Participants were recruited from pediatrics, neonatology and radiology departments, reflecting the multidisciplinary nature of care for premature infants with bronchopulmonary dysplasia. The study collected demographic information and questionnaire responses on knowledge and attitudes toward the condition. The analysis included 233 valid questionnaires completed by physicians, nurses and medical technicians; 134 participants, or 57.51%, were female. The research was not a clinical trial, and the supplied abstract does not describe any intervention or comparison of clinical outcomes.

Multivariable logistic regression identified several factors independently associated with adequate knowledge. Male participants had higher odds of demonstrating adequate knowledge than female participants (odds ratio [OR] 2.014, 95% confidence interval [CI] 1.097–3.699; P = 0.024). Compared with participants whose highest qualification was an associate degree or below, those with a bachelor’s degree had lower odds of adequate knowledge (OR 0.238, 95% CI 0.060–0.938; P = 0.040), as did those with a master’s degree or higher (OR 0.176, 95% CI 0.040–0.768; P = 0.021). Knowledge score was independently associated with a positive attitude (OR 1.149, 95% CI 1.085–1.218; P < 0.001). These regression estimates describe associations in the surveyed population and do not establish that demographic characteristics or knowledge caused the reported attitudes.

Similar patterns were observed in an analysis restricted to physicians, according to the abstract. The full methodological and statistical details needed to evaluate that subgroup, including its sample size and uncertainty estimates, are not provided in the supplied material, so the physician-only results should be interpreted cautiously. More broadly, the questionnaire design and multivariable regression do not establish causal effects, and the abstract does not report the setting, recruitment dates or measures of response rate. The findings therefore describe knowledge and attitudes among the included professionals rather than their influence on the assessment or management of bronchopulmonary dysplasia.

Subject of Research: Healthcare professionals’ knowledge of and attitudes toward bronchopulmonary dysplasia in premature infants

Article Title: Knowledge, attitudes, and associated factors toward bronchopulmonary dysplasia in premature infants among healthcare professionals

Article References: Huang, H., Li, J., Lu, T., & Chen, W. (2026). Knowledge, attitudes, and associated factors toward bronchopulmonary dysplasia in premature infants among healthcare professionals. BMC Medical Education. https://doi.org/10.1186/s12909-026-10463-9

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10463-9

Keywords: bronchopulmonary dysplasia, premature infants, healthcare professionals, medical knowledge, attitudes, questionnaire survey, multivariable logistic regression, neonatology, pediatrics, radiology, Knowledge, associated

Bronchopulmonary dysplasia, or BPD, is the most common chronic lung disease of infancy and a defining complication of extreme prematurity. It arises when the immature lung, forced onto mechanical ventilation and oxygen therapy in its first weeks of life, sustains injury that interrupts the delicate development of airways and blood vessels. Clinicians grade its severity at 36 weeks post-menstrual age, the point at which a baby would have been roughly full term had pregnancy continued. Grade 2 and grade 3 BPD represent the moderate and severe ends of that spectrum, marked by a continuing need for respiratory support, and in the most severe cases by invasive ventilation through a breathing tube. It is precisely this population, the authors note, for which the question of tracheostomy placement becomes most pressing and most contested.

The research team, led by Jonathan C. Levin of the Division of Newborn and Pulmonary Medicine at Boston Children’s Hospital, together with biostatistician Joshua Ray Tanzer, Christopher H. Schmid of the Brown School of Public Health, and Robin L. McKinney of Warren Alpert Medical School of Brown University, drew on the multi-center BPD Collaborative registry. That consortium of referral centers cares for unusually large volumes of infants with severe BPD, making it one of the few settings where enough tracheostomy cases accumulate to build and test a statistical model at all. The investigators assembled a retrospective cohort of infants with grade 2 or 3 BPD and defined their primary outcome as the combined endpoint of tracheostomy placement or death prior to hospital discharge, a composite that reflects the clinical reality that both outcomes signal a failure of the baby’s lungs to recover on conventional support.

Technically, the study followed the established architecture of modern clinical prediction modeling. The researchers developed two separate models, one derived at 36 weeks post-menstrual age and a second derived at 44 weeks, roughly two months later. Each model harmonized a common set of candidate predictors drawn from three domains: data known at birth, the specific respiratory support the infant was receiving at the assessment point, and the medications being administered. Because infants at 44 weeks represent a selected population, those who survived and remained hospitalized without already having received a tracheostomy, the two models address distinct clinical moments. The 36-week model answers the early question of how worried to be when BPD severity is first graded, while the 44-week model refines that forecast for the substantial subset of babies still fighting for breath well past their original due date.

The sample sizes underscore how demanding this kind of modeling is in neonatology. In the training set, 854 infants contributed data at 36 weeks post-menstrual age, but only 319 remained available at 44 weeks, a reflection of the attrition inherent in following this fragile population. Across the full cohort, 914 infants were included in model development and 1,375 in independent validation. Performance was quantified using the area under the receiver operating characteristic curve, or AUC, the standard metric for how well a model separates babies who experience the outcome from those who do not. An AUC of 0.5 indicates performance no better than a coin flip, while 1.0 indicates perfect discrimination, and values above 0.8 are generally considered strong for clinical prediction.

The results were consistent across both time points and both datasets. In the training data, the 36-week model achieved an AUC of 0.89 and the 44-week model matched it at 0.89, indicating that the combination of birth characteristics, medication exposure, and ventilator support captured nearly all of the signal relevant to tracheostomy or death. Critically, the models held up when applied to the separate validation cohort, achieving AUCs of 0.86 at 36 weeks and 0.85 at 44 weeks. Just as important for bedside use, the models demonstrated good calibration, meaning that when a model predicted, for example, a 30 percent probability of tracheostomy or death, roughly that fraction of similar infants actually experienced the outcome. Predicted percentages for specific combinations of predictors are presented in the published figures, giving clinicians a concrete mapping from a baby’s status to an individualized risk estimate.

The clinical significance of such a tool is difficult to overstate. Tracheostomy placement in infants with severe BPD varies enormously between centers, and prior work from the BPD Collaborative has documented wide inter-center variation in the rate of death or tracheostomy placement, suggesting that the decision is shaped substantially by local practice patterns rather than by differences in the babies themselves. Previous attempts at prediction, including an earlier model published by some overlapping investigators in 2014, have informed the field but left room for refinement. By anchoring predictions to the objective variables of ventilator mode and support intensity at standardized post-menstrual ages, the new models offer a common reference point that could help align decision-making across institutions and give families a quantified picture of their child’s trajectory rather than a vague range of possibilities.

Timing matters in another way that the two-model design captures directly. Evidence from long-term outcome studies suggests that tracheostomy in infants with BPD, when it is ultimately needed, can relieve some of the burdens of prolonged intubation, with reports of improved growth and developmental activity after placement, while delayed or avoided tracheostomy in babies who truly require chronic ventilation carries its own risks. Conversely, performing the surgery in a baby whose lungs would have recovered condemns a child to unnecessary airway surgery and device dependence. A validated 36-week estimate allows teams to begin early, informed conversations and care planning, while the 44-week update provides a second, more refined checkpoint for babies still ventilator-dependent, a point at which continued invasive support is increasingly likely to reflect a chronic, rather than transient, need.

The methodological rigor behind the models also deserves attention. The authors followed contemporary best practices in prediction modeling, including principled handling of missing data through multiple imputation, careful variable selection in the presence of imputed datasets, and use of flexible generalized linear mixed modeling frameworks implemented in modern statistical software. Validation techniques for logistic regression models were applied to confirm that the models’ discrimination and calibration extended beyond the centers and infants used to build them. The work was supported by a Clinical and Translational Science Award from the National Institute of General Medical Sciences, and the researchers have stated that a de-identified dataset will be made available upon request, opening the door to external replication and further refinement by other groups.

Caveats remain, as they do for any retrospective model. The study population was drawn from specialized referral centers within a single collaborative, and outcomes such as tracheostomy placement are influenced by family preferences, ethics discussions, and local resources, factors that no physiological model fully captures. The researchers themselves frame the tools as decision support rather than decision replacement, a way to quantify risk in a domain where clinicians have historically relied on experience alone. Still, for the parents of a premature infant lingering on a ventilator week after week, and for the neonatologists and pulmonologists counseling them, the arrival of validated, calibrated risk estimates at 36 and 44 weeks post-menstrual age represents a meaningful shift: the most consequential surgical decision in severe BPD can now begin from a foundation of measured probability rather than instinct.

Subject of Research: Prediction of tracheostomy or death in infants with grade 2 or 3 bronchopulmonary dysplasia using ventilator support data at 36 and 44 weeks post-menstrual age

Article Title: Predicting tracheostomy using ventilator support at 36 and 44 weeks in infants with grade 2 or 3 bronchopulmonary dysplasia

Article References: Levin, J. C., Tanzer, J. R., Schmid, C. H., & McKinney, R. L. (2026). Predicting tracheostomy using ventilator support at 36 and 44 weeks in infants with grade 2 or 3 bronchopulmonary dysplasia. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02926-0

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02926-0

Keywords: bronchopulmonary dysplasia, tracheostomy, premature infants, neonatology, prediction model, ventilator support, post-menstrual age, BPD Collaborative, clinical prediction, receiver operating characteristic, infant mortality, Journal of Perinatology

The physics behind lung ultrasound is deceptively simple. The probe, placed on the chest wall, cannot image aerated lung directly, because air scatters ultrasound almost completely. Instead, clinicians read artifacts: the shimmering, to-and-fro movement of the pleural line known as lung sliding, the horizontal reverberation lines called A-lines that indicate normal aeration, and the vertical comet-tail artifacts known as B-lines that signal fluid or collapsed, non-aerated tissue beneath the probe. In preterm infants with respiratory distress syndrome, a disease of surfactant deficiency in which alveoli collapse, the typical pattern includes diffuse B-lines, thickened or irregular pleural lines, and consolidated, tissue-like areas where lung has lost its air entirely. As surfactant therapy recruits alveoli and aeration returns, these findings evolve in real time, giving clinicians a functional, dynamic picture of the lung rather than the static snapshot offered by a chest radiograph.

That dynamism is precisely what makes the technology attractive for one of the most consequential decisions in neonatology: whether and when to administer surfactant. The review highlights a multicenter pragmatic study by Raimondi and colleagues, published in Chest in 2021, in which lung ultrasound findings were used to guide surfactant administration in preterm infants with respiratory distress. Related work by De Martino and colleagues showed that a lung ultrasound score obtained shortly after birth could predict the need for surfactant in extremely preterm neonates, and Badurdeen and colleagues demonstrated that ultrasound performed during newborn resuscitation predicted surfactant requirement in very and extremely preterm infants. Even more striking, the ULTRASURF randomized controlled trial by Rodriguez-Fanjul and colleagues tested early surfactant replacement guided by lung ultrasound against conventional management in preterm newborns with respiratory distress syndrome, providing some of the strongest evidence that the modality can drive treatment decisions rather than merely describe disease.

The scoring systems at the heart of these studies deserve technical attention. Most divide the chest into a grid of zones, commonly four, six, eight, or twelve, and assign each zone a numerical grade based on the worst finding present: zero for normal aeration with A-lines, rising through increasing numbers of well-separated B-lines, to coalescent B-lines, and finally to large consolidations with air bronchograms for the most severely affected regions. Summing the zone scores yields a global aeration index. The review compares these protocols explicitly, noting that the choice of zone count affects sensitivity, examination time, and reproducibility. A 2025 systematic review by Sartorius, Brunet, and De Luca catalogued the characteristics of the many neonatal lung ultrasound scores now in circulation, and a 2022 narrative review by Corsini and colleagues mapped how they are used in clinical practice. The proliferation of scoring schemes, the authors caution, is both a sign of the field’s vitality and a source of its fragmentation.

Perhaps the most clinically consequential application is the prediction of bronchopulmonary dysplasia, the chronic lung disease of prematurity that remains one of the most common and feared outcomes for infants born extremely early. Because BPD is diagnosed clinically at 36 weeks postmenstrual age, clinicians often spend weeks caring for an infant without a clear sense of that infant’s long-term pulmonary trajectory. Lung ultrasound offers a potential early warning system. A prospective multicenter diagnostic accuracy study by Alonso-Ojembarrena and colleagues, published in Chest in 2021, evaluated the predictive value of lung ultrasound scores for developing BPD, and a multicenter longitudinal cohort study by Loi and colleagues in the American Journal of Respiratory and Critical Care Medicine showed that serial ultrasound could monitor extremely preterm infants and predict BPD. Oulego-Erroz and colleagues demonstrated that early assessment of lung aeration using an ultrasound score could serve as a biomarker of subsequent BPD, and Mohamed and colleagues reported similar predictive performance in a prospective diagnostic cohort of extreme preterm neonates.

The prognostic reach of the technique extends beyond the diagnosis itself. Zong and colleagues showed that a lung ultrasound score could predict the severity of bronchopulmonary dysplasia in neonates born at or before 25 weeks of gestation, while Aldecoa-Bilbao and colleagues characterized distinct ultrasound patterns and predictors in very preterm infants with the disease. In a comparison that underscores the score’s discriminative power, Alonso-Ojembarrena and colleagues found that lung ultrasound outperformed NT-proBNP, a widely used biomarker, in predicting moderate to severe BPD. Modified scores have been developed specifically for the BPD population, and Hoshino and colleagues used lung ultrasound to predict respiratory outcomes in patients with established disease. Savoia and colleagues even showed that the ultrasound score follows the trajectory of chronic pulmonary insufficiency of prematurity into early infancy, suggesting the technique can track disease evolution well beyond the NICU.

That longer-term horizon is where the review points toward the future. Shen and colleagues reported that a modified lung ultrasound score for BPD predicted late respiratory outcomes in preterm infants, and a 2024 study published in JAMA Network Open by Bonadies and colleagues linked lung ultrasonography scores in preterm infants to respiratory outcomes at age two. Stephenson and her own group had previously published work on outpatient assessment of bronchopulmonary dysplasia using point-of-care lung ultrasound, extending the modality from the intensive care unit into the clinic. The review also notes emerging data on monitoring pulmonary edema: Kasniya and colleagues assessed pulmonary edema in neonates with chronic lung disease before and after diuretic therapy, and a pilot study by Alonso-Ojembarrena and colleagues examined lung ultrasound scores and diuretics in infants born before 32 weeks. Together, these studies sketch a vision of lung ultrasound as a continuous, longitudinal readout of pulmonary health from the delivery room through early childhood.

The modality’s diagnostic repertoire is not limited to surfactant decisions and BPD prediction. The review situates lung ultrasound within the broader landscape of neonatal pulmonary imaging, citing evidence that it can diagnose and differentiate transient tachypnea of the newborn from respiratory distress syndrome, detect pneumothorax with performance that a systematic review by Fei and colleagues suggested may make it a better first choice than radiography, and identify pneumonia, including in neonates with fungal infections. It can also inform weaning from mechanical ventilation: Soliman and colleagues used lung ultrasound to predict extubation readiness in preterm infants, and El Amrousy and colleagues evaluated its value in predicting weaning success in ventilated neonates. Because extubation failure carries real costs in a preterm population, a bedside tool that quantifies aeration and diaphragm-adjacent lung recruitment at the moment of decision could meaningfully change practice.

Yet the review is candid about the field’s limitations. Interpretation of the existing evidence is constrained by heterogeneity in acquisition protocols, scoring systems, and the timing of assessments, and by the fact that lung ultrasound is fundamentally operator dependent. A score obtained with a twelve-zone protocol by an experienced sonographer is not interchangeable with a four-zone scan performed by a trainee, and the timing of an assessment, whether in the first minutes of life, during the first days of respiratory distress, or in the weeks before a BPD diagnosis, can dramatically alter its predictive meaning. Most studies to date have been single center or modest in size, and few have tested whether ultrasound-guided management actually improves hard outcomes such as mortality, ventilator days, or long-term neurodevelopment, as opposed to simply changing when surfactant is given. The authors call explicitly for further multicenter studies with standardized protocols to define the role of lung ultrasound in routine neonatal respiratory care.

Even with those caveats, the trajectory is unmistakable. A technique that requires no radiation, sits at the bedside, delivers results in minutes, and can be repeated without limit addresses nearly every weakness of the chest radiograph in neonatology, where transport to the X-ray suite is hazardous, images are snapshots rather than movies, and cumulative dose is a genuine concern for infants who may need hundreds of days of intensive care. If ongoing trials confirm that standardized lung ultrasound scores can reliably triage surfactant, time extubation, and stratify BPD risk early enough to change management, the handheld probe may become as fundamental to the preterm infant’s care as the stethoscope once was, turning the NICU’s most vulnerable lungs into an open book read in real time.

Subject of Research: Lung ultrasound applications for respiratory distress syndrome and bronchopulmonary dysplasia in preterm infants

Article Title: Applications of lung ultrasound in preterm infants: implications for respiratory distress syndrome and bronchopulmonary dysplasia

Article References: Stephenson, N., Carr, C. B., Park, D., & Laughon, M. (2026). Applications of lung ultrasound in preterm infants: implications for respiratory distress syndrome and bronchopulmonary dysplasia. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02849-w

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02849-w

Keywords: lung ultrasound, preterm infants, respiratory distress syndrome, bronchopulmonary dysplasia, surfactant therapy, neonatal intensive care, medical imaging, lung ultrasound score, extubation readiness, predictive markers, neonatology, point-of-care ultrasound

The clinical story began with what seemed, at first, to be a routine neonatal complaint. According to the case report, the infant had shown skin jaundice for two days before admission, and in the three hours before she was brought to the hospital she had decreased her milk intake and cried persistently. These are among the most common reasons newborns are evaluated by pediatricians, and none of them points specifically toward sepsis. That ambiguity is precisely what makes the case instructive, the authors argue: neonatal Edwardsiella tarda septicemia presents with non-specific clinical manifestations, which makes early diagnosis exceptionally challenging. A delayed or missed diagnosis of bacterial sepsis in a newborn can be fatal, so the stakes of recognizing unusual pathogens are high.

Blood culture provided the decisive answer. Culturing the infant’s blood allowed the laboratory to identify Edwardsiella tarda as the organism circulating in her bloodstream, confirming the diagnosis of neonatal septicemia. Blood culture remains the diagnostic gold standard for neonatal sepsis, because the clinical signs of infection in newborns, from temperature instability to poor feeding and lethargy, overlap so heavily with other neonatal illnesses that laboratory confirmation is essential before targeted therapy can be chosen. In this case, the identification of an organism that most pediatricians will never encounter in a newborn blood culture immediately placed the infant’s care in uncommon territory.

Edwardsiella tarda is a Gram-negative bacterium in the family Enterobacteriaceae, and its natural history is dominated by aquatic environments and cold-blooded animals. It is a well-documented pathogen of fish, causing disease in farmed and wild species, and it can also colonize reptiles and amphibians. Human infections are uncommon and typically occur through exposure to contaminated water or aquatic food sources, most often producing gastrointestinal illness. When the bacterium does invade the bloodstream, the consequences can be severe; the authors note that Edwardsiella tarda bacteremia can be a fatal disease in humans. Its appearance in the blood of a five-day-old infant is an event rare enough that the Jiangyou team combined their case with a review of the published literature to map what is known about this infection in newborns.

One of the most striking elements of the case involved a finding that extended beyond the bloodstream infection itself. During hospitalization, the infant was found to have a subgaleal hematoma over the left parietal region of her skull, a collection of blood between the scalp and the skull covering that had been present on imaging. That hematoma progressed to abscess rupture during her hospital stay, meaning the blood collection became infected and broke down. A subgaleal abscess in a newborn represents a serious complication, because the potential space between the galea aponeurotica and the skull can allow blood and pus to spread widely across the scalp, and infection in this compartment can seed the underlying structures. The progression of a sterile hematoma into an abscess in the setting of bacteremia illustrates how a circulating infection and a local collection of blood can reinforce one another, with bacteria seeding the hematoma and the hematoma providing a protected environment in which the bacteria can proliferate beyond the reach of circulating antibiotics.

Treatment combined two complementary strategies. The infant received meropenem, a broad-spectrum carbapenem antibiotic active against many Gram-negative organisms, including Enterobacteriaceae such as Edwardsiella tarda. Carbapenems are typically reserved for severe infections or for situations in which resistance to narrower agents is a concern, and their use here reflects the gravity of neonatal septicemia and the need to achieve rapid, reliable bacterial killing. Alongside the antibiotic, the clinicians administered adjunctive intravenous immunoglobulin, or IVIG, a blood-derived product concentrated with antibodies that can support the immature immune system of a newborn. Neonates have limited capacity to produce their own antibodies and to opsonize encapsulated and Gram-negative bacteria effectively, and IVIG is sometimes used as adjunctive therapy in severe neonatal sepsis to supplement the infant’s antibody repertoire while antibiotics address the underlying infection.

Supportive care completed the therapeutic picture. Newborns with septicemia require meticulous management of fluid balance, nutrition, temperature, and organ function, because the physiological reserves of a five-day-old are minimal and the systemic inflammatory response to bacterial sepsis can rapidly destabilize multiple organ systems. In this infant, the combination of meropenem, IVIG, and supportive measures succeeded in clearing the infection and resolving the local complication. The subgaleal abscess, despite its rupture during hospitalization, did not prevent a full recovery, and the authors report that the infant was discharged without long-term complications, an outcome that stands in welcome contrast to the potentially fatal trajectory of untreated Edwardsiella tarda bacteremia.

The rarity of this infection in newborns is what gives the case report its scientific value. By pairing their single case with a literature review, the authors have assembled a reference point for clinicians who may encounter similar presentations. The published record of Edwardsiella tarda infections in neonates is sparse, and each documented case contributes to a collective understanding of how the infection is acquired, how it manifests, and how it responds to treatment. The authors emphasize that awareness of potential environmental or aquatic exposures may be helpful when considering Edwardsiella tarda infection in neonates, a recommendation that reflects the bacterium’s ecology. In practice, this means that when a newborn presents with sepsis and cultures yield an unexpected aquatic-associated organism, clinicians should think to ask about the environments the mother and infant have contacted, from household water sources to contact with fish or aquatic animals.

The case also highlights the role of maternal exposure in the chain of transmission. The article’s keywords include maternal exposure, underscoring the authors’ interest in how a newborn so young, with no independent contact with the outside world beyond the delivery environment, could acquire a bacterium associated with water and aquatic animals. Possible routes in such cases include contamination during labor and delivery, contact in the home environment after discharge, or transmission from a colonized mother. The report does not resolve this question definitively for this infant, but by flagging maternal and environmental exposure as a consideration, it gives pediatricians a concrete line of inquiry when the unusual diagnosis arises.

For the wider medical community, the takeaways are practical. First, neonatal sepsis remains a diagnosis in which the clinical picture can deceive: jaundice and poor feeding, two of the most ordinary findings in a newborn, were the opening signs of a life-threatening bloodstream infection. Second, blood cultures must be obtained promptly whenever sepsis is suspected, because identifying the organism is the only way to move from empiric coverage to targeted therapy, particularly when the pathogen involved is as unusual as Edwardsiella tarda. Third, unusual organisms demand unusual histories, and asking about aquatic and environmental exposures can illuminate infections that would otherwise remain unexplained. Finally, the case demonstrates that even a rare and potentially fatal neonatal infection can have a good outcome when it is diagnosed by culture, treated with appropriate broad-spectrum antibiotics and adjunctive immunotherapy, and monitored closely for local complications such as the infected subgaleal hematoma that complicated this infant’s course. The authors, Qinnan Shao, Haixia Xie, Haixia Liu, and Hong Lin, all of the Department of Pediatrics at Jiangyou People’s Hospital, published the case as an open-access report so that clinicians elsewhere can draw on the experience when the same rare pathogen next appears in a newborn’s blood culture.

Subject of Research: Neonatal septicemia caused by Edwardsiella tarda

Article Title: Neonatal septicemia caused by Edwardsiella tarda: a case report and literature review

Article References: Shao, Q., Xie, H., Liu, H., & Lin, H. (2026). Neonatal septicemia caused by Edwardsiella tarda: a case report and literature review. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07819-x

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07819-x

Keywords: Edwardsiella tarda, neonatal sepsis, bloodstream infection, blood culture, meropenem, intravenous immunoglobulin, subgaleal hematoma, abscess, aquatic exposure, maternal exposure, neonatology, bacterial infection

The trial, led by Asghar Marzban and SeyedehFatemeh Mousavi of Zanjan University of Medical Sciences, set out to answer a deceptively simple question: if you give nebulized epinephrine on a fixed schedule after extubation, can you prevent the baby from failing to breathe on their own? Epinephrine, the same adrenaline-derived compound that has saved countless infants from croup, constricts blood vessels in the airway mucosa and is thought to shrink the edema that narrows the passage. It is widely used in neonatal units exactly for this purpose, often as a rescue treatment when stridor appears. But as the authors note, the randomized evidence supporting its prophylactic use in newborns has been thin, and the practice has persisted largely on physiological plausibility and clinical habit rather than on firm trial data.

To settle the question, the investigators designed a randomized, double-blind, placebo-controlled trial at the level III neonatal intensive care unit of Ayatollah Mousavi Hospital in Zanjan, running from May to December 2025. They enrolled invasively ventilated neonates who met standardized readiness criteria for their first planned extubation after less than seven days of intubation, with written informed consent from a parent or legal guardian. Neonates with contraindications to epinephrine, major congenital or structural upper-airway abnormalities, inherited metabolic or neuromuscular disorders, critical conditions at the time of extubation, or recent epinephrine exposure were excluded. The narrow focus on short-term intubation was deliberate: the longer a tube sits in the airway, the more complex the edema and the harder it is to attribute failure to a single reversible cause.

The intervention itself was meticulously standardized. Participants were randomized to receive nebulized L-epinephrine at a dose of 0.5 milligrams per kilogram per dose, drawn from a 1:1000 solution and diluted with saline to a total volume of four milliliters, or a volume-matched saline placebo. The drug was delivered through a nebulizer over fifteen minutes at an oxygen flow of six liters per minute, every twelve hours for three days, with continuous cardiorespiratory monitoring throughout. The primary outcome was extubation failure, defined as the need for reintubation within seventy-two hours. The team also tracked reintubation within twenty-four hours, forty-eight hours, and seven days as secondary, time-windowed analyses, along with post-extubation respiratory distress and adverse effects such as tachycardia.

Ninety-seven neonates were randomized, fifty-one to the epinephrine arm and forty-six to placebo. When the data came in, the primary endpoint showed no difference between the groups. Seven of the fifty-one babies in the epinephrine arm, or 13.7 percent, needed reintubation within seventy-two hours, compared with seven of the forty-six babies, or 15.2 percent, in the placebo arm. The risk ratio was 0.90 with a 95 percent confidence interval of 0.34 to 2.38, and the absolute risk difference was minus 1.5 percent with a confidence interval spanning from minus 15.5 percent to plus 12.5 percent. The p value was 1.00. In plain terms, the scheduled epinephrine regimen did nothing to reduce the likelihood that a baby would fail extubation in the critical first three days.

The time-windowed secondary analyses told the same story. Failure rates were similar at twenty-four hours, forty-eight hours, and seven days, and, notably, no reintubations occurred at all between seventy-two hours and seven days in either arm. Post-extubation respiratory distress was numerically lower with epinephrine, 13.7 percent versus 21.7 percent, but the difference was not statistically significant, with a risk ratio of 0.63 and a confidence interval of 0.26 to 1.52 and a p value of 0.423. Adverse effects were infrequent and balanced between the arms, with tachycardia rates of 3.9 percent in the epinephrine group and 4.3 percent in the placebo group. The regimen, in other words, was not associated with excess short-term harm, but neither did it deliver the benefit that clinicians have long hoped for.

The authors are careful to frame their conclusions within the statistical limits of the study. The confidence intervals were wide and did not exclude clinically meaningful benefit or harm. With only fourteen reintubations across both arms, the trial was powered for a much larger effect than the roughly 14 to 15 percent failure rate actually observed. A risk ratio of 0.90 with a confidence interval reaching down to 0.34 means the data are compatible with anything from a modest reduction to a substantial one, and equally with a modest increase in risk. The low event rate, paradoxically a sign of good neonatal care, makes it statistically harder to detect a true benefit, and the authors explicitly state that a clinically meaningful effect cannot be excluded on the basis of this trial alone.

What does this mean for the neonatal units that have been reaching for the nebulizer after every extubation? The most direct implication is that scheduled nebulized epinephrine, initiated after extubation in neonates ventilated for less than one week, should not be assumed to prevent extubation failure. The trial does not rule out benefit in selected subgroups, such as babies with more severe airway edema or those with specific risk factors for obstruction, and it does not address rescue use of epinephrine once stridor has already appeared. But as a one-size-fits-all prophylactic regimen, the fixed twelve-hourly dosing schedule tested here did not move the needle on the outcome that matters most: keeping the tube out.

The study also highlights a broader truth about neonatal intensive care research. Extubation failure remains a major challenge in the field, and post-extubation upper-airway obstruction due to mucosal edema is a potentially reversible contributor, which is precisely why the epinephrine hypothesis has endured. But the trial demonstrates how easily a plausible mechanism can fail to translate into clinical benefit when tested rigorously. The regimen was safe, with no excess adverse events, which means the negative result is not a story about harm but about the limits of a widely used practice. For clinicians, the message is that the decision to use nebulized epinephrine after extubation should rest on individual clinical judgment rather than on the assumption that a fixed schedule will protect every baby.

For now, the trial stands as a rigorous test of a common practice, registered prospectively in the Iranian Registry of Clinical Trials and approved by the ethics committee of Zanjan University of Medical Sciences. It does not close the book on nebulized epinephrine in neonates, but it does raise the bar for the evidence required before the drug is deployed as routine prophylaxis. As the authors conclude, scheduled nebulized epinephrine initiated after extubation in neonates ventilated for less than one week did not reduce extubation failure compared with placebo, and given the low event rate and wide confidence intervals, a clinically meaningful effect cannot be excluded. In the high-stakes world of the neonatal intensive care unit, where every breath counts and every tube removal is a calculated gamble, that is a finding worth taking seriously.

Subject of Research: Neonatology

Article Title: Nebulized epinephrine to prevent extubation failure in neonates after short-term intubation: a randomized, double-blind, placebo-controlled trial

Article References: Marzban, A., Mousavi, S., Mokhtari, S., Jafari, N., Bagherivand, M., Habibi, S., Esmaeili, F., & Motiei Langroudi, S. M. (2026). Nebulized epinephrine to prevent extubation failure in neonates after short-term intubation: a randomized, double-blind, placebo-controlled trial. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07825-z

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07825-z

Keywords: neonatology, extubation failure, nebulized epinephrine, randomized controlled trial, mechanical ventilation, upper airway obstruction, BMC Pediatrics, Nebulized, epinephrine, prevent, extubation, failure

The clinical half of the study drew on 366 hospitalized neonates born between 2018 and 2023 at Sun Yat-sen Memorial Hospital. What makes this dataset unusual is the timing of the blood work: every infant had serum 25-hydroxyvitamin D, or 25(OH)D, the standard laboratory marker of vitamin D status, measured within 72 hours of birth and, crucially, before any vitamin D supplementation had been given. That timing matters because it captures the vitamin D status the infant acquired in utero, through placental transfer of the vitamin from the mother, rather than any status achieved after birth through feeding or supplementation. The researchers then tracked which of these infants went on to be diagnosed with neonatal sepsis during their hospitalization.

The numbers that emerged were striking. The median 25(OH)D concentration across the cohort was just 37.7 nanomoles per liter, a figure that sits well below the 50 nanomoles per liter threshold generally considered sufficient in pediatric practice. Nearly eight in ten infants fell short of that mark: 28.4 percent were frankly deficient, with concentrations below 30 nanomoles per liter, and another 49.5 percent were insufficient, landing between 30 and 50. In other words, vitamin D inadequacy was the norm rather than the exception in this population of hospitalized newborns, a pattern consistent with the widespread vitamin D deficiency documented among pregnant women in many parts of the world, since the newborn’s stores largely mirror the mother’s.

When the researchers ran the statistical analysis, they prespecified the 235 term neonates in the cohort as the primary analysis population, a decision that reflects the clinical reality that preterm infants face a fundamentally different risk landscape for sepsis, with immature skin barriers, invasive procedures, and prolonged hospital stays all playing outsized roles. Among those term infants, the association was clear: every 10-nanomole-per-liter increase in 25(OH)D was associated with roughly 30 percent lower odds of neonatal sepsis, with an adjusted odds ratio of 0.70 and a 95 percent confidence interval of 0.54 to 0.90, reaching statistical significance at p equals 0.006. The adjustment accounted for potential confounders, meaning the relationship held even after accounting for other factors that might independently influence sepsis risk.

But an observational association, however carefully adjusted, always leaves open the possibility of reverse causation or residual confounding. Perhaps sepsis-prone infants are simply sicker in ways that also depress their vitamin D levels, or perhaps some unmeasured factor, from maternal nutrition to socioeconomic circumstances, drives both. This is where the second half of the study comes in. The team turned to Mendelian randomization, a technique that exploits the random allocation of genetic variants at conception to approximate a randomized trial. Because single-nucleotide polymorphisms, or SNPs, that influence vitamin D levels are fixed at conception and generally not confounded by later environmental exposures or disease processes, they can serve as proxies for lifelong vitamin D status, allowing researchers to ask whether genetically predicted higher 25(OH)D is associated with disease outcomes in ways that are harder to dismiss as mere correlation.

Using summary statistics from large genome-wide association studies, the researchers performed a two-sample Mendelian randomization analysis examining whether genetically predicted vitamin D status relates to sepsis outcomes. The result was intriguing but deliberately cautious in its interpretation: genetically predicted higher 25(OH)D was nominally associated with lower odds of streptococcal septicemia, with an odds ratio of 0.96 per unit increase and a confidence interval of 0.924 to 0.996, yielding a p value of 0.029. The word nominal is doing important work here. In the context of multiple genetic instruments and multiple outcomes, a p value just under the conventional 0.05 threshold does not constitute strong evidence, and the authors were explicit that this exploratory estimate, while directionally consistent with the cohort finding, does not establish causality. The effect size, roughly a 4 percent reduction in odds per genetically predicted increase in 25(OH)D, is modest, and the confidence interval grazes the null value at its upper bound.

Still, the convergence of two very different lines of evidence is what gives the study its interest. The retrospective cohort captures real-world clinical variation in vitamin D status at a moment, the first 72 hours of life, when intervention might theoretically still be possible through maternal supplementation during pregnancy or early neonatal dosing. The genetic analysis, for all its limitations, offers a triangulation point that is immune to the reverse-causation problem, since a newborn’s germline variants cannot be altered by the sepsis that follows. That the two approaches point in the same direction, with the genetic signal specifically implicating streptococcal septicemia, a major bacterial cause of neonatal sepsis, lends biological plausibility to the association, even if neither line alone can settle the question.

The mechanistic backdrop is also worth understanding. Vitamin D is not merely a bone-regulating hormone; its active form binds to the vitamin D receptor expressed on immune cells, including macrophages and dendritic cells, and modulates the production of antimicrobial peptides such as cathelicidin, which play a direct role in killing bacteria. In the neonatal period, when the innate immune system is still maturing and the adaptive arm is largely naive, this antimicrobial pathway may be particularly consequential. Animal models and in vitro studies have long suggested that vitamin D deficiency impairs antibacterial responses, and the neonatal context, with its immature immune defenses and high vulnerability to bloodstream infection, is precisely where such a deficit might matter most.

The authors are careful about what their study cannot say. This was a selected cohort of hospitalized neonates who had clinician-directed 25(OH)D testing, which means the sample may overrepresent infants already suspected of having problems, and the retrospective design means sepsis diagnoses were drawn from clinical records rather than standardized prospective criteria. The cohort was also drawn from a single center in southern China, and vitamin D status varies substantially across populations, seasons, and latitudes, so the generalizability of the 37.7 nanomole-per-liter median and the magnitude of the association remain open questions. The Mendelian randomization analysis, meanwhile, relied on genetic instruments developed primarily in European-ancestry populations, which can limit the precision and transportability of the estimates when applied to other populations.

What the study does establish is a well-defined hypothesis worth testing prospectively: that early neonatal vitamin D status, established largely in utero, is associated with sepsis risk in term infants, and that the relationship may be at least partially causal. The authors call for prospective multicenter validation, which would mean following newborns forward from birth with standardized 25(OH)D measurements and sepsis surveillance, ideally across diverse populations. If such studies confirm the association and the genetic signal strengthens, the implications could be significant for a condition where prevention options remain limited. Maternal vitamin D supplementation during pregnancy is already recommended in many guidelines for skeletal health, and if the immune benefits extend to sepsis prevention, the case for ensuring adequate maternal and neonatal vitamin D status would become considerably stronger. For now, the message is one of cautious promise: a cheap, widely available nutrient, a common deficiency in newborns, and a serious infection, all linked by evidence that is suggestive but not yet definitive.

Subject of Research: The association between early neonatal vitamin D status and neonatal sepsis, examined through a retrospective cohort and Mendelian randomization

Article Title: Early neonatal vitamin D status and neonatal sepsis: a retrospective cohort study complemented by Mendelian randomization

Article References: Xie, X., Chen, Y., Jin, N., Sha, S., Zhou, R., Bamo, A., Chen, J., Yu, Z., & Ouyang, Y. (2026). Early neonatal vitamin D status and neonatal sepsis: a retrospective cohort study complemented by Mendelian randomization. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07678-6

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07678-6

Keywords: neonatal sepsis, vitamin D, 25-hydroxyvitamin D, Mendelian randomization, newborns, term neonates, Sun Yat-sen University, retrospective cohort, genetic analysis, streptococcal septicemia, neonatology, immune regulation

The research team, led by paediatric nephrologist A. Raaijmakers together with S.J.C. Tapawan and senior author S. Bolisetty of the University of New South Wales, combed through outpatient records from 2012 to 2017. Out of 5,117 infants seen at the clinic, 237 newborns carried a diagnosis of hydronephrosis, a prevalence of 4.6 percent that sits comfortably within the internationally reported range. The investigators applied strict inclusion rules: every severity grade of antenatal hydronephrosis was welcome, but infants lost to follow-up, those without a confirmed prenatal diagnosis, and the small number who required surgery within their first year were set aside. Thirty-eight newborns were excluded on those grounds, leaving a cohort of 199 infants whose natural history could be tracked without the distorting effect of early operative intervention.

The technical yardstick at the centre of the analysis is the anteroposterior diameter, the APD, the front-to-back measurement of the renal pelvis that ultrasound machines capture in milliseconds. Recovery was defined as an APD of 10 millimetres or less, the threshold at which the dilated collecting system is considered resolved rather than merely improved. When the researchers ran the statistics, using Pearson Chi-square and Fisher’s exact tests for categorical comparisons and Spearman correlation coefficients to probe the relationship between recovery and potential confounders, the headline finding leapt out: 186 infants, or 93.5 percent of the cohort, showed spontaneous resolution within the first year of life.

Even more remarkable is the tempo of that resolution. Of the infants who recovered, 94.1 percent did so before they reached two months of age. In other words, the swollen kidney that alarmed the prenatal scan typically deflated within the first weeks of life, often before the family had finished the battery of postnatal imaging appointments. For clinicians, this tempo matters enormously. It suggests that the first two months are the decisive window, and that an infant whose APD remains stubbornly elevated past that point deserves closer scrutiny, while the vast majority can be managed with observation alone.

One demographic pattern confirmed what ultrasound literature has long hinted at: boys dominated the cohort, with 156 males versus 43 females. The male predominance reflects well-known anatomical realities, including the higher incidence of pelvi-ureteric junction obstruction and vesico-ureteral reflux in infant boys. But here the study delivered a counterintuitive twist: sex had no bearing on recovery at all, with a p-value of 0.738 indicating that the correlation was statistically indistinguishable from chance. A baby boy with hydronephrosis was just as likely as a baby girl to see the swelling resolve without any intervention.

The determinants that did matter were comorbidities. Forty infants in the cohort, 20.1 percent, carried a relevant additional condition, and this group told a very different story. Infants with congenital anomalies showed a negative Spearman correlation with spontaneous recovery, r-s of minus 0.273 with a p-value of 0.001, while those who developed infections fared even worse, r-s of minus 0.283 with a p-value of 0.002. The negative signs are the crucial technical detail: they mean that as the presence or severity of these comorbidities increases, the probability of the hydronephrosis resolving on its own decreases. A swollen kidney in an otherwise healthy newborn is a waiting game; a swollen kidney in a newborn with a congenital anomaly or a urinary tract infection is a signal that the underlying anatomy or physiology may need active management.

For the clinical community, these correlations translate directly into follow-up strategy. The findings suggest that the routine postnatal workup, which often includes ultrasound surveillance and, in selected cases, a micturating cysto-urethrogram to exclude reflux, can be calibrated to the infant’s overall health status. Newborns free of comorbidities can be followed with confidence and minimal invasiveness, while those with congenital anomalies or early infections warrant tighter imaging intervals and a lower threshold for investigating obstruction or reflux. The study’s authors are careful to note that these associations are correlational, not causal, and that validation in future cohorts is essential before the numbers become firm clinical rules.

For parents, the reassurance value may be the study’s most viral contribution. Antenatal hydronephrosis generates enormous anxiety precisely because it is discovered before birth, when families have months to imagine the worst. The new data show that in more than nine out of ten cases, the condition melts away within the first year, and in almost all of those, within the first two months. The infant who needs surgery is the rare exception, not the rule, and the presence of other health problems, not the severity of the kidney swelling alone, is what tips the balance toward intervention.

The study is not without limitations, and the authors acknowledge them candidly. It is a single-centre retrospective review, which means referral patterns and local practice could shape the cohort in ways a multi-centre prospective design would control. The exclusion of infants lost to follow-up, while necessary for analytical integrity, removes exactly the cases whose outcomes might be least typical. And the definition of recovery as an APD of 10 millimetres or less, though widely used, is one threshold among several proposed in the literature. Still, the scale of the cohort, nearly two hundred infants tracked over five years, and the consistency of the comorbidity correlations give the findings real weight.

What the Randwick team has produced, in the end, is a natural history map of one of prenatal medicine’s most common findings. It tells clinicians where to look, at the infant with comorbidities rather than the infant with isolated swelling, and when to look, in the first two months rather than across an anxious year. It tells parents that the odds overwhelmingly favour spontaneous resolution. And it reminds the field that sometimes the most powerful diagnostic tool is time itself, allowed to run its course under careful observation.

Subject of Research: Pediatrics

Article Title: Antenatally diagnosed hydronephrosis and determinants of spontaneous resolution

Article References: Raaijmakers, A., Tapawan, S., & Bolisetty, S. (2026). Antenatally diagnosed hydronephrosis and determinants of spontaneous resolution. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07628-2

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07628-2

Keywords: antenatal hydronephrosis, pediatrics, prenatal ultrasound, kidney, neonatology, spontaneous resolution, comorbidities, urinary tract infection, Antenatally, diagnosed, hydronephrosis, determinants

The research team, led by Lotte Schuitmaker and colleagues in the Department of Bioethics and Health Humanities, conducted in-depth, semi-structured interviews with 17 neonatologists at a Dutch academic hospital. Using thematic analysis, a rigorous qualitative method that systematically codes interview transcripts to identify recurring patterns of meaning, the researchers distilled the physicians’ perspectives into three overarching themes: trusting AI in practice, maintaining control over trusted AI systems, and the limits of trust. The study protocol was reviewed by the research quality control committee of the University Medical Center Utrecht and deemed exempt from the Medical Research Involving Humans Act under research proposal number 23U-0364, and the work was carried out in accordance with the Declaration of Helsinki.

Perhaps the most technically significant finding is the physicians’ insistence on a conceptual distinction that has often been blurred in the AI ethics literature: the difference between trust, confidence, and reliance. In the philosophical sense the neonatologists invoked, trust implies a relationship in which the trusted party is expected to act in the trustor’s interest even under uncertainty, whereas confidence describes a settled expectation based on evidence of performance, and reliance describes the practical act of depending on a system’s output. The neonatologists argued that these are not interchangeable. They can rely on an AI tool’s output without trusting it, and they can trust a colleague’s judgment without relying on it in every case. This distinction matters because much of the current debate about medical AI treats the problem as one of calibration—getting physicians to have the right degree of confidence in an algorithm’s accuracy. The Utrecht interviews suggest the real challenge is deeper: physicians want to know what kind of relationship they are entering into with these systems before they decide whether trust is appropriate at all.

Across the interviews, one condition for trust emerged as non-negotiable: AI’s role must be supplemental to the physician’s own role. The neonatologists welcomed AI in neonatal clinical settings overall, but only on the understanding that the technology augments rather than replaces human judgment. This is not mere professional self-protection. In neonatology, where patients cannot communicate their symptoms and clinical data streams continuously from monitors, ventilators, and laboratory tests, the physician’s integrative judgment—weighing ambiguous signals against the individual patient’s trajectory—is precisely the kind of reasoning that current AI systems, however impressive in narrow imaging tasks, cannot fully replicate. The specialists’ insistence on supplementarity reflects a technically informed understanding of where AI’s strengths and weaknesses lie in data-rich but context-heavy medical domains.

The second pillar of trust identified in the study is validation combined with adequate oversight. The physicians considered rigorous validation of AI systems essential before those systems earn a place in bedside decision-making, and they regarded ongoing human oversight as equally indispensable. This aligns with the well-documented gap between AI’s technical advancement and its practical use in clinical care: a disparity persists between what algorithms can demonstrably do in controlled evaluations and what they can safely do in the messy, evolving conditions of real patient care. The neonatologists’ demand for validation and oversight is a demand for evidence that performance holds up outside the laboratory, and for institutional structures that keep humans in the loop as systems evolve.

Equally important to the physicians was preserving human expertise while working with AI in clinical settings. This concern goes beyond the immediate question of whether an algorithm’s output is accurate. If AI systems gradually take over parts of clinical reasoning, the physicians worried, the expertise needed to supervise those systems—and to catch their failures—could erode. This is a technically recognized phenomenon in human factors research: skills that are rarely exercised degrade, and physicians who habitually defer to algorithmic recommendations may lose the very competence that makes their supervision meaningful. The Utrecht interviews show that neonatologists see this erosion risk as a genuine limit on how much responsibility AI can be given, not as a vague anxiety about change.

The third theme, the limits of trust, surfaced most frequently in the form of two specific worries: overreliance and the incompatibility of clinical intuition with AI in practice. Overreliance—the tendency of humans to accept algorithmic outputs even when those outputs are wrong—is a documented failure mode in human-AI interaction, and the neonatologists named it as a primary reason they might lose trust in AI systems. The second worry is subtler and arguably more consequential for the future of medical AI. Clinical intuition in neonatology is built on years of pattern recognition across thousands of patient encounters, integrating signals that resist formalization into training data. When an AI recommendation conflicts with that intuition, the physician faces a genuine epistemic dilemma: the algorithm may be drawing on population-level patterns the physician has not consciously registered, or it may be failing to capture context the physician knows matters. The interviews reveal that neonatologists experience this incompatibility not as a bug to be engineered away but as a structural feature of how AI and human reasoning differ.

The study’s conclusions carry practical weight for hospitals and regulators moving to deploy AI in neonatal care. The researchers recommend clarifying what is expected of physicians in terms of reliance on AI at the bedside, and formulating concrete guidance for trust in AI. This is a pointed recommendation: in the absence of explicit institutional guidance, individual physicians are left to improvise their own standards for when to accept algorithmic output, when to override it, and when to distrust it entirely. The Utrecht findings suggest that improvisation is already happening, guided by the physicians’ own conceptual frameworks of trust, confidence, and reliance—but that hospitals would do better to make these expectations explicit rather than leave them to bedside discretion.

What makes this study resonate beyond neonatology is its methodological honesty. Rather than surveying physicians with predetermined questions about AI acceptance, the researchers let the themes emerge from open-ended conversation, capturing the ambivalence that quantitative surveys often flatten. The result is a portrait of physicians who are neither AI enthusiasts nor AI skeptics: they welcome the technology’s promise to improve patient outcomes, increase efficiency, and reduce healthcare costs, while insisting on conditions—supplementarity, validation, oversight, preserved expertise—that current deployment strategies often treat as afterthoughts. As AI expands from radiology into neonatology and other data-rich domains, the Utrecht interviews offer a technically grounded answer to the question that will determine medical AI’s real-world success: not whether the algorithms are accurate enough, but whether physicians can determine when they can reasonably be trusted.

Subject of Research: Physicians' trust in medical AI in neonatology

Article Title: Trust in artificial intelligence at the bedside: a qualitative interview study with neonatologists

Article References: Schuitmaker, L., Drogt, J., Hartman, S. D., & Jongsma, K. (2026). Trust in artificial intelligence at the bedside: a qualitative interview study with neonatologists. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07890-4

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07890-4

Keywords: artificial intelligence, neonatology, medical AI, clinical decision-making, trust in AI, qualitative research, BMC Pediatrics, healthcare ethics, Trust, artificial, intelligence, bedside

The numbers behind this rarity are striking. Trisomy 22 is found in 2 to 5 percent of spontaneous abortions across all populations studied, making it the second most common autosomal trisomy in pregnancy loss, behind only trisomy 16. The vast majority of affected fetuses are lost in the first trimester. The estimated incidence of liveborn complete trisomy 22 is between 1 in 30,000 and 1 in 50,000 births. As with most aneuploidies, increased maternal age is a risk factor, and the extra chromosome most often arises from a non-disjunction error during maternal meiosis one, when the chromosome pair fails to separate properly. More affected infants are female, a pattern the authors attribute to higher pregnancy loss among male fetuses, a sex ratio seen in other aneuploidies as well.

Because complete trisomy 22 is a lethal condition, the phenotypic spectrum has been largely characterized through reports of mosaic trisomy 22, in which only a fraction of cells carry the extra chromosome. Mosaic patients can survive into adolescence and adulthood, with documented cases alive at 7, 14, 17, and even 19 years of age, though they typically show growth restriction, developmental delay, and variable congenital anomalies. In complete trisomy 22, the most common cause of death is respiratory insufficiency. Reported features include intrauterine growth restriction, microcephaly, congenital heart disease, renal anomalies, anal atresia, thumb anomalies, hypotonia, and dysmorphic facies with hypertelorism, epicanthal folds, a flat nasal bridge, and low-set ears. Neonates with complete trisomy 22 more often show anomalous great vessels, whereas septal defects are more commonly reported in mosaic aneuploidy.

The baby in this report was born at 37 weeks and 1 day via spontaneous vaginal delivery to a 28-year-old mother with one prior spontaneous miscarriage. The father was also 28, the parents were non-consanguineous, and there were no reported teratogenic exposures. Prenatal ultrasounds had already flagged a large ventricular septal defect, an abnormal aorta, dilated small bowel, a pelvic right kidney, and micrognathia. A non-invasive prenatal testing result was inconclusive but suggested a possible sex chromosome anomaly involving the X chromosome, with low risk for trisomy 13, 18, and 21, triploidy, and 22q11.2 microdeletion syndrome. Chromosome 22 was not tested. No invasive prenatal genetic tests were obtained per the family’s preference, and the final diagnosis became available only after the patient’s death.

At delivery, the infant was small for gestational age, under the 10th percentile for weight at 1,750 grams, length at 42.5 centimeters, and head circumference at 30 centimeters. Her Apgar scores were 2, 4, and 4 at 1, 5, and 10 minutes. She was cyanotic with a weak cry and unresponsive to stimulation. Bagging ventilation failed to improve her heart rate or oxygen saturation, and intubation was unsuccessfully attempted five times. Chest compressions were initiated and epinephrine was given before a laryngeal mask airway was successfully placed. She was later intubated using a 2.9 millimeter rigid bronchoscope with a 3.0 millimeter endotracheal tube, after clinicians noted that her epiglottis and airway were extremely anterior and difficult to visualize. Rigid tracheoscopy revealed a patent trachea and mainstem bronchi without apparent tracheoesophageal fistula.

Physical examination and imaging revealed a constellation of congenital anomalies. She had a single umbilical artery, microcephaly, dysmorphic facial features with hypertelorism, downward-slanting palpebral fissures, microphthalmia, bilateral microtia with periauricular tags, and neck webbing. Ocular findings included an absent red reflex, corneal haze with an irregular pupil on the right, and microcornea on the left. She had an imperforated anus with rectovestibular fistula, bilateral clinodactyly of the fifth digits, and bilateral distal and proximal transverse palmar creases running in parallel across the full width of the palm. An echocardiogram within 24 hours of birth showed Tetralogy of Fallot, a large secundum atrial septal defect, a large patent ductus arteriosus, a dilated main pulmonary artery, thickened pulmonary, aortic, and tricuspid valves, and mild hypoplasia of the transverse aortic arch. Abdominal ultrasound revealed low-lying, small-for-age kidneys. Head ultrasound showed absence of the septum pellucidum, and a three-hour video electroencephalogram on day four showed diffuse cerebral dysfunction with no distinction between awake and sleep states, though no seizures.

The clinical course deteriorated rapidly. She developed severe hypoglycemia and bilateral pneumothorax on day 1 of life, requiring bilateral chest tubes. Ventilation remained challenging despite high settings, and surfactant and inhaled nitric oxide produced no improvement. She received a five-day course of ampicillin and ceftazidime for maternal chorioamnionitis, and on day four was diagnosed with coagulase-negative Staphylococcus sepsis, for which vancomycin was started. Persistent thrombocytopenia required multiple platelet transfusions, and impaired thermoregulation required warmer therapy. By day four, evidence of pulmonary hypertension emerged with predominantly right-to-left shunting across the patent ductus arteriosus, and she required daily hydrocortisone for hypotension. On day six, her hypotension worsened, requiring epinephrine and calcium chloride. On day seven, life-sustaining therapies were withdrawn, and she passed away approximately 1.5 hours later. A mitogen-stimulated peripheral blood chromosome study showed trisomy 22 in all 50 cells analyzed, with the karyotype 47,XX,+22. Autopsy was not performed.

The authors note that the diagnosis was established only after the patient had passed, causing significant uncertainty for both the multidisciplinary care team and the family, who were required to make complex medical decisions without adequate time to fully understand the underlying condition and its prognosis. The case also highlights the limits of current prenatal screening. Both the American College of Medical Genetics and Genomics and the American College of Obstetricians and Gynecologists recommend that non-invasive prenatal testing be made available to all pregnant patients regardless of risk, but most laboratories only report abnormalities in chromosomes 13, 18, 21, and the sex chromosomes, and do not screen for rarer aneuploidies like trisomy 22. The testing relies on placental rather than fetal DNA, which can limit its ability to fully detect fetal genetic conditions and necessitates confirmatory invasive tests such as chorionic villus sampling or amniocentesis. The authors suspect the positive sex chromosome screen in this case was a false-positive result unrelated to the confirmed trisomy 22, though a chromosomal microarray was not completed, so a small copy number variant could not be ruled out.

The diagnostic landscape is evolving. Chromosomal microarray analysis is recommended as a first-tier diagnostic test for fetuses with structural anomalies, because it identifies all aneuploidies detected by karyotype while additionally detecting submicroscopic copy number variants in approximately 6 percent of cases with a normal karyotype. Whole exome sequencing and whole genome sequencing can provide superior diagnostic yields compared to microarray alone, and while current guidelines recommend them only when other tests have failed to arrive at a diagnosis in a fetus with multiple congenital anomalies, these technologies can provide earlier and more precise characterization of complex fetal phenotypes.

The case contributes to the limited literature on complete trisomy 22 and highlighted additional findings not previously reported to the authors’ knowledge, including corneal haze, microcornea, and absence of the septum pellucidum. The most common eye abnormality reported in mosaic and complete trisomy 22 is coloboma. By better understanding the clinical presentation, the team hopes to facilitate early recognition, appropriate management, and counseling. Given the high likelihood of fetal demise or limited life expectancy, the authors emphasize that preparing the family for potential outcomes and collaboratively planning interventions that align with the family’s values and goals becomes essential from the point of initial diagnosis, underscoring the importance of interdisciplinary collaboration and adaptability in providing optimal care for this rare and devastating condition.

Subject of Research: A clinical case report of a liveborn female neonate with complete trisomy 22, documenting congenital anomalies, neonatal management, and prenatal diagnostic challenges.

Article Title: Liveborn trisomy 22: a case report

Article References: Jares Baglivo, S., Morand, M. P., Velagaleti, G. V. N., Jain, S. K., & Cooney, E. (2026). Liveborn trisomy 22: a case report. Frontiers in Pediatrics, 14, Article 1920011. https://doi.org/10.3389/fped.2026.1920011

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1920011

Keywords: trisomy 22, aneuploidy, case report, neonatology, prenatal testing, genetics, Liveborn, trisomy, case, report, scientific research

The research, published in Frontiers in Pediatrics, followed 173 preterm infants born at 32 weeks of gestation or earlier and/or weighing less than 1,500 grams—the very low birth weight category that represents some of the highest-risk patients in neonatology. Of these, 117 infants, or 67.6 percent, began enteral feeding within 48 hours of life, while 56 infants, or 32.4 percent, started later. The team, led by Javier Torres-Muñoz of Universidad del Valle, compared clinical outcomes between the two groups across four endpoints that matter most in the neonatal intensive care unit: necrotizing enterocolitis, sepsis, bronchopulmonary dysplasia, and mortality.

The physiological rationale for early feeding is compelling. Preterm birth interrupts fetal development during the third trimester, a critical stage of accelerated organ maturation, and infants with very low birth weight rarely achieve adequate nutritional intake in their first postnatal days. Observational studies suggest that cumulative deficits in energy and protein account for roughly half of the decline in weight-for-age between birth and hospital discharge. Beyond calories, early enteral feeding offers trophic stimulation of the gastrointestinal tract, promotes a healthy gut microbiota, strengthens the mother-infant bond, and supports the neurological maturation of sucking and swallowing—benefits that intravenous nutrition cannot replicate.

Methodologically, the study was ambitious for a resource-limited setting. The researchers fitted separate multivariable logistic regression models with robust standard errors for each outcome, adjusting for gestational age, birth weight, five-minute Apgar score, and study institution; the sepsis and bronchopulmonary dysplasia models were additionally adjusted for neonatal resuscitation. To address confounding by indication—the problem that sicker babies are more likely to have feeding delayed in the first place—the team estimated propensity scores among 159 infants with complete data and performed one-to-one nearest-neighbor matching with replacement, using a caliper of 0.05 and restricting the analysis to the region of common support. After matching, all standardized mean differences fell below 10 percent, indicating adequate covariate balance.

The primary full-cohort analyses delivered a clear message: delayed initiation of enteral feeding was not significantly associated with any of the four major outcomes. The adjusted odds ratios were 1.13 for necrotizing enterocolitis, 1.32 for sepsis, 1.08 for bronchopulmonary dysplasia, and 0.68 for mortality, all with confidence intervals crossing unity and p values well above 0.05. In other words, once baseline characteristics and institution were accounted for, waiting more than 48 hours to start feeding did not appear to protect infants from gut disease, infection, chronic lung disease, or death.

The picture grew more nuanced in the propensity score–matched sensitivity analysis, which included 38 infants with delayed feeding initiation and 38 weighted control observations derived from just 18 unique early-fed infants. In this smaller, more carefully balanced sample, delayed initiation was associated with a longer time to achieve full enteral nutrition—a weighted mean difference of 6.19 days—and with markedly higher odds of bronchopulmonary dysplasia, defined as the need for supplemental oxygen at 36 weeks’ postmenstrual age, with an odds ratio of 8.25. Intriguingly, mortality appeared lower in the delayed group in this analysis, an exploratory finding the authors attribute to possible survival bias, since infants who died within the first 48 hours were excluded by design.

These findings align with a growing body of evidence from randomized trials. A 2022 Cochrane meta-analysis of 14 trials involving 1,551 neonates found that delaying progressive enteral feeding beyond four days of life did not reduce the risk of necrotizing enterocolitis. A separate 2022 meta-analysis by Walsh and colleagues, covering seven trials and 872 very preterm or very low birth weight infants, found that delayed feeding actually increased the risk of invasive infection. Earlier work by Konnikova and colleagues observed that infants born before 33 weeks who began enteral feeding after the third postnatal day had a 4.5-fold increase in chronic lung disease compared with those fed earlier—consistent with the bronchopulmonary dysplasia signal in the Colombian matched analysis.

The study also revealed striking institutional differences. Delayed feeding occurred in 53.1 percent of newborns at Hospital Universitario del Valle but only 6.6 percent at Clínica Versalles, and birth at the public hospital was independently associated with higher adjusted odds of all four complications. The authors caution that these associations likely reflect differences in patient complexity, referral patterns, and clinical protocols rather than a direct institutional effect. Notably, infants with delayed feeding more often required neonatal resuscitation—92.9 percent versus 60.9 percent—and more often had respiratory distress syndrome, suggesting that clinical severity drove the decision to withhold feeding, a classic example of confounding by indication.

The limitations are substantial and the authors are candid about them. The observational design cannot establish causation, and because the retrospective database lacked precise onset times for sepsis and necrotizing enterocolitis, reverse causality remains possible: early clinical deterioration may have delayed feeding initiation rather than the reverse. The small number of events, particularly for necrotizing enterocolitis, limited statistical power, and nonsignificant findings should not be read as proof of safety. The matched analysis relied on only 18 unique controls, producing imprecise estimates with wide confidence intervals, and generalizability to centers with high rates of human milk use remains uncertain.

Nevertheless, the study offers something rare: prospective-quality evidence from a middle-income country, where exclusive early enteral feeding trials in India and elsewhere have shown shorter hospitalizations and better weight gain without increased complications. The authors conclude that their findings do not provide consistent evidence that feeding within the first 48 hours increases the frequency of major complications, but they stop short of declaring safety, calling instead for larger prospective multicenter studies in low- and middle-income settings. For the roughly 60 percent of the city’s births handled by these two institutions, the message is pragmatic: early enteral nutrition, advanced at 20 to 30 milliliters per kilogram per day, appears compatible with good outcomes—and delaying it may simply prolong the wait for full nutrition while offering no clear protection.

Subject of Research: Early enteral nutrition and clinical outcomes in very preterm infants in a middle-income country

Article Title: Clinical outcomes of preterm infants under 32 weeks who receive early enteral nutrition in a low- and middle-income country

Article References: Torres-Muñoz, J., Chamorro, L., Torres-Figueroa, J., Ortega, J., Garzón, R., & Quintero, P. (2026). Clinical outcomes of preterm infants under 32 weeks who receive early enteral nutrition in a low- and middle-income country. Frontiers in Pediatrics, 14, Article 1952558. https://doi.org/10.3389/fped.2026.1952558

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1952558

Keywords: preterm infants, enteral nutrition, necrotizing enterocolitis, bronchopulmonary dysplasia, neonatology, low- and middle-income countries, Clinical, outcomes, preterm, infants, under, weeks