 177 (66.5%) of the study respondents knew about condoms, but none of them utilized .The likelihood of practicing short birth interval was about 2 times more likely in mothers who were married at age less than 18 years as compared to mothers who were married at age 18 years and above . The odds of practicing short birth interval was about 3 times more likely in respondents who had no formal education as compared to those who had formal education . In the same way, the probability of having female index child was about 2 times more likely to increase the chance of getting short birth as compared to those mothers who had male index child . Study respondents who preferred birth spacing of less than 36 months were about 4 times more likely to have short birth interval as compared to those who preferred 36–60 months . Mothers who had a duration of breast feeding < 24 months were 3 times more likely to have short birth interval as compared to those who breastfeed for ≥24 months . The odds of not using modern contraceptives in the mothers who practiced a short birth interval were 2 times higher than among those using modern contraceptives  The prevalence of short birth interval in this study was found to be 59.9%. The remaining, 35.7 and 4.5% were practicing optimal and long birth interval respectively. Although, 36–60 months of interval between births is the currently recommended, still the prevalence of short birth interval outweighs the optimal one. This finding is almost consistent with a study conducted in southern Ethiopia, 57.6% of mothers were practicing short birth interval and 35.8% were practicing optimal birth interval and the remaining were long birth interval. This might be due to relative similarity in socio-economic background of the study respondents. Again, this finding was relatively similar with the study conducted in Mozambique in which 46, 35 and 19% of the women were practicing short, optimal and long birth interval respectively. However, in the current study, long birth interval was lower than study conducted in Mozambique , 15. TheThose women who had married at age less than 18 years were about 2 times more likely to practice short birth interval as compared to those who had married at age 18 years or above. This finding was consistent with the study done in Uganda, Zimbabwe and Jordan , 17.Sex of the index child was associated with short birth interval. According to the result of this study women’s who had female index child were about 3 times more likely to have short birth interval as compared to mothers who had male index child which was consistent with studies done in Arba - minch Zuria District and Southern Ethiopia , 8.Mothers who had no formal education were about 3 times more likely to have short birth interval. A similarly study conducted in Arba-Minch showed the same finding with the current study  , 8. ThisThe other predictor of short birth interval was duration of breastfeeding. Mothers who breastfeed their child for less than 24 months were about 3 times more likely to practice short birth interval as compared to those who breastfeed ≥24 months which is in line with a study conducted in Illubabor zone, South West Ethiopia  . This waThe odds of not using modern contraceptive was about 2 times to have short birth interval as compared to those users of modern contraceptives . Which was similar with a study conducted in Arba-Minch district, Lemo district and rural communities of southern Ethiopia , 8, 15. The prevalence of short birth spacing among mothers of childbearing age in serbo town was high (59.9%) which shows mothers were giving birth with short birth interval.Early marriage, sex of the index child, mother’s preference of birth interval, educational status, and short duration of breast feeding and lack of modern contraceptive utilization were independent predictors of short birth interval. Therefore Minister of health and Regional Health bureau should strengthen actions to prevent early marriage and increase mothers’ awareness of modern contraceptive and importance of exclusive breastfeeding for the first six month and continue breast feeding until two years old through health extension professionals, and attention should be given on actions to increase modern contraceptive utilization.


Newborn screening (NBS) for cystic fibrosis (CF) improves nutritional outcomes. Despite early dietetic intervention some children fail to grow optimally. We report growth from birth to 2 years in a cohort of children diagnosed with CF by NBS and identify the variables that influence future growth.One hundred forty-four children were diagnosed with CF by the West Midlands Regional NBS laboratory between November 2007 and October 2014. All anthropometric measurements and microbiology results from the first 2 years were collated as was demographic and CF screening data. Classification modelling was used to identify the key variables in determining future growth.p = 0.33. By the first clinic visit the difference was significant: 3.42 kg (− 1.39) vs 4.60 kg (− 0.48); p < 0.0001. Weight and height remained lower in PI infants in the first year of life. In the first 2 years of life, 18 (14%) infants failed to regain their birth weight z score. The median time to achieve a weight z score of − 2, − 1 and 0 was 18, 33 and 65 weeks respectively. The median times to reach the same z scores for height were 30, 51 and 90 weeks. Birth weight z score, change in weight z score from birth to first clinic, faecal elastase, isolation of Pseudomonas aeruginosa, isolation of Staphylococcus aureus and sweat chloride were the variables identified by the classification models to predict weight and height in the first and second year of life.Complete data were available on 129 children. 113 (88%) were pancreatic insufficient (PI) and 16 (12%) pancreatic sufficient (PS). Mean birth weight (z score) was 3.17 kg (− 0.32). There was no significant difference in birth weight (z score) between PI and PS babies: 3.15 kg (− 0.36) vs 3.28 kg (− 0.05); Babies with CF have a lower birth weight than the healthy population. For those diagnosed with CF by NBS, the weight difference between PI and PS babies was not significantly different at birth but became so by the first clinic visit. The presence of certain factors, most already identifiable at the first clinic visit can be used to identify infant at increased risk of poor growth. The implementation of newborn screening (NBS) has fundamentally changed the care of children with cystic fibrosis (CF) . They arDespite early diagnosis and the initiation of appropriate treatment, some infants diagnosed with CF by NBS do not achieve optimal growth . AntenatA cohort of 144 children diagnosed with CF by NBS was identified. This included all babies with a positive CF NBS from the West Midlands Regional Screening Laboratory between 1st November 2007 and 31st October 2014 who had a confirmed diagnosis of CF (identification of two CF-causing mutations and/or a sweat chloride ≥60 mmol/L). Five children categorized as Cystic Fibrosis Screen Positive Inconclusive Diagnosis (CF SPID)  were excPseudomonas aeruginosa and Staphylococcus aureus. These data were obtained from the West Midlands NBS Laboratory database, patient’s clinical notes and the electronic results systems at the two CF Centres. All height and weight measurements were converted into z scores using the WHO-UK anthropometric calculator. This corrects for sex and gestational age. To summarise growth, the following four outcomes were calculated for each child: mean weight z score in first year of life, mean weight z score in second year of life, mean height z score in the first year of life and mean height z score in second year of life. The median time for children to achieve height and weight z scores of − 2, − 1 and 0 was calculated and children who did not regain their birth weight z score in the first 2 years of life were identified.Demographic and newborn screening data were collected. These included date of diagnosis (taken as date of first clinic visit or date of diagnosis of meconium ileus), gender, ethnicity, birth weight, the presence of meconium ileus, mean immunoreactive trypsinogen, CFTR mutations, sweat chloride, faecal elastase (measured at first clinic appointment), weight at first clinic visit and mode of feeding (exclusive breast / exclusive formula / mixed). All weight and length measurements recorded in the first 2 years of life were then collated. Insufficient data points were available for head circumference to allow meaningful analysis. We also recorded age at first isolation of Before classification modelling could be undertaken, the cohort had to be validated using a clustering algorithm (k-means) . This enp = 0.004. 121/129 (94%) children were Caucasian and 8/129 (6%) were Asian, Afro-Caribbean or other white. 68/129 (53%) were homozygous and 122/129 (95%) heterozygous for the Phe508del variant.The sample included 63 (49%) girls and 66 (51%) boys. Mean (SD) gestation age was 38.9 (1.8) weeks with 8 (6%) born < 37 weeks gestation. Twenty one (16%) children had meconium ileus. Median (IQR) age at diagnosis was 22 (17–25) days. This was later in pancreatic sufficient (PS) compared to pancreatic insufficient (PI) babies: 25.5 (21.5–32) vs 20 (16–25), The mean (SD) birth weight of the entire cohort was 3.17 (0.51) kg giving a mean (SD) z score of − 0.32 (1.13). The mean (SD) birth weight was 3.21 (0.50) kg for boys and 3.12 (0.53) kg for girls. The mean (SD) birth weight z scores were − 0.35 (1.07) for boys and − 0.30 (1.20) for girls. Using a faecal elastase cut-off of 200 μg/g, 113 (88%) children were PI and 16 (12%) PS. When reviewed at their first clinic visit, 29 (22%) infants were exclusively breast-fed, 60 (47%) were exclusively formula milk and 40 (31%) were mixed feeding. There was no difference in mode of feeding between PI and PS. All babies were started on standard treatment on the day of diagnosis. The difference in weight between PI and PS infants was not significant at birth but became so by the time of the first clinic visit. Height and weight was significantly lower in PI children in the first year of life. The difference was less in the second year and no longer significant. See Table Staphylococcus aureus prophylaxis. Staphylococcus aureus was isolated in 16 of the 129 children in the first 2 years of life. The median (IQR) age of the first isolate was 0.22 (0.08–0.63) years. Pseudomonas aeruginosa was isolated in 45 children in the first 2 years of life. The median (IQR) age of the first isolate was 1.18 (0.82–1.49) years. All these isolates were non-mucoid. No child met the Leeds Criteria for chronic Pseudomonas aeruginosa infection in the first 2 years of life [All the children were on oral  of life .Pseudomonas aeruginosa, isolation of Staphylococcus aureus and sweat chloride were the variables of use in predicting future growth. Importantly, the mode of feeding was not identified as a predictor of infant growth by any of the classification models.The unsupervised cluster analysis identified two distinct groups. See Table 2 in This study reports growth from birth to 2 years in a cohort of children diagnosed with CF by NBS. Classification modelling is also used to identify the variables affecting infant growth, to our knowledge this it is the first time this methodology has been used in this group.Previous cohort studies show CF babies have a lower birth weight than healthy children although it is usually still within the normal range , 17. OurPostnatally, pancreatic function has a clear effect with the weight difference between the PS and PI infants becoming statistically significant at the first clinic visit when the child had ‘untreated CF’ for an average of 22 days. The degree of faltering growth observed in this short period was one of the most important variables identified by the classification model in predicting infant growth. Therefore, infants who experience the most severe nutritional consequences before treatment, continue to do so after this is started. These infants are likely to be those with mutations associated with the most severe loss of CFTR function. Despite treatment with pancreatic enzyme replacement therapy, PI infants had a significantly lower height and weight in the first year of life than PS infants. This difference reduced in the second year showing catch-up growth can be achieved with prolonged treatment pancreatic enzyme replacement therapy and appropriate nutritional support.Infants with CF who are PI are more likely to have lower weight and height z scores than those who are PS . It is tThe importance of birth weight in predicting future growth is well established in the healthy children. The GECKO Drenthe Birth Cohort included 2447 healthy infants and identified birth weight and mode of feeding as the most important factors at predicting growth in the first 6 months of life . The claOur study has several limitations. As we did not have a matched control group of non-CF infants from the same area we relied on the WHO-UK anthropometric calculator to generate z scores but accept this may miss local variations. There are potentially a huge number of variables that could affect infant growth. Due to the retrospective nature of this study we were limited as to which factors we could collect data on. Relevant variables which we were unable to collect data on included: parental height and weight, maternal smoking status, maternal diet during pregnancy, pulmonary exacerbations, treatment regimen, nutritional support, adherence with treatment and socioeconomic status. All of these may affect infant growth . We usedThis cohort study confirms children with CF have a lower birth weight than non-CF babies. The effect of pancreatic insufficiency on weight was not significant at birth but became so by the first clinic visit and remained so for the first year of life. A number of CF babies did not regain their birth weight z score by 2 years of age. Identification of predictors of poor infant growth such as low birth weight and poor weight gain from birth to first clinic should enable focused interventions by clinicians and dieticians to optimise nutritional outcomes. The possible effect of CFTR on antenatal growth and the role of other factors such as adherence to treatment and socioeconomic status on infant growth warrants further investigation.


Fetal giant cervical cyst (FGCC) is a rare congenital anomaly. Sometimes FGCC may extend into the mediastinum, and result in severe tracheal compression, which is a life-threatening event at birth.We present a rare case of FGCC, which extended from the right neck into the superior mediastinum, and resulted in severe tracheal compression.An FGCC was observed by ultrasonography and magnetic resonance imaging (MRI) at 27+4 weeks’ gestation (WG). Fetal MRI at 35+1 WG showed that the FGCC was 3.3 × 8.2 × 7.5 cm and extended from the right neck into the superior mediastinum. Severe tracheal compression was observed and the inside diameter of the narrowest section of tracheostenosis appeared thread-like and measured only 0.1 cm.Cervical cyst reduction was performed prenatally under ultrasound guidance to alleviate the tracheal compression and maximize the chance of fetal survival 2 days before birth. At 36+3 WG, cesarean section was performed, and a female neonate was immediately delivered and intubated (3.5-mm tube) by an experienced anesthesiologist. Neonatal intralesional sclerotherapy and cystic component aspiration as guided by digital subtraction angiography were performed under general anesthesia. Anesthesia was maintained only with sevoflurane 3% in 2 L/min oxygen. Extubation was performed soon after surgery.The neonate recovered uneventfully and was discharged 2 days postoperatively. After 140 days of follow-up, the neonate had recovered completely.If an FGCC is suspected by abdominal ultrasound, a fetal MRI is recommended to assess the severity of tracheal compression before birth, if feasible. An anesthesiologist should assess the risk of intubation failure at birth according to those results. If fetal severe tracheal compression is detected and it may result in inability of intubation at birth, prenatal cervical cyst reduction under ultrasound guidance may be effective for alleviating tracheal compression at birth, if feasible. This could maximize the chance of fetal survival. Improvement of fetal short- and long-term outcomes is important. Fetal cervical cysts are soft, benign, and occur by fluid-filled cystic dilation, and are typically found in the posterior triangle of the neck. A few of these cysts may extend into the axilla or mediastinum. If these cysts extend into the mediastinum, a severe fetal giant cervical cyst (FGCC) may result in severe tracheal compression, which is a life-threatening event at birth. We present here a rare case of an FGCC, which extended from the right neck into the superior mediastinum, and resulted in severe tracheal compression, but completely recovered.Fetal tumors are rare congenital anomalies, with an estimated incidence of 1/12,000 to 1/30,000 births.2A 31-year-old woman  was registered with other hospital. After initial assessment, she was closely followed at 2-week intervals until 27 weeks’ gestation (WG), which is when the first ultrasonography was performed. An FGCC was observed by ultrasonography. For further diagnosis and treatment, she was transferred to our hospital. Fetal magnetic resonance imaging (MRI) was performed at 27 + 4 WG and showed a giant (2.2 × 4.1 × 3.6 cm) cervical cyst that caused localized tracheal compression  was performed immediately by an experienced anesthesiologist. An approximately 10- × 7- × 6-cm elastic soft mass was palpable on the right side of her neck (Fig. Informed consent was obtained from the mother for publication of this case report and accompanying images. Intralesional sclerotherapy was preformed because surgical resection for complete removal was difficult and complications are frequent. After standard monitoring according to the American Society of Anesthesiologists guidelines, general anesthesia was then maintained with sevoflurane 3% in 2 L/minute oxygen and assisted ventilation. Spontaneous respiration was maintained at a tidal volume of 20 ml and a respiration rate of 40 to 45 bmp, and artificial assisted ventilation was performed when necessary. Any neuromuscular-blocking drugs were avoided. With strict aseptic precaution, approximately 45 ml of bloody cystic components of the lesion were aspirated with guidance by digital subtraction angiography. Sclerotherapy was then performed, and radiography showed that mixed infusion was deposited in the lesion (Fig. 3 This sometimes results in severe tracheal compression, which is a life-threatening event at birth. For those fetuses that survive during the antenatal period, airway obstruction may be the most life-threatening event at birth and securing airway safety has the biggest impact on immediate outcomes. The difficulty of airway control for infants with FGCC was demonstrated in a previous report. Of 35 fetuses who were evaluated and neck masses were diagnosed prenatally, nine died perinatally. Two fetuses died from a lack of an airway when an EXIT procedure could not be achieved, and 1 who required tracheostomy at EXTT died late because of tracheostomy complications of prematurity, respiratory failure, and sepsis. A newborn who does not establish breathing within 5 minutes of birth may suffer from hypoxic ischemic brain injury or even death. Therefore, congenital FGCC may require considerable planning to optimize perinatal management. Any management decisions include assessment of airway safety and consideration of short- and long-term outcomes.FGCC, which is a rare type of fetal tumor, may cause considerable fetal and perinatal effects because of compression from the mass on surrounding cervical and facial structures.Early diagnosis and treatment of FGCC is critical, and may avoid a life-threatening situation at birth. Diagnostic ultrasound is generally regarded as safe and has been used clinically in obstetrics for over 50 years. Currently, ultrasonography may play a major role in early diagnosis of FGCC. Fetal MRI is not a general screening tool for this purpose, and should only be used in occasional specific high-risk situations or used to answer specific questions raised by ultrasonography. However, FGCC is one of the appropriate fetal MRI indications. Therefore, if an FGCC is suspected by abdominal ultrasonography, fetal MRI should be performed to assess the severity of tracheal compression before birth, if feasible. This is important for subsequent clinical decisions and treatment to improve fetal short- and long-term outcomes.Findings from our case suggested that, if treated correctly, the outcome of a fetus with FGCC is good. We suggest the following recommendations. For patients with an FGCC, airway status is critical and directly determines the fetal prognosis. When an FGCC is suspected, a multidisciplinary team comprising senior staff of the Departments of Gynecology, Obstetrics, Anesthesiology, Neonatology, Pediatrics, and Pediatric Surgery should be immediately established and discussion begun. Initial counseling should be set up immediately after sonographic diagnosis. The anesthesiologist has an important role in management of the airway. In our case, the potential for tracheal compression resulting in an inability to intubate needed to be assessed before birth to ensure safe airway management at birth. At 35 + 1 WG, fetal MRI showed that the cyst had grown to 3.3 × 8.2 × 7.5 cm and extended from the right neck into the superior mediastinum. The pharynx, trachea, and vessels were compressed and greatly deviated to the left. The inside diameter of the narrowest section of tracheostenosis appeared thread-like and measured only 0.1 cm. These findings indicated that a fetal neck cyst may be progressive, and the likelihood of intubation failure at birth may increase. This information is important to anesthesiology and obstetrics, and suggested that the EXIT procedure could not be achieved because of failure of intubation if untreated. Prenatal cervical cyst reduction under ultrasound guidance was then performed, and the fetus survived. Findings from our case suggested that an anesthesiologist should assess the risk of intubation failure at birth according to those results. If fetal severe tracheal compression is detected and it may result in inability to intubate at birth, which is a life-threatening event, prenatal cervical cyst reduction under ultrasound guidance may be an effective method, if feasible. This method could alleviate tracheal compression at birth and maximize the chance of fetal survival.As shown in our case, intralesional sclerotherapy may be an alternative to surgical resection. During the procedure, appropriate anesthetic agents are required for an adequate depth of anesthesia. In our case, general anesthesia was performed only by an inhaled anesthetic, sevoflurane, and no neuromuscular-blocking drugs were used. The reasons for this are as follows. First, sevoflurane with rapid onset and offset, allowed easy titration of the anesthetic depth. Propofol was also titrated to maintain an adequate anesthetic depth. However, propofol causes bradycardia, hypotension, and desaturation, and its use in the neonatal period is controversial. Second, we only took 10 minutes to perform intralesional sclerotherapy. When the procedure was over, sevoflurane could be quickly expelled from the body, and extubation was performed smoothly. Intraoperative extraction of 45 ml made the mass considerably smaller. Finally, digital subtraction angiography was performed to ensure that there was no progressive bleeding in the lesion. In addition to the above-mentioned reasons, long-term endotracheal intubation required sedative drugs, which aggravate neonatal pneumonia and increase the financial burden. Therefore, extubation was performed after sclerotherapy.In conclusion, we report a rare case of an FGCC, which extended from the right neck into the superior mediastinum, and resulted in severe tracheal compression. If an FGCC is suspected by abdominal ultrasound, fetal MRI is recommended to assess the severity of tracheal compression before birth, if feasible. An anesthesiologist should assess the risk of intubation failure at birth according to these results. If fetal severe tracheal compression is detected and it may result in inability to intubate at birth, prenatal cervical cyst reduction under ultrasound guidance may be effective for alleviating the tracheal compression at birth and maximizing the chance of fetal survival, if feasible. Improving fetal short- and long-term outcomes is important. Successful management of the airway by an anesthesiologist at birth and intralesional sclerotherapy by a pediatrician after birth are also necessary for recovery. Therefore, a well-established multidisciplinary team is also important in ensuring complete recovery of neonates with FGCC.Data curation: Yanming Kang.Investigation: Fumin Zhao.Project administration: Yushan Ma, Xuemei Lin.Supervision: Xuemei Lin.Writing – original draft: Yushan Ma.Writing – review & rditing: Xiaoqin Jiang.


Turritopsis dohrnii undergo reverse development in response to physical damage, adverse environmental conditions, or aging. Senescent, weakened or damaged medusae transform into a cluster of poorly differentiated cells (known as the cyst stage), which metamorphose back into a preceding life cycle stage, the polyp. During the metamorphosis, cell transdifferentiation occurs. The cyst represents the intermediate stage between a reverting medusa and a healthy polyp, during which cell transdifferentiation and tissue reorganization take place. Here we characterize and compare the transcriptomes of the polyp and newborn medusa stages of T. dohrnii with that of the cyst, to identify biological networks potentially involved in the reverse development and transdifferentiation processes. The polyp, medusa and cyst of T. dohrnii were sequenced through Illumina RNA-sequencing and assembled using a de novo approach, resulting in 92,569, 74,639 and 86,373 contigs, respectively. The transcriptomes were annotated and comparative analyses among the stages identified biological networks that were significantly over-and under-expressed in the cyst as compared to the polyp and medusa stages. Biological processes that occur at the cyst stage such as telomerase activity, regulation of transposable elements and DNA repair systems, and suppression of cell signaling pathways, mitotic cell division and cellular differentiation and development may be involved in T. dohrnii’s reverse development and transdifferentiation. Our results are the first attempt to understand T. dohrnii’s life-cycle reversal at the genetic level, and indicate possible avenues of future research on developmental strategies, cell transdifferentiation, and aging using T. dohrnii as a non-traditional in vivo system.Medusae of  Turritopsis dohrnii  are present only in the medusa, whereas other cell types  occur in the polyps only. Tissue excision experiments have provided insight on the cellular mechanism that underlies life-cycle reversal in T. dohrnii  into a less-specialized state within the same lineage  the first transcriptome assembly and annotation of three stages in the medusa-to-polyp life cycle reversal, i.e., the medusa, cyst and polyp stages; 2) comparative GO annotation and functional gene enrichment analyses to identify GO terms, with a focus on biological processes that are over-or under-expressed in the cyst stage as compared to the polyp and medusa stages. This work provides baseline information to understand the molecular mechanisms underlying both cell transdifferentiation and life cycle reversal in T. dohrnii.The cyst stage represents an intermediate step between a regressing, aging, or damaged medusa and a new, healthy polyp. It is also the stage in which tissue reorganization and cell transdifferentiation – starting from the regressing medusa – proceed further and gradually prepare the re-expression of the polyp phenotype. Investigating the gene expression patterns of the cyst is thus interesting from an organismal, developmental, cellular, and molecular perspective. In this paper we present a comparative analysis of the gene expression landscapes across the different life stages of T. dohrnii colonies bearing medusa buds were collected in Otranto, Italy in July 2013. Individual colonies were kept isolated in glass bowls to collect newly released medusae. The colony and medusae were preserved separately in RNAlater RNA stabilization solution (ThermoFischer Scientific) and stored in -80C for further processing. In Bocas del Toro, Panama in July 2015, newly released medusae from polyps found in the field were isolated in glass bowls and starved to induce into cysts (24-48 hr). Cysts were preserved in RNAlater and stored in -80C for further processing. Some polyp tissue was preserved for DNA barcoding purposes. Prior to RNA extraction, total DNA was extracted from polyp tissue from both collections using a protocol provided by th of reagent amounts were utilized due to the small amounts of tissue; 3) Increase the number of ethanol washes to additionally purify RNA. The concentration of RNA extracts were determined using the ThermoScientific NanoDrop2000 Spectrometer, and their integrity was validated through the Agilent Technologies Bioanalyzer prior to initiating library construction for sequencing . Three replicates of the cyst stage with the highest quantity/concentration (ng/uL) of DNA based on NanoDrop readings, and highest quality of RNA based on the detection of the strongest 18S (1.8kb-2kb) and 28S (4kb-5kb) bands with the least degradation, samples C1, C2 and C3, were selected for further processing.Total RNA was extracted from the multiple polyps and a pooled sample of medusae  collected in Italy using Qiagen’s RNAeasy Mini Kit (Cat. #: 74104) following manufacturer’s instruction. Epicentre’s MasterPureTM RNA Purification Kit (Cat. #: MCR85102) was used to extract total RNA from multiple replicates of individual cysts collected in Panama. The protocol was carried out with the following minor modifications recommended by the manufacturer: 1) Pre-rinsing and removing RNAlater from tissue using the T&C Buffer provided by the Epicentre kit; 2) 1/5The sequencing library for the polyp stage was constructed by University of Notre Dame’s Genomic and Bioinformatic Core Facility using the TruSeq RNA Sample Prep Kit v2 (Illumina Sequencing Technologies (Cat. #. RS-122-2001)) following manufacturer’s protocols. The construction of the medusa and cyst library was conducted at TAMU’s Agrilife Genomic and Bioinformatics sequencing facility. Due to the small amount of output RNA (less than 100 ng), a pre-prep amplification step using a Poly-A based SMARTer Ultra Low Input RNA for Sequencing v4 kit (Clontech Laboratories (Cat .#: 634888)) was performed prior to library preparation according to manufacturer’s protocol. The cDNA from the polyp library was sequenced using the Illumina MiSeq platform (Illumina Sequencing Technologies) generating 83bp paired-end (PE) reads . The cDNA from the medusa library was sequenced using the Illumina HiSeq2500v4 platform generating 125bp PE reads. The cDNA from the cyst libraries were individually sequenced using the Illumina HiSeq4000 platform generating 150bp PE reads for each library. The raw RNA-seq datasets have been deposited into GenBank under NCBI BioProject ID: PRJNA563171; Accession #: SAMN12669943 - SAMN12669945.T. dohrnii, the stages were collected and data processing was performed at different times and localities. RNA-seq reads from the polyp and medusa were processed through the Trinity version 2.2.0 software pipeline where quality trimming via trimommatic . The three libraries from the cyst were aligned separately to the assembled polyp and medusa assembly to briefly assess quality of reads. Two of the datasets that had high alignment percentages and low percentages of broken reads were chosen  and pooled together. The pooled reads were processed using the Trinity pipeline using default parameters for transcriptome assembly. Assembly statistics were generated using the trinitystats.pl script within Trinity’s toolkit.All transcriptomes were constructed individually with the consistent assembly methods. Though acknowledged as a non-traditional approach to perform comparative transcriptomic analyses with individually constructed datasets, due the difficulty in collecting all three stages of mommatic , read noIn silico normalization) from all three stages were mapped back to the assembled contigs via TopHat2.1 and CLC Genomic Workbench v8 alignment software using default parameters to evaluate the quality of the assemblies . The BUSCO v2.0 software (http://busco.ezlab.org) was used for the assessment with default settings .Normalized reads  functional annotation was conducted using the following parameters: annotation cutoff of 55, GO weight of 5, expectation value of e-6 and HSP-Hit coverage cutoff of 0. InterProScan , sequences that had top hits to R. filosa were re-blasted against the metazoan database and the annotation pipeline was re-performed.Due to the predicted ecological contamination in the polyp transcriptome of taxa closely related to the Protista species vs. Polyp; 2) Cyst vs. Medusa; 3) Cyst vs. Polyp+Medusa combined. The biological processes domain was chosen for the enrichment analyses.Functional gene enrichment analyses were conducted using the FatiGO  NanoDrop and Bioanalyzer results to assess quality; B) Number of raw, trimmed and normalized reads for each stage; C) Cyst RNA-seq alignment to evaluate triplicate datasets; D) Read mapping evaluation of each transcriptome; E) KEGG enzyme mapping; F) De novo assembly statistics, gene content completeness, and functional annotation comparison among cnidarian transcriptomes; G) BLASTx top hit species distribution; H) Summary of Blast2GO transcriptome annotation; I) Names of transcripts from BLASTx annotation and corresponding stages they were identified in; J) Cyst vs. Polyp GO comparative analysis; K) Cyst vs. Medusa GO comparative analysis; L) Cyst vs. Polyp+Medusa GO comparative analysis; M) Top 10 over-expressed biological processes categories in the Cyst as compared to the Polyp and Medusa; N) Annotation profiling of the life cycle stages; O) Ranking of top 100 GO terms based on direct GO count for the Cyst, Polyp and Medusa; P) Reciprocal tBLASTx search of telomerase related mRNA transcripts; Q) Top 10 under-expressed biological processes categories in the Cyst as compared to the Polyp; R) GO categories associated with cellular communication and signaling, cell differentiation and specialization, and development that were under-expressed in the Cyst in comparison to the Polyp and the Medusa. The RNA-sequencing datasets generated and analyzed during the current study are available in NCBI’s GenBank’s repository under NCBI BioProject ID: PRJNA563171, Accession #: SAMN12669943 - SAMN12669945. Supplemental material available at figshare: T. dohrnii .Polyps and newborn medusae were collected in Otranto, Italy. Cysts were induced and collected in Bocas del Toro, Panama. All specimens were barcoded using the mitochondrial 16S gene to confirm identification. The 16S sequence showed 100% similarity and identity with i.e., multiple polyps in colony) were extracted, prepped into cDNA libraries and sequenced using the Illumina MiSeq platform (83bp PE reads) and the medusa using HiSeq2500v4 (125bp PE reads). RNA was extracted from individual cysts and individual libraries were sequenced using HiSeq4000 (150bp PE reads). Due to the different approaches in number of individuals used for extraction , different times and locality of specimen collected and rearing laboratory, library preparation and sequencing, the sequences from the cDNA libraries were assembled separately into three individual, stage-specific transcriptomes .Although chosen polyps were not actively budding medusae, we cannot exclude the presence of developing medusa buds. RNA from pooled polyps  were utilized for the assessment. In both assessments, the Polyp assembly exhibited more than 10% lower mapping percentages  than the Medusa  and Cyst  .Normalized reads resulting from Trinity’s e.g., platform, read length, depth, etc.) could affect the overall length and contiguity of the assembled contigs. This was reflected in our assembly statistics . This threshold was chosen as our work is exploratory as there were no reported transcript annotations or genome for any Turritopsis species. We also did not want to limit our search to the few published hydrozoans, which have not been reported to undergo reverse development and do not share similar life histories .The Blast2GO pipeline was used to assign names and functional terms to the assembled contigs of each transcriptome. InterProScan  was alsoReticulomyxa filosa (Protista), which showed up in the top-blast hits . Sequences with top-hits to R. filosa were re-blasted using the Metazoa database to best filter out sequences and annotations that originated from protists.There was a concern of contamination of epibiontic organisms in the Polyp transcriptome, specifically the foraminiferan H. vulgaris, E. pallida, A. digitifera, and N. vectensis, ranked 1st to 4th in the same order in all three stages . This indicates that all three transcriptomes are highly composed of transcript annotations from our target organism  as opposed to contaminant, non-target organisms that may naturally occur with T. dohrnii . Ultimately, there were 38,686, 27,443, and 31,633 contigs annotated with at least one GO term in the Polyp, Medusa and Cyst, respectively  contigs in the Polyp, 33,836 out of 74,639 (45.33%) contigs in the Medusa, 38,565 out of 86,373 (44.65%) contigs in the Cyst assembly showed significant similarity to proteins in the NR database in the BLASTx step . The majority of the top-hits belonged to four cnidarian species, ectively . In all,Turritopsis species . In addition, the published Acidovorax sp. KK102) as the 3rd highest top-hit species, which is most likely the outcome of contamination.Our BLASTx results differed from a recently published transcriptome of various stages of an undetermined T. dohrnii stages, and to assess the functional differences among them. We performed comparative functional gene enrichment analyses on the Cyst, Polyp and Medusa transcriptomes, with the Cyst as the central stage of comparison, to gain more insight on the over and under-expressed GO categories in the Cyst. We acknowledge that our transcriptomes assemblies are catalogs of transcripts and thus, there is no separation between lowly expressed and highly expressed transcripts, and therefore cannot detect differential expression of specific transcripts. Our enrichment results are preliminary and need further confirmation with normalized library replicates for each stage. However, these comparative analyses provide useful and novel insights on the processes that are active and suppressed in the Cyst.Categorizing the data based on GO terms creates the opportunity to understand specific physiological components found in different vs. Polyp; 2) Cyst vs. Medusa; and 3) Cyst vs. Polyp+Medusa. Due to the larger number of total contigs with GO annotations in the Polyp transcriptome, the Cyst vs. Polyp+Medusa will show slight bias toward the Polyp stage in the reference dataset. This test however was designed to uncover the over- and under-expression of gene categories that are highly specific to the Cyst.We focused on the biological processes domain that includes recognized series of molecular events and networks pertinent to the functionality of the cell, organs, or organism as a whole. The FatiGO , along with DNA integration, and DNA biosynthesis related processes, may have a significant role in the regenerative events occurring in the Cyst.The top three most specific GO categories significantly over-expressed in the Cyst when compared to the Polyp were related to DNA biosynthesis, integration, and telomere maintenance  . The topmparison , with thT. dohrnii, an invertebrate, basal metazoan. Such annotated transcripts likely represent ancestral orthologous transcripts involved in embryonic development that have been conserved throughout lower and higher metazoans, similarly reported with bilaterian specific genes found in the hydrozoan Clytia hemisphaerica  . ‘Chorda pathway .Overall, DNA integration, repair and telomere maintenance related processes were highly enriched in the Cyst stage as compared to the Polyp and Medusa. System and cellular development, transport and signaling pathways were found to be suppressed in the Cyst as compared to the Polyp and Medusa. Here below, we further analyze specific GO categories and their child terms that are of interest for further exploration .vs. Polyp comparison, most of the highest expressed categories are directly involved in DNA synthesis, integration, and metabolic processes. The top 10 over-expressed gene enrichment categories in the Cyst vs. Medusa comparison involved processes such as the synthesis and metabolism of cellular compounds, particularly related to nitrogen. Cellular metabolic processes involving nucleic acid constituents (in reference to GO:006139) were both found to be highly enriched in the Cyst in comparison to the Polyp (ranked 7th) and Medusa (ranked 8th). When the Cyst was compared to the Polyp and Medusa combined, DNA metabolic processes were the top over-expressed categories.The top 10 over-expressed gene enrichment categories for each analysis are cumulatively reported in Additional File M. In the Cyst vs. Polyp and Cyst vs. Polyp + Medusa analyses . Moreover, the Cyst vs. Medusa comparison indicated that there was an enrichment of ‘DNA integration’ in the Cyst (‘DNA integration (GO:0015074)’, was among the top 10 over-expressed categories in the Cyst the Cyst . The Cysvs. Polyp and Cyst vs. Polyp+Medusa analyses  were over-expressed in the Cyst analyses . The Cysth) but absent in the Polyp and Medusa among the 20 terms . Overall, DNA Repair ranked 14th in the Cyst, 31st in the Polyp and 23rd in the Medusa in GO terms in biological processes for all levels . These results potentially indicate that the Cyst is prioritizing DNA repair processes more than the Polyp and the Medusa.Furthermore, in the Cyst stage, the category ‘DNA repair (GO:0006281)’ was also found to be over-expressed in all three comparative analyses . The CysT. dohrnii’s reverse development. Active transposons are mutagenic and it has been shown that in Hydra, another Cnidarian taxa with regeneration capabilities, transposon repression and regulation by Piwi pathway occurs both in the I-cells and in the somatic cells  were found in all three stages . DKC1, the Dsykerin component, exhibited an e-value of 0.0 and the highest bit score (714.5) in all stages .T. dohrnii’s life cycle reversal, and should therefore be the focus of future studies.Our results indicate that the regulation of telomere length may be a key component of the overall regulatory network enabling The top 10 under-expressed enrichment categories for each analysis are cumulatively reported in Additional File Q. When compared to the Polyp, the prominent processes that are suppressed in the Cyst stage are directly related to the maintenance, specifically the synthesis, of proteins ’, GO:0042254). In addition, processes involved in the synthesis of cell components were highly suppressed in the Cyst. When compared to the Medusa, processes involved in cell signaling and communication  and mitotic cell division (GO:0098763) are down regulated in the Cyst.vs. Polyp, Cyst vs. Medusa, Cyst vs. Polyp+Medusa) and processes of interest that pertained specifically to cell surface receptor signaling were reported in . The only over-expressed signaling GO category was ‘Phosphorelay signal transduction system (GO:0000160)’, and was found to be over-expressed in all analyses . Our results are consistent with the finding of T. sp., in which in the Cyst stage incorporated the lowest representation of transcripts belonging to the cell communication and signaling pathways. Processes associated with the Wnt signaling pathway  were found to be under-expressed in the Cyst, particularly when compared to the Polyp.More than 100 different GO categories involved in cellular communication and signaling were found to be under-expressed in the Cyst when compared to the Polyp and Medusa in at least one of the three analyses . GO categories that were significant in all three analyses . The inhibition of the Notch signaling pathway has been shown to be associated with cell transdifferentiation in specific systems , much fewer than in the Polyp (77 contigs), and much more than in the Cyst (7 contigs). Broader categories of aging , were also found to be under-expressed in the Cyst when compared to the Polyp stage , 4 under-expressed in the Cyst vs. Medusa , and 12 under-expressed in the Cyst vs. Polyp and Medusa combined ). ‘Mitotic cell cycle phase (GO:0098763)’ was the 9th overall most under-expressed category in the Cyst when compared to the Medusa .A considerable number of GO categories associated with mitotic cell division were suppressed in the Cyst when compared to the other stages, with 27 total categories under-expressed in the Cyst Despite the fact that gene categories related to mitotic cell division were under-expressed in the Cyst, processes involved in DNA synthesis, maintenance, integration, transposition and repair, were significantly over-expressed , 3 when compared to the Medusa , and 84 when compared to both stages combined . Due to the large number of under-expressed categories, the results were condensed to represent broader categories, along with the only two exceptions of categories associated with the response to stimuli over-expressed in the Cyst , namely A large number of categories that are involved in cell differentiation and organization were down-regulated in the Cyst as compared to the Polyp and Medusa stages . In addition, 54 categories with the key word ‘development’ were reported to be under-expressed in the Cyst in comparison to the Polyp , 6 categories compared to the Medusa , and 29 categories when compared to both the stages combined . Due to the large number of under-expressed categories associated with organismal development, broader categories were reported in Additional File R.de novo assembly, and functional annotation were performed to characterize the transcriptome profiles of the Polyp, the Medusa and the Cyst, three life cycle stages of the cnidarian Turritopsis dohrnii. Comparative functional gene enrichment analyses were conducted using the Cyst as the central stage of comparison to identify biological pathways that are potentially involved in the reverse development and transdifferentiation in T. dohrnii. Our results show that categories associated with DNA synthesis, repair processes, telomerase activity and telomere maintenance are over-expressed in the Cyst when compared to the Medusa and the Polyp stages. On the other hand, transcripts associated to specialized functions involving lifespan and aging, response to stimuli, cell division and cell differentiation and development, are under-expressed in the Cyst when compared to the Medusa and the Polyp stages. Our study of the life-stage specific T. dohrnii transcriptomes gives a glimpse of the molecular regulatory gene network controlling the stability and reprogramming of differentiated cells, tissue homeostasis, longevity, and the associated potential for organismal rejuvenation in a promising in vivo system. This research has produced a transcriptomic landscape for the analysis of the extraordinary potential of reverse development and cell transdifferentiation in T. dohrnii. As a corollary, it suggests the foundation of a new experimental paradigm to gain novel insights on regeneration, cell plasticity, aging, and the directionality of ontogeny in a non-model, in vivo metazoan system. Finally, it identifies biological processes such DNA repair and integrity, role of transposable elements, cell to cell communication, and telomerase activity, as processes that occur at the Cyst stage and that are worth of further investigation.RNA-sequencing,