25 TH

ANNIVERSARY
FEBRUARY 2025
Vol. 26 No. 2
www.neoreviews.org

ARTICLES
Decoding Hearts: Genetic Insights and
Clinical Strategies in Congenital
Heart Disease

Effects of Assisted Reproductive

Technology on Genetics, Obstetrics,
and Neonatal Outcomes

Applications of Metabolomics and

Lipidomics in the Neonatal Intensive
Care Unit

MATERNAL-FETAL CASE STUDIES

Managing Fetal Anemia: A Case of
Parvovirus Infection in Pregnancy

VISUAL DIAGNOSIS
A Late Preterm Neonate With a Small Chest

OUTCOMES OF NICU GRADUATES

Preterm Infants With Bronchopulmonary
Dysplasia and Pulmonary Hypertension

NeoReviews® and NeoReviewsPlus™ are supported,

on, a proud supporter of the American Academy

of Pediatrics.
 NeoReviews
ARTICLES Editor-in-Chief: Dara Brodsky, Boston, MA
Associate Editor, IOS Cases: Elizabeth Schulz, Bethesda, MD
e73 Decoding Hearts: Genetic Insights and Clinical Strategies in Associate Editor, IOS Cases: Jayasree Nair, New York, NY
Associate Editor, CME: Santina A. Zanelli, Charlottesville, VA
Congenital Heart Disease Associate Editor, NeoQuest: Rita Dadiz, Rochester, NY
Christopher M. Stark, Brian N. Hughes, John Paul Schacht, Theresa M. Urbina Associate Editor, Perspectives: Mamta Fuloria, Bronx, NY
Associate Editor, Maternal-Fetal Medicine: Brett Young, Boston, MA
Associate Editor, Video Corner: Akshaya Vachharajani, Columbia, MO
e89 Effects of Assisted Reproductive Technology on Genetics, Assistant Editor, CME: Theodore De Beritto, Los Angeles, CA
Obstetrics, and Neonatal Outcomes Associate Editor, Complex Fetal Care:
Carl Backes, Columbus, OH
Lateia Taylor, Alexis Hood, Francesca Mancuso, Sofia Horan, Zachary Walker
EDITORIAL BOARD
Jane E. Brumbaugh, Rochester, MN
e100 Applications of Metabolomics and Lipidomics in the Anisha Bhatia, Canton, OH
Neonatal Intensive Care Unit Colby Day, Jacksonville, FL
Jennifer Hanford, Columbia, MO
Jonathan D. Reiss, Samson J. Mataraso, Lindsay F. Holzapfel, Ivana Marić, Alison Chu, Los Angeles, CA
Maya M. Kasowski, Camilia R. Martin, Jonathan Z. Long, David K. Stevenson, Corinne L. Leach, Buffalo, NY
Krithika Lingappan, Houston, TX
Gary M. Shaw, on behalf of the Stanford Metabolic Health Center Sai Mukthapuram, Cincinnati, OH
Zeynep Salih, Carmel, IN
Thomas E. Wiswell, Honolulu, HI
Clyde Wright, Aurora, CO
INDEX OF SUSPICION IN THE NURSERY
Manager, Journal Publishing: Josh Sinason
e115 Multicystic Lobar Lung Lesion in a Preterm Neonate Publisher: American Academy of Pediatrics
Sarah E Diamond, Sarah Perez, Vikramaditya Dumpa, Sateesh Jayappa, President: Susan J. Kressly
Chief Executive Officer/Executive Vice President: Mark Del Monte
Laura Gonzalez, Evgeniya Pasternak, Sidney Melvin Dassinger, Vice President, Publishing: Mark Grimes
Indirapriya Avulakunta Director, Journal Publishing: Joseph Puskarz
NeoReviews™
e119 Term Infant With Apnea and Seizure-Like Activity (ISSN 1526-9906) is owned and controlled by the American Academy of Pediatrics. It is
published monthly by the American Academy of Pediatrics, 345 Park Blvd., Itasca, IL
Ina A. Lee, Erin Von Klein, Laura Petrauskas, Gabriella L. Crane, Kevin Louie, 60143. Statements and opinions expressed in NeoReviews™ are those of the authors and
Lyndy Wilcox not necessarily those of the American Academy of Pediatrics or its Committees.
Recommendations included in this publication do not indicate an exclusive course of
treatment or serve as a standard of medical care. Subscription price for NeoReviews™ for
2025: AAP/CPS Member, $160; AAP In-Training/National Affiliate Member, $145;
Nonmember, $199; Nonmember In-Training / Allied Health, $125; AAP Perinatal Section
MATERNAL-FETAL CASE STUDIES Member, $145. Institutions call for pricing (866-843-2271).
© AMERICAN ACADEMY OF PEDIATRICS, 2025. All rights reserved. Printed in USA. No part
may be duplicated or reproduced without permission of the American Academy of
e123 Managing Fetal Anemia: A Case of Parvovirus Infection Pediatrics.
in Pregnancy POSTMASTER: Send address changes to NEOREVIEWS™, American Academy of
Pediatrics, Member and Customer Care, 345 Park Blvd., Itasca, IL 60143.
Rodolfo Fernandez Criado, Stephanie Ros Saposnik
CME/MOC Information:
The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for
physicians.
VISUAL DIAGNOSIS The AAP designates this journal-based CME activity for a maximum of 24.0 AMA PRA
Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the
e127 A Late Preterm Neonate With a Small Chest extent of their participation in the activity.
Abhilasha Gupta, Prashanth Ranya Raghavendra, Sruthi Nair, In order to earn CME credits and/or ABP MOC Part 2 points, you must participate in this
activity online at www.neoreviews.org, where you will view additional information,
Anitha Haribalakrishna complete your CME quizzes, and claim credit online.
The American Academy of Pediatrics is committed to principles of equity, diversity, and
inclusion in its publishing program.

OUTCOMES OF NICU GRADUATES facebook.com/neoreviews

e132 Preterm Infants With Bronchopulmonary Dysplasia twitter.com/AAPJournals

and Pulmonary Hypertension
Kathryn Hasselfeld, Erik Hysinger, Melissa House

Answer Key appears on page e140.

 ARTICLE

Decoding Hearts: Genetic Insights

and Clinical Strategies in Congenital
Heart Disease
Christopher M. Stark, MD, MHS,1 Brian N. Hughes, DO,2 John Paul Schacht, DO,1 Theresa M. Urbina, DO3

EDUCATION GAPS

A genetic etiology of structural congenital heart disease (CHD) can be iden-

tified in 20% to 30% of cases. However, only half of newborns with CHD are
tested for a genetic condition. Clinicians should be aware of prenatal and
postnatal diagnostic approaches and recommendations for genetic testing
in fetuses/neonates with CHD and how these recommendations vary in
cases of isolated and syndromic CHD.

OBJECTIVES After completing this article, readers should be able to:

1. Describe the genetic mediators and signal pathways implicated in

cardiac embryology.
2. Be able to classify the etiology of a patient’s congenital heart disease
(CHD) as syndromic or isolated.
3. Identify the implicated genetic mediators of CHD for common
syndromes.
4. Recognize the common syndromes associated with structural CHD and
their extracardiac manifestations.
5. Explain the role of genetic prenatal and postnatal genetic testing in this
population.

ABSTRACT
Structural congenital heart disease (CHD) represents a heterogeneous
group of cardiac anomalies of variable embryologic and molecular origins.
A basic understanding of the genetics implicated in nonsyndromic (isolated)

1
AUTHOR DISCLOSURE: Dr Urbina has traveled with the support of the AAP as part of the TECaN Department of Pediatrics, Walter Reed
exectuive committee. Drs Stark, Hughes, and Schacht have disclosed no financial relationships National Military Medical Center, Bethesda,
relevant to this article. This article does not contain a discussion of an unapproved/investigative Maryland; 2Department of Pediatrics,
use of a commercial product/device. This work was prepared as part of the official duties of the Uniformed Services University of the Health
authors who are employed by the US Army, US Air Force, and US Department of Defense. The Sciences, Bethesda, Maryland; and
3
views expressed in this article are those of the authors and do not reflect the official policy or Department of Pediatrics, Madigan Army
position of the US Army, US Air Force, US Department of Defense, or US government. Medical Center, Tacoma, Washington
Accepted for Publication Date: October 2, 2024
https://doi.org/10.1542/neo.26-2-010
Copyright © 2025 American Academy of Pediatrics

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e73

 and syndromic structural CHD can better inform management decisions and family counseling. When a fetus or neo-
nate develops CHD as a result of a genetic cause, it can be due to a mutation or a monogenic, oligogenic, or polygenic
pathogenic variant. In this review, we summarize basic cardiac embryology in the context of genetic signaling path-
ways and proteins that are commonly implicated in syndromic and nonsyndromic structural CHD. We also provide an
overview of the basic genetic evaluation in infants with common syndromic structural CHD.

INTRODUCTION the basic genetic evaluation in infants with common syn-

Structural congenital heart disease (CHD) affects approxi- dromic structural CHD. The genetics of congenital cardiac
mately 1% of all live births and is the most common birth conduction anomalies and primary cardiomyopathies are
defect in human infants. CHD occurs as a result of disrup- well-described elsewhere and will not be covered in this
tions in normal cardiac development causing malformations review.11–14
of the heart, the great arteries, or the pulmonary veins.1 These
malformations can occur in isolation or in combination with EMBRYOLOGY
other cardiac and noncardiac malformations. Medical teams The formation of the human heart is a complex embryologi-
must tailor their management strategies to the patient’s clini- cal process that starts during the third week of gestation
cal phenotype, taking a distinct approach for fetuses/neo- with differentiation of the embryonic germ layers (ecto-
nates with extracardiac comorbidities compared with those derm, endoderm, and mesoderm) and ends with the folding
with isolated CHD.2 and division of the primitive heart tube to form the fetal
Nearly 50% to 60% of patients born with structural CHD heart. The study of animal embryos has significantly
are diagnosed in utero because of improvements in fetal enhanced the understanding of the intricate pathways
imaging techniques and more detailed fetal screening of responsible for cardiac morphogenesis because the genetic
the heart because of the recommendation by The American pathways involved are largely conserved across species. The
College of Obstetricians and Gynecologists to include a interplay between genetic signaling pathways, transcription
4-chamber cardiac view with outflow tracts and a 3-vessel factors, cell migration and differentiation, programmed cell
view.3–5 Rapid advancements and expanded availability of apoptosis, and fetal blood flow leaves the heart uniquely vul-
molecular genetic testing over the past decade have increased nerable to errors during development. Splanchnic meso-
identification of single and multigenic changes linked to derm cells differentiate into the primitive heart tube, the
structural heart defects.6 Epidemiological studies have found primary heart field, and an adjacent pool of cardiogenic cells
that 20% to 30% of patients with CHD have an identifiable called the secondary heart field.15 Driven by molecular sig-
genetic cause, with the most common causes being chromo- naling pathways and transcription factors, the primary and
somal anomalies (8%–10%), pathogenic copy number secondary heart fields each contribute cells to the develop-
variants (3%–25%), and monogenic pathogenic variants ing heart at discrete time points and at specific locations
(PVs) (8%).6 throughout morphogenesis.15
The overall infant mortality due to CHD has drastically During lateral folding of the embryo, the splanchnic mes-
decreased over the past 50 years because of advancements oderm of the primary heart field fuses together to form the
in surgical techniques and approaches.7,8 As survival primary heart tube around day 20 of gestation.15 Under the
improves in this patient population, defining the genetic control of numerous signaling and transcriptional cascades,
etiology of a patient’s structural CHD is increasingly more the heart tube elongates via the addition of cardiomyocytes
relevant and carries clinical implications for the patient, from the undifferentiated progenitor cells of the secondary
their future siblings, and even their future children. The heart field.15 These cells join the primitive heart tube, leading
comorbidities and neurodevelopmental differences associ- to the creation of the atria, right ventricle, and outflow tracts.
ated with CHD will impact these patients as they progress Following elongation, heart tube looping occurs as the primi-
through childhood and onward to adulthood.9,10 tive ventricle bulges ventrally and moves rightward, whereas
In this review, we summarize basic cardiac embryology the primitive atrium bulges dorsally and to the right and left
in the context of genetic signaling pathways and proteins of the evolving outflow tract (Figure 1).15 As cardiac looping
that are commonly implicated in syndromic and nonsyn- of the heart tube occurs, many complex events take place
dromic structural CHD. We also provide an overview of to divide the heart tube into 4 chambers with distinct

e74 NeoReviews
FIGURE 1. View from the ventral side of the embryonic heart during the rotation and folding of the primitive heart tube.

circulations. Table 1 provides a brief summary of select Nonsyndromic CHD

events that occur during normal cardiac development and Monogenic PVs often exhibit distinct cardiac phenotypes
the involved molecular regulators. ranging from septal defects to abnormalities in cardiac cham-
Many of the events detailed in Table 1 occur concurrently ber development.20 Monogenic (single-gene), oligogenic
over the span of about 5 weeks’ gestation as cardiac looping is (involving 3 or more gene loci), or polygenic (involving many
complete at the end of the eighth week of development as the gene loci) PVs have been associated with many CHDs.
embryo transitions into a fetus. Developmental diversions Although a genetic etiology can be identified in 20% to 30%
during the embryonic period due to errors in signaling path- of patients with CHD, epigenetics and environmental expo-
ways, expression or repression of key transcription factors, or sures are thought to play a key role as well.6,15,19,21 Addi-
cell migration can lead to various cardiac defects. The tional risk factors for CHD may include exposures in the
embryologic origins of structural CHD have been previously pregnant person (eg, valproic acid, retinoic acid), congenital
described in detail, and a more in-depth review of abnormal infections (eg, rubella), obesity in the pregnant person, and
cardiac embryology is outside of the scope of this review.16 gestational diabetes (hyperglycemia).22–24 Importantly,
approximately 50% of CHD cases have no identifiable cause.25
PVs may disrupt the crucial signaling pathways that gov-
CLINICAL MANIFESTATIONS ern myocardial patterning, chamber septation, and vascular
Although the majority of CHD cases are sporadic, CHD with morphogenesis, which can ultimately lead to disruptions in
an identifiable genetic cause can be broadly categorized as syn- CHD embryogenesis.6 Current estimates suggest that there
dromic or nonsyndromic. Genetic changes may be inherited are several hundred single-gene PVs associated with clini-
in a Mendelian pattern, which is based on single-gene traits, cally significant structural CHD.21 Monogenic PVs have
or a non-Mendelian pattern, which is multifactorial and been implicated in the disruption of native sarcomeric
may involve multiple genes and environmental influences. development, chromatin remodeling, transcription factor
Patients with syndromic CHD typically have extracardiac man- regulation, ciliary defects, or other molecular and cellular
ifestations and neurodevelopmental differences (ranging dysfunction.26 Although an exhaustive list of single-gene
from mild cognitive or processing difficulties to autism spec- and multigenic PVs is too extensive for this review,
trum disorder, intellectual disabilities, and global develop- Table 2 includes several commonly implicated PVs in iso-
mental delays). Syndromic CHD is often due to autosomal lated CHD. These PVs disrupt cardiac embryologic develop-
recessive PVs, de novo monogenic PVs, or chromosomal ment, resulting in phenotypic variance depending on
anomalies.17–19 Nonsyndromic CHD, on the other hand, is penetrance and expressivity. Genetic testing may be com-
thought to be multifactorial due to the interactions of multiple pleted prenatally or postnatally and consists of multiple
genes and the environment.19 modalities, including chromosome analysis, microarray

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e75

 TABLE 1. Key Signaling Pathways and Transcription Factors in the Embryologic Development of the Heart
Key Signaling Pathways Transcription Factor Genes Cell Origins
a a
Primary heart field FGF, BMP, TGF-β-Nodal, TBX5, MESP1, GATA4, NKX2–5, Embryonoic cardiac regions and
Wnt, Shh MEF2c, ISL1, HAND1, HAND2 derived structures
Secondary heart field FGF, Notch, Retinoic acid,a MEC2c, ISL1, FOXH1, TBX20,
Nodal, Shh GATA4, NKX2–5, TBX1a
Ventriclesb
Right ventricle HAND2, MEC2c Secondary heart field
Left ventricle HAND1,27 TBX2, TBX5,a TBX18 Primary heart field
Interventricular septum TBX18
Venous pole
Atriac Wnt IRX4, GATA6, PITX2c Primary and secondary
(sinus venosus, pulmonary
vein, septal and nonseptal
myocardium) heart fields
Caval veins
Pulmonary veinsd NKX2–5,a ISL1
Atrioventricular (endocardial)e
Valves ErbB (1–4), EGF NFATC Endocardial cushion
Cushion BMP2, TGF-β, Notch,a FGF, TBX2, TBX3, TBX5, GATA5, Endocardial cells lining
EGF, Wnt, Hedgehog, VEGF NKX2–5,a MSX2, TBX20, the atrioventricular canal
SOX9, ISL1
Arterial polef
Aorta and pulmonary HAND28 ISL1, NKX2–5, AP2α Neural crest cells, secondary
arteries heart field
Semilunar valvesg a
EGF, ErbB1, RAS-Erk, calcineurin,
VEGF, Notch
Right and left ventricular Wnt, FGF8/10, BMP, retinoic PAX3, AP2α, HOXa, FOXc1, Neural crest cells
and outlet tracts acid,a Shh FOXc2, SOX, SLUG, TBX1,a ISL1

Abbreviations: BMP, bone morphogenetic protein; EGF, epidermal growth factor; ErbB, erythroblastosis oncogene B; FGF, fibroblast growth factor;
Shh, sonic hedgehog; TGF-β, transforming growth factor β; VEGF, vascular endothelial growth factor; Wnt, wingless-related integration site.
This table was adapted from Sizarov et al.
a
Gene is associated with a known genetic syndrome/defect discussed in the body of this article.
b
The wall bordering the connection between the trabeculated portions of the primitive right and left ventricles becomes the crest of the ventricular
septum, which grows via cell proliferation to divide the inferior portions of the ventricles. The space above the growing muscular septum is
remodeled to become the subaortic outlet to the aorta and the right ventricular inlet.
c
The thin primary atrial septum grows toward the endocardial cushions to divide the common atrium into 2 distinct sides with a patent foramen (or
opening) at the superior edge to allow continued connection between the 2 chambers. The larger secondary atrial septum that completes the
septum comes from a fold of the right atrial wall rather than a separate and discrete structure.
d
The wall of the main pulmonary venous stem is absorbed into the roof of the left atrium, leaving each pulmonary vein opening in the 4 corners of
the left atrium.
e
To separate the atria and the ventricles, 2 mesenchymal cushion pairs (1 superior/inferior and 1 lateral) form and enlarge to create the valve
primordia. The endocardial cushions eventually fuse with the ridges of the proximal left ventricular outflow tract and right ventricular inlet,
becoming the membranous portion of the ventricular septum. The centrally located atrioventricular cushion eventually fuses with the atrial
septal mesenchymal cap.
f
Cardiac neural crest cells migrate into the pharyngeal arches and into the outflow tracts and are responsible for the formation and septation of the
great arteries. A pair of cushions are formed at the proximal part of the outflow tract, and cell migration and replication eventually cause these
cushions to fuse and separate the 2 spiraling outflow tracts of the aorta and pulmonary artery.
g
Fetal hemodynamics and blood flow are important for the continued development of the fetal heart.

analysis, single-gene testing, multigene panels, and whole abnormalities), copy number variants (duplications or
exome or genome sequencing (Table 3). The role of prenatal deletions), and monogenic PVs. These genetic changes often
and postnatal testing will be discussed later in this review. arise de novo, although some forms can be inherited.
Although a detailed review of every syndrome associated with
Syndromic CHD CHD is beyond the scope of this review, the bedside clinician
The noncardiac phenotypic features in an infant with syn- should have a basic understanding of those commonly seen
dromic CHD pose unique diagnostic and management chal- in practice (Table 4).
lenges due to the resulting clinical comorbidities. The
associated syndromes are characterized by diverse pheno- Aneuploidies
typic expressions necessitating a comprehensive approach Down syndrome (ie, trisomy 21) is the leading cause of syn-
to evaluation and clinical care. dromic CHD. Common cardiac defects seen in Down syn-
Syndromic CHD can be due to chromosomal abnormal- drome include atrial septal defects (ASDs), ventricular
ities (whole-chromosome aneuploidies and structural septal defects (VSDs), or atrioventricular canal defects.19

e76 NeoReviews
TABLE 2. Select Monogenic Pathogenic Variants Associated With Cardiovascular Malformations
Possible Cardiovascular
Gene Phenotype(s) Role(s)
Transcription factors
GATA4 ASD, VSD, AVSD, PVS, TOF Regulation of genes involved in embryogenesis and myocardial
differentiation92,93
NR2F2 AVSD, AS, CoA, VSD, HLHS, TOF Controls arteriovenous differentiation by regulating cell cycle94,95
NKX2–5 ASD, TOF, HLHS, TGA Regulates heart field development and cardiomyocyte differentiation96,97
Cell signaling and adhesion proteins
ACVR1 AVSD Endocardial-to-mesenchymal transformation and arterial pole
morphogenesis98
PDGFRA TAPVR Mediates differentiation, migration, and function of mesenchymal cells99,100
SMAD6 BAV, CoA, AS Regulates bone morphogenetic protein and transforming growth factor-β
signaling pathways101,102
Structural proteins
DCHS1 MVP Cadherin acting in the regulation of cell migration involved in valve
formation103
MYH7 Ebstein anomaly, LVNC Encodes myosin heavy-chain involved in cardiac muscle development
and contractility104,105
MYH11 PDA Encodes myosin heavy-chain involved in cardiac muscle development
and contractility106
Ciliary components
NEK2 Heterotaxy Regulates centrosome separation107
EVC2 AVSD Hedgehog signaling108

Abbreviations: AS, aortic valve stenosis; ASD, atrial septal defect; AVSD, atrioventricular septal defect; BAV, bicuspid aortic valve; CoA, coarctation of
the aorta; HLHS, hypoplastic left heart syndrome; LVNC, left ventricular noncompaction cardiomyopathy; MVP, mitral valve prolapse; PDA, patent
ductus arteriosus; PVS, pulmonary valve stenosis; TAPVR, total anomalous pulmonary vascular return; TGA, transposition of the great arteries;
TOF, tetralogy of Fallot; VSD, ventricular septal defect.

TABLE 3. Overview of Commonly Used Genetic Tests

Test Primary Uses Considerations
Chromosomal analysis Major numerical or structural Best test if there is a high suspicion for aneuploidy
chromosomal changes
Fluorescence in situ Aneuploidies or copy number Rapid results
hybridization variants Ideal when clinical suspicion for a specific aneuploidy or copy number
variant is high, eg: trisomy 13, 22q11.2 deletion syndrome
Largely replaced by chromosomal microarray
Chromosomal microarray Copy number changes May detect variants of uncertain significance
(deletions/duplications) May detect pathogenic variants that are unrelated to the infant’s
presentation (incidental findings)
Cannot detect balanced translocations or inversions (balanced
rearrangements)
Targeted gene sequencing Monogenic variants Typically used when there is a high suspicion for 1 particular diagnosis
May detect variants of uncertain significance
Next generation sequencing Single nucleotide variants May detect variants of uncertain significance and incidental findings
Whole exome sequencing Copy number changes Costly
Whole genome sequencing

Information in this table was adapted from Rosen et al74 and Gilner et al.81

Common extracardiac manifestations include characteristic Wnt, and bone morphogenetic protein (BMP) signaling
facial features, poor growth, hypotonia, pulmonary hyperten- pathways.31
sion, and neurodevelopmental differences.29,30 Most cases Nearly 45% to 95% of infants born with Edwards syn-
of Down syndrome, as well as Edwards syndrome and drome (ie, trisomy 18) will have some form of structural
Patau syndrome, are due to errors in maternal meiosis, with CHD along with typical dysmorphic features.32 Common
a small subset attributed to balanced Robertsonian transloca- structural abnormalities seen in Edwards syndrome include
tion. There are many genes involved in cardiac development VSD, patent ductus arteriosus (PDA), or ASD. Many genes
that are implicated in Down syndrome, including GATA4, are implicated in the development of cardiac anomalies in
CHD7, and other genes that are involved in the Notch, Edwards syndrome including downregulation of some in

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e77

 TABLE 4. Common Syndromes Associated With Structural Congenital Heart Disease With Their Classic Extracardiac Findings and Common Heart Defects
Highlighted
Classic Extracardiac Features

e78 NeoReviews
Syndrome Renal MSK GU CNS FD Eye ENT GI Endo NDD Genetic Testinga
1q21.1109 + + + + CMA
Alagille + + + + + + + Targeted, CMA
Cardiofaciocutaneous syndrome110 + + + + + + + CMA
CHARGE syndrome + + + + + + Targeted, CMA
Char syndrome111 + + Targeted (TFAP2), CMA
Cornelia de Langeb + + + + Targeted, CMA
Costello syndrome112,113 + + + + Targeted (HRAS), CMA
Del1p36114 + + + + + CMA
Del8p23c + + + + + CMA
Del11q24–25 (Jacobsen syndrome)d + + + + CMA
Del15q11.2115 + + + CMA
DiGeorgee + + + + + + + Targeted, CMA > FISH
Holt-Oram + Targeted, CMA
Kabuki syndrome116 + + + Targeted (KMT2D, KDM6A), CMA
Noonan syndrome + + + + Targeted, CMA
Rubinstein Taybi117 + + + + + Targeted (CREBBP, EP300), CMA
Sotos syndromef + + + + + Targeted (NSD1), CMA
Trisomy 9118 + + + + + Karyotype, CMA
Turner syndrome + + + + + Karyotype, CMA
Patau syndrome + + + + + + + Karyotype, CMA
Edwards syndrome + + + + Karyotype, CMA
Down syndrome + + + + + + Karyotype, CMA
Williams syndrome + + + CMA
Wolf-Hirschhorn syndrome + + + + + + Karyotype, CMA
Right-sided obstructive lesions Left-sided obstructive lesions Conotruncal anomalies Mixing lesions Other cardiac defects
ToF - Trisomy 9, Patau, Edwards, DS, Bicuspid aortic valve - Turner, DS DORV - Wolf-Hirschhorn, AV canal defect - DS, Del3p25.1, Del8p23 PDA - Trisomy 9, Patau, Edward,
Wolf-Hirschhorn, DiGeorge, Del1p36, HLHS - Turner, Del11q24–25 DiGeorge, 1q21.1 ASD or VSD – 1q21.1, CHARGE, Cornelia de Del1p36, Sotos, Holt-Oram,
Del15q11.2, Cornelia de Lange, AS - Williams, Rubinstein Taybi TGA - DiGeorge, 1q21.1 Lange, DiGeorge, DS, Del8p23, Del1p36, Cornelia de Lange, Rubinstein-
Alagille, CHARGE CoA - Turner, DS, Del1p36 ToF - See right-sided Del3p25.1, Del15q11.2, Edward, Holt-Oram, Taybi, Char, CHARGE
Pulmonic atresia IAA - 22q11 obstructive lesions Jacobsen, Noonan, Patau, Rubinstein TAPVR - Del15q11.2
Wolf-Hirschhorn, Del15q11.2 Taybi, Trisomy 9, Turner, Sotos, William, PAPVR – Turner
Pulmonic stenosis Wolf-Hirschhorn Valvular anomalies - Del1p36,
William (branch), Del8p23, Noonan, Cornelia de Lange,
Alagille, Rubinstein Taybi Cardiofaciocutaneous

Abbreviations: AS, aortic stenosis; ASD, atrial septal defect; AV, atrioventricular; CHARGE, coloboma, heart defects, atresia of the choanae, retarded growth, genital anomalies, ear malformations; CMA,
chromosomal microarray; CNS, central nervous system; CoA, coarctation of the aorta; NDD, neurodevelopmental differences; DORV, double-outlet right ventricle; DS, Down syndrome; ENT, ear, nose, and
throat; Endo, endocrine; Eye, ophthalmologic anomalies; FD, facial dysmorphisms; FISH, fluorescence in situ hybridization; GI, gastrointestinal; GU, genitourinary; HLHS, hypoplastic left heart syndrome;
IAA, interrupted aortic arch; MSK, musculoskeletal; PAPVR, partial anomalous pulmonary venous return; PDA, patent ductus arteriosus; TAPVR, total anomalous pulmonary venous return; TGA,
transposition of the great arteries; ToF, tetralogy of Fallot; VSD, ventricular septal defect; WES, whole exome sequencing.
a
Targeted gene panels available; nonchromosomal syndromes listed can also be diagnosed via next-generation sequencing techniques.
b
More than 90% of patients have dentition anomalies.
c
Congenital diaphragmatic hernia.42
d
Including bone marrow failure.119
e
Including immune deficiency.
f
Classic triad includes characteristic facial features, intellectual disability, and overgrowth.120
the T-box family (TBX1 and TBX4) and inhibitors of the BMP neurodevelopmental differences, and connective tissue and
signaling pathway (NOG).19 endocrine abnormalities. Williams syndrome is most often
Patau syndrome (ie, trisomy 13) is associated with major caused by a de novo deletion but can also be inherited in
anomalies of multiple organ systems, and most liveborn an autosomal dominant fashion.42 The supravalvular aortic
infants die in the first year after birth.33 The majority of stenosis found in affected patients is typically progressive
patients with Patau syndrome are born with a structural and related to an elastin arteriopathy caused by ELN
CHD, with ASD, PDA, and VSD being the most common. deletion.43
Patients with Patau syndrome have shown gain-of-function Deletions in 8p23.1, causing haploinsufficiency in GATA4
PVs in FOXO1 and other genes that have transcriptional and SOX7, are characterized by structural CHD and congeni-
functions in cardiac development.19 tal diaphragmatic hernia.44 PVs in GATA4 have been linked
Turner syndrome (ie, monosomy X) is associated with to ASDs (most commonly), VSDs, and tetralogy of Fallot, and
structural CHD, dysmorphic features, short stature, renal they are more likely due to the role of GATA4 in the primary
and skeletal anomalies, and neurodevelopmental and behav- heart field, the early structure that gives rise to much of the
ioral differences. The CHDs in patients with Turner syn- heart’s left ventricle and atria during embryogenesis.44 SOX7
drome are typically left-sided obstructive heart lesions such is thought to lie upstream of GATA4 in the regulatory signal-
as coarctation of the aorta, bicuspid aortic valve, and others ing pathway, as haploinsufficiency of SOX7 is presumed to
and are associated with haploinsufficiency of the SHOX result in more severe cardiac phenotypes in patients with
(short-stature homeobox) gene, which is involved in pharyn- GATA4 deletions (eg, hypoplastic left heart syndrome and
geal arch development.34,35 Female patients with a diagnosis pulmonary valve stenosis).44
of a bicuspid aortic valve or left-sided obstructive lesions Coloboma, heart defects, atresia of the choanae, retarded
should undergo a genetic evaluation for Turner syndrome.36 growth, genital anomalies, ear malformations (CHARGE)
syndrome is an inherited disorder characterized by colo-
Deletions/Duplications boma, heart defects, atresia of the choanae, retarded growth,
DiGeorge syndrome, or velocardio-facial syndrome, is due to genital anomalies, and ear malformations due to PVs in the
a loss of DNA in chromosome 22q11, which can affect either CHD7 gene.45 These PVs frequently arise de novo but can
TBX1 or CRKL.37 TBX1 is expressed in the outflow tracts of occasionally be inherited in an autosomal dominant man-
the heart and regulates patterning of the inflow-outflow poles ner.45 The cardiac phenotype in CHARGE syndrome varies
because of its role in neural crest cell migration, whereas widely, with defects ranging from ASDs and PDAs to more
CRKL serves as a modulator of TBX1. Mouse models have severe conotruncal anomalies such as tetralogy of Fallot.46
demonstrated that the balance between TBX1 function and CHD7 plays a critical role in neural crest cell development,
retinoic acid signaling is vital for normal pharyngeal and con- contributing to the multiple anomalies observed in
otruncal development.38 Given that genetic errors in these CHARGE syndrome, and the location of PVs in different
pathways affect neural crest cell migration and pharyngeal functional domains of CHD7 leads to distinct cardiac man-
arch development, DiGeorge syndrome is characterized by ifestations, emphasizing the genotype-phenotype correlation
conotruncal anomalies and extracardiac manifestations within this syndrome. Clinical overlap exists between
related to pharyngeal arch maldevelopment (hypocalcemia, CHARGE, DiGeorge, and Kabuki syndromes due to shared
thymic aplasia, and cleft lip or palate).39 genetic pathways and interactions between their implicated
PVs in another T-box gene, TBX5, are implicated in the genes. For instance, 2 genes associated with DiGeorge syn-
clinical features of Holt-Oram syndrome characterized by drome, CHD7 and TBX1, are mediated through effects on
CHD and upper-limb anomalies.40 TBX5 plays an important p53. Similarly, Kabuki syndrome results from PVs in genes
role in atrial septation and endocardial cushion formation (in involved in chromatin remodeling pathways that overlap
combination with GATA4 and NKX2–5); thus, PVs have been with those affected by CHD7, highlighting why some syn-
associated with ASDs and VSDs in this group of patients. dromes share phenotypic similarities.46
Although most PVs in Holt-Oram syndrome arise de novo,
they can also be familial with an autosomal dominant inher- Single-gene Variants
itance pattern with complete penetrance but variable Cornelia de Lange syndrome is most often due to de novo
expressivity.40,41 PVs in 1 of 3 cohesin-associated genes (NIPBL, SMC1L1,
Williams syndrome, which is due to a deletion of and SMC3). It is characterized by distinctive facial features,
the Williams-Beuren critical region on chromosome growth restriction, and hypertrichosis and is often associated
7q11.23, is characterized by supravalvular aortic stenosis, with structural CHD.47 The cardiac anomalies most often

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e79

 seen in Cornelia de Lange syndrome are pulmonic stenosis, PRENATAL DIAGNOSIS AND MANAGEMENT
VSD, and ASD and may be due to decreased expression of Structural CHD is often first diagnosed at a routine prenatal
NKX2–5 and MESP1 as a result of PVs in the NIPBL ultrasonogram anatomy evaluation. When a suspected cardiac
gene.48,49 anomaly is identified, further imaging with a detailed transabdo-
Many genes have been implicated in the development of minal fetal echocardiogram is recommended, optimally
Noonan syndrome, which is characterized by dysmorphic between 18 to 22 weeks’ gestation.5 In some cohorts, prenatal
facies, short stature, structural CHD, and neurodevelopmental echocardiography identified nearly 60% of severe structural
differences. Pulmonic stenosis (strongly associated with PVs in CHD, although its sensitivity and specificity vary depending
PTPN11) is most common, but patients may also present with
on the gestational age of testing.59 If CHD is suspected, a detailed
tetralogy of Fallot, ASDs, or VSDs. Many genes have been
anatomical survey must be completed to identify the presence of
implicated in Noonan syndrome and are inherited in an auto-
extracardiac congenital anomalies. Results from a complete fetal
somal dominant fashion, although a minority of patients have
ultrasonogram and detailed family history identifying first- or
de novo PVs.50 Noonan is one of many RASopathies (including
second-degree relatives with a history of CHD can help genetic
Costello syndrome, cardiofaciocutaneous syndrome, and
specialists target recommendations for genetic testing.
Noonan syndrome with multiple lentigines) that show shared
Unfortunately, not all patients with structural CHD will be
disruption in the Ras/mitogen-activated protein kinase signal
identified in the prenatal period because of multiple factors.
transduction pathway responsible for valvular morphogene-
Hemodynamics and blood flow play an important role in
sis.51 In contrast to moderate and severe pulmonic stenosis
heart development, and a routine prenatal anatomy evalu-
in Noonan syndrome, milder versions tend to be nonprogres-
ation may miss cardiac defects that worsen as the fetus grows
sive and often will not require intervention.52
(ie, severe valvular stenosis). In addition, pulmonary vascular
Single-gene PVs in JAG1 and NOTCH2 are implicated in
abnormalities are often not identified in the prenatal period
the CHD seen in Alagille syndrome.53 Alagille syndrome is
because of limited pulmonary blood flow in utero. Advances
characterized by cholestasis due to a paucity of liver bile
in imaging technology, including the use of fetal cardiac
ducts, butterfly vertebrae, posterior embryotoxon, and struc-
magnetic resonance imaging, may soon be more widely
tural CHD.54 Although peripheral pulmonary artery stenosis
is the most common CHD described in Alagille syndrome, adopted to augment fetal echocardiogram and increase rates
affecting about two-thirds of patients, other cardiac defects of prenatal detection of CHD.60
such as tetralogy of Fallot and left-sided obstructive lesions Although an anatomy scan and fetal echocardiography are
have also been described.55 NOTCH2 is involved in cardio- the best available tests for prenatal CHD screening, they cannot
myocyte differentiation into ventricular-like cardiomyocytes definitively differentiate between nonsyndromic and syn-
and has been implicated in patients with hypoplastic left dromic diagnoses. Prenatal genetic testing, fetal ultrasono-
heart and other outflow tract anomalies.56 In patients with gram findings, and serum biomarker screening in the
Alagille syndrome, defects in the Notch signaling pathway pregnant person are standard components of prenatal obstet-
lead to disruptions in neural crest cell migration to the sixth ric care. Like prenatal echocardiography, prenatal genetic test-
aortic arch during embryonic development, which contribute ing has limitations based on the type of test completed.
to the pulmonary vasculature.57 PVs in JAG1 have also been Cell-free fetal DNA (cffDNA) testing detects the presence
implicated in families with multiple generations of periph- of fetal DNA shed by placental trophoblasts into the blood
eral pulmonic stenosis in the absence of liver disease.55 circulation of the pregnant person. This test is performed
JAG1 plays a critical role in the Notch signaling pathway on the pregnant patient’s blood sample obtained at 9 to 10
and is essential for proper development of the heart’s outflow weeks of gestational age to ensure detection of fetal cells
tract and valve formation. Mutations in JAG1 can lead to a in the circulation of the pregnant person. cffDNA testing
range of CHD phenotypes, including pulmonic stenosis, is limited in scope because of the relative instability of fetal
tetralogy of Fallot, and VSDs.58 DNA.61,62 Aneuploidy (eg, trisomies 13, 18, 21) is the earliest
The syndromes described in this section underscore the identifiable genetic cause of CHD detected by cffDNA and
connection between genetic aberrations and the resulting has a greater than 99% negative predictive value depending
disruptions in the molecular regulators of cardiac morpho- on risk stratification in the pregnant person.63
genesis. Advances in genetic testing have allowed for the If high suspicion exists for syndromic CHD, then more
identification of specific genetic variations linked to syn- extensive genetic testing should be offered to the family.
dromic CHD, providing valuable insights into the underly- Amniocentesis allows for chromosomal analysis, microarray
ing pathophysiology. evaluation, and monogenic testing (including multigene

e80 NeoReviews
panels and exome sequencing) and is preferably done between family’s emotional readiness, the constraints of diagnostic
15 to 20 weeks’ gestation, although it can also be performed tests, and the availability or restrictions of pregnancy termina-
later for families desiring a prenatal diagnosis.64 Chorionic vil- tion, if desired. The presence of genetic and extracardiac
lus sampling (CVS) allows for chromosomal analysis and anomalies are associated with a greater likelihood to pursue
microarray evaluation of fetal cells. CVS may also be used pregnancy termination.72,73 Families should also be informed
to evaluate for monogenic conditions via gene panels and of the indications, risks, and benefits of additional testing.
exome analysis. CVS is preferably completed before 13 weeks cffDNA testing poses no risk to the developing fetus but is lim-
of gestation and may not be feasible if the diagnosis occurs ited in its diagnostic capabilities, whereas amniocentesis and
during the standard screening ultrasonogram.65 CVS have greater diagnostic capabilities but present a small
risk of fetal injury, miscarriage, or preterm birth.
Family Counseling Effective risk counseling is a crucial aspect of prenatal
If CHD is suspected or identified based on prenatal imaging, care, ensuring families are well-informed about potential
counseling becomes a crucial component to guiding families complications and outcomes related to their pregnancy. All
through the complex perinatal period and decision-making families should receive counseling and support regarding
process. In cases of an isolated and uncomplicated cardiac the risks associated with their pregnancy, including prema-
lesion with no known or suspected family history of CHD, ture delivery, prolonged infant hospitalizations, and any
genetic testing can be deferred and reconsidered after birth anticipated long-term outcomes.74 An accurate, early diagno-
if new concerns arise in the postnatal period. In the setting of sis with evidence-based information regarding the prognosis
a suspected syndrome, prenatal genetic testing may confirm and the expected disease course of a fetus with syndromic
a suspected diagnosis and facilitate risk stratification, which and nonsyndromic structural CHD is important, and clear
allows clinicians to provide more informed counseling to aid documentation is paramount.
in a family’s decision-making regarding their pregnancy.
A prenatal diagnosis of CHD has a significant impact on a
family and the pregnancy. A prenatal diagnosis of CHD is POSTNATAL DIAGNOSIS AND MANAGEMENT
associated with significant familial psychological stress.66 Postnatal transthoracic echocardiography is noninvasive and
Pregnancies affected by fetal CHD have a higher incidence offers real-time assessment of cardiac anatomy and function,
of preterm birth compared with pregnancies unaffected by with a high sensitivity and specificity for diagnosis of struc-
CHD (23% vs 10%, respectively).67,68 Pregnancies affected tural CHD.75 Prenatally diagnosed cardiac lesions should be
by fetal CHD have a higher risk of pregnancy loss (5.3%; confirmed postnatally on a timeline commensurate with the
95% CI, 3.7–7.6) compared with the general population clinical significance of the lesion to allow for a more complete
(0.6%; adjusted relative risk [aRR], 9.0; 95% CI, 6.0–13.0). cardiac evaluation. If prenatally identified cardiac lesions are
Furthermore, 1.4% of pregnancies with isolated (ie, nonsyn- concerning for ductal dependency or physical examination
dromic) fetal CHD resulted in pregnancy loss, with an aRR of findings are concerning for a genetic syndrome, echocardi-
2.0 (95% CI, 1.0–6.0) compared with the general popula- ography should be completed shortly after birth and a genetic
tion.69 Extracardiac anomalies, genetic diagnoses, or valve evaluation, if clinically indicated, should be coordinated
regurgitations identified prenatally further exacerbate this before hospital discharge.
risk.70 In addition, in cases of syndromic or inoperable fetal Understanding differences in nonsyndromic and syn-
CHD (eg, hypoplastic left heart syndrome with nutmeg dromic structural CHD management is crucial to optimizing
lung), some families may elect to pursue pregnancy termina- outcomes. It is appropriate to perform a screening
tion or comfort care following delivery.71 echocardiogram for patients with dysmorphic features or
Because of the potentially complex decisions affected fam- multiple extracardiac anomalies suggestive of an underlying
ilies may face, a multidisciplinary approach is crucial. genetic syndrome. Echocardiography should be performed,
Maternal-fetal medicine specialists, genetic counselors, pedi- even if the prenatal echocardiogram was unremarkable, as
atric cardiologists, and neonatologists should collaborate to not all CHDs can be detected prenatally. In an infant with
provide comprehensive information about the nature of prenatally diagnosed CHD and multiple anomalies present
the suspected condition, potential outcomes, and treatment at birth, an anatomic survey may be considered. Diagnostic
options. Emotional support should be offered to allow fam- studies to consider, depending on the suspected phenotype,
ilies time and space to grieve the loss of previous expectations include a postnatal echocardiogram, ophthalmologic exami-
for their pregnancy. Decisions regarding further testing nation, skeletal survey, and ultrasonographic evaluation of
should be discussed on a timeline that considers both the the abdomen, kidneys, brain, and spine.76 A clinical

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e81

 geneticist or genetic counselor can further guide clinical If a genetic etiology is suspected and confirmatory post-
evaluation depending on the dysmorphisms on examination natal genetic testing is desired, umbilical cord or neonatal
and imaging. Results of anatomic survey and subsequent lab- blood samples should be collected.84 Although laboratory
oratory evaluations assist the selection of high-yield genetic requirements may vary, genetic testing often requires large
tests to improve overall diagnostics and prognosis. quantities of blood, ranging from 1 to 2 mL for each labora-
tory test. Placental blood samples, which contain fetal blood,
Postnatal Genetic Testing should be collected whenever possible: 2 lithium heparin
Recommendations for genetic testing for isolated structural (typically green caps) tubes for chromosome analysis and
CHD vary based on the lesion, clinical course, and family his- microarray and 1 EDTA (typically purple caps, but there is
tory. Routine genetic testing is generally not required for iso- more variation and can be test/laboratory-specific) tube for
lated lesions without a family history suggestive of variability. a multigene panel or microarray.
Some cardiac lesions, such as hypoplastic left heart syndrome, The increased use of exome or genome sequencing as a
are more often associated with a familial history of CHD, tool for identifying causal PVs has led to an increase in the
increasing the pretest probability of an identifiable genetic identification of secondary or incidental findings for pheno-
diagnosis.77 In cases of nonsyndromic CHD with a concern- types or diseases beyond the original intention of the test.85
ing or unknown family history, testing for genetic etiologies The American College of Medical Genetics regularly releases
via a multigene panel or chromosomal microarray is indi- an updated gene list of “medically actionable secondary find-
cated.78 The American College of Medical Genetics maintains ings” and recommends the possibility of sharing this infor-
broad recommendations for genetic testing, including whole mation with the geneticist for subsequent discussion with
exome or whole genome sequencing, in pediatric patients with the family at the time of consent to ensure an informed deci-
complex CHD or other systemic developmental abnormal- sion is made regarding their disclosure.86
ities.79 A chromosomal microarray is recommended in any
infant with 2 or more major anomalies (eg, structural CHD, Prognosis
neural tube defects), multiple minor anomalies, or growth Syndromic and nonsyndromic structural CHD outcomes
restriction with congenital anomalies.76,80 can vary significantly, reflecting the diverse underlying
Care must be taken to select appropriate patients for test- genetic and clinical factors associated with each category.
ing to ensure a cost-effective approach that minimizes the Individuals with syndromic CHD, including those with
risk of false-positive results that may increase stress for Down syndrome or DiGeorge syndrome, face additional
the family.81,82 Whole exome sequencing has emerged as health challenges beyond their cardiac anomalies. The pres-
an important follow-up test in scenarios where multigene ence of multiple congenital anomalies contributes to a more
panels are negative despite family history or physical exami- complex clinical course, which is associated with prolonged
nation features suggesting a genetic etiology. Trio testing, in hospitalizations and variable long-term outcomes. For exam-
which the child and both biological parents are tested, may ple, in a Korean retrospective cohort study comparing
assist with the interpretation of whole exome or whole patients with and without Down syndrome who underwent
genome results. The identification of single-gene PVs may total correction for CHD, hospital length of stay was signifi-
facilitate characterization of additional phenotypes associ- cantly longer for the Down syndrome cohort (14 days vs
ated with specific genetic findings, with implications on 11 days; P < .0001).87 Individuals with nonsyndromic CHD
future disease screenings and developmental support. may experience more favorable outcomes in terms of overall
These results may also help inform families regarding future health and neurodevelopment.10
pregnancies and family planning. The Pediatric Cardiac Genomics Consortium, formed in
When an infant is suspected of having syndromic CHD, 2009 by the National Heart, Lung, and Blood Institute, is a
cytogenetic testing (eg, microarrays), exome sequencing, or a research network focused on congenital or acquired heart
multigene panel with an optional follow-up with whole disease in children to accelerate clinical translation of
exome sequencing should be offered to the family.79 If a CHD-related investigations.88 Such research networks
chromosomal microarray is indicated, the families must should expand to create open lines of communication to
receive appropriate pretest and posttest counseling by a allow rapid dissemination of rigorously tested diagnostic
trained geneticist, a genetic counselor, or another provider tools and new information. Additionally, ongoing research
with expertise in interpreting genetic tests.83 Negative in medical and surgical management in pediatric CHD
genetic testing results do not necessarily preclude an under- patients has contributed to improved outcomes in both pop-
lying genetic cause such as intronic or other variants. ulations. Recent advances in survival have highlighted

e82 NeoReviews
a knowledge gap in understanding long-term outcomes References
in these populations and focus areas of ongoing research 1. Data and statistics. Centers for Disease Control and Prevention.
efforts to ultimately improve quality of life and minimize Updated May 15, 2024. Accessed June 24, 2024. https://www.
comorbidities.89 Research shows that physician and family cdc.gov/heart-defects/data/?CDC_AAref_Val=https://www.cdc.
gov/ncbddd/heartdefects/data.html
priorities for complex patients can be incongruent.90
2. Yasuhara J, Garg V. Genetics of congenital heart disease: a
Researchers must include family members and older
narrative review of recent advances and clinical implications.
children with syndromic CHD in research discussions Transl Pediatr. 2021;10(9):2366–2386. PubMed doi: 10.21037/
to create relevant methods and evaluations for primary tp-21-297
stakeholders. 3. Bakker MK, Bergman JEH, Krikov S, et al. Prenatal diagnosis
and prevalence of critical congenital heart defects: an
Individuals with structural CHD may face challenges
international retrospective cohort study. BMJ Open. 2019;9(7):
related to cardiac function, exercise tolerance, and potential e028139. PubMed doi: 10.1136/bmjopen-2018-028139
late-onset systemic complications, which are poorly under- 4. Del Bianco A, Russo S, Lacerenza N, et al. Four chamber
stood.91–93 Comprehensive multidisciplinary follow-up view plus three-vessel and trachea view for a complete
care, including pediatric cardiologists and developmental evaluation of the fetal heart during the second trimester.
J Perinat Med. 2006;34(4):309–312. PubMed doi: 10.1515/JPM.
pediatricians, is crucial to addressing evolving health care 2006.059
needs of these patients. Longitudinal monitoring, risk 5. Moon-Grady AJ, Donofrio MT, Gelehrter S, et al. Guidelines and
stratification, and patient education may enhance the qual- recommendations for performance of the fetal echocardiogram:
ity of life for individuals with CHD as they grow into an update from the American Society of Echocardiography. J Am
Soc Echocardiogr. 2023;36(7):679–723. PubMed doi: 10.1016/j.
adulthood.10 echo.2023.04.014
6. Pierpont ME, Brueckner M, Chung WK, et al; American
Heart Association Council on Cardiovascular Disease in the
CONCLUSION Young; Council on Cardiovascular and Stroke Nursing; and
Council on Genomic and Precision Medicine. Genetic basis
Newborn hospitalists, neonatologists, and pediatric cardiolo- for congenital heart disease: revisited: a scientific statement
gists are responsible for the initial diagnosis and manage- From the American Heart Association. Circulation. 2018;
138(21):e653–e711. PubMed doi: 10.1161/CIR.
ment of infants with structural CHD after delivery.
0000000000000606
Syndromic and nonsyndromic structural CHD may result
7. Boneva RS, Botto LD, Moore CA, Yang Q, Correa A, Erickson
from monogenic, oligogenic, or polygenic PVs that disrupt JD. Mortality associated with congenital heart defects in the
normal embryogenesis. Structural CHD is increasingly iden- United States: trends and racial disparities, 1979–1997.
Circulation. 2001;103(19):2376–2381. PubMed doi: 10.1161/01.
tified prenatally with fetal echocardiography, which has led to
CIR.103.19.2376
an increasing role for prenatal and postnatal genetic testing.
8. Gilboa SM, Salemi JL, Nembhard WN, Fixler DE, Correa A.
In appropriate clinical scenarios, genetic testing can assist Mortality resulting from congenital heart disease among children
with acute or long-term management, prognostic under- and adults in the United States, 1999 to 2006. Circulation. 2010;
standing, and future family planning. A basic understanding 122(22):2254–2263. PubMed doi: 10.1161/CIRCULATIONAHA.110.
947002
of the genetic basis of these complex diagnoses will assist
9. Lynn MM, Salemi JL, Meath CJ, et al. Lesion-specific mortality
with appropriate management and disposition and improve due to congenital heart disease in U.S. adults from 1999 to
the understanding of long-term prognosis. 2017. Birth Defects Res. 2022;114(13):725–745. PubMed doi: 10.
1002/bdr2.2044
10. Sood E, Newburger JW, Anixt JS, et al; American Heart
Association Council on Lifelong Congenital Heart Disease and
Heart Health in the Young and the Council on Cardiovascular
American Board of Pediatrics and Stroke Nursing. Neurodevelopmental outcomes for
Neonatal-Perinatal Content individuals with congenital heart disease: Updates in
neuroprotection, risk-stratification, evaluation, and management:
Specification a scientific statement from the American Heart Association.
• Know the pathophysiology, including genetics, of a Circulation. 2024;149(13):e997–e1022. PubMed doi: 10.1161/CIR.
0000000000001211
cyanotic neonate.
• Know the anatomy and pathophysiology, including 11. Asatryan B, Medeiros-Domingo A. Molecular and genetic
insights into progressive cardiac conduction disease. Europace.
genetics, of a neonate with a left-sided cardiac obstruc-
2019;21(8):1145–1158. PubMed doi: 10.1093/europace/euz109
tive lesion
12. Lee CK. Prenatal counseling of fetal congenital heart disease.
• Know the anatomy and pathophysiology, including
Curr Treat Options Cardiovasc Med. 2017;19(1):5. PubMed doi: 10.
genetics, of a neonate with a right-sided cardiac 1007/s11936-017-0502-1
lesion

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e83

 13. Bagnall RD, Singer ES, Wacker J, et al. Genetic basis of 28. Srivastava D. HAND proteins: molecular mediators of cardiac
childhood cardiomyopathy. Circ Genom Precis Med. 2022;15(6): development and congenital heart disease. Trends Cardiovasc
e003686. PubMed doi: 10.1161/CIRCGEN.121.003686 Med. 1999;9(1–2):11–18. doi: 10.1016/s1050-1738(98)
14. Guerri G, Krasi G, Precone V, et al. Cardiac conduction defects. 00033-4
Acta Biomed. 2019;90(10-S):20–29. PubMed 29. Dimopoulos K, Constantine A, Clift P, et al; for Down Syndrome
15. Sizarov A, Baldwin HS, Srivastava D, Moorman International (DSi). Cardiovascular complications of Down
AFM.Development of the heart: morphogenesis, growth, and syndrome: scoping review and expert consensus. Circulation.
molecular regulation of differentiation. In: Allen HD, Shaddy 2023;147(5):425–441. PubMed doi: 10.1161/CIRCULATIONAHA.
RE, Penny DJ, Feltes TF, Cetta F, eds. Moss & Adams’ Heart 122.059706
Disease in infants, Children, and Adolescents: Including the Fetus 30. Visootsak J, Mahle WT, Kirshbom PM, et al.
and Young Adult. 9th ed. Wolters Kluwer; 2016. Neurodevelopmental outcomes in children with Down syndrome
16. Kloesel B, DiNardo JA, Body SC. Cardiac embryology and and congenital heart defects. Am J Med Genet A. 2011;155A(11):
molecular mechanisms of congenital heart disease: a primer for 2688–2691. PubMed doi: 10.1002/ajmg.a.34252
anesthesiologists. Anesth Analg. 2016;123(3):551–569. PubMed 31. Mouat JS, Li S, Myint SS, et al. Epigenomic signature of major
doi: 10.1213/ANE.0000000000001451 congenital heart defects in newborns with Down syndrome. Hum
17. Understanding the genetics of congenital heart defects: new Genomics. 2023;17(1):92. PubMed doi: 10.1186/s40246-023-00540-1
evidence traces congenital heart defects to healthy parents. 32. Kepple JW, Fishler KP, Peeples ES. Surveillance guidelines
Accessed June 24 2024. Nature. https://www.nature.com/ for children with trisomy 18. Am J Med Genet A. 2021;185(4):
articles/d42473-018-00345-0#:~:text=In%20syndromic%20CHD 1294–1303. PubMed doi: 10.1002/ajmg.a.62097
%2C%20where%20the,t%20inherited%20from%20the% 33. Cortezzo DE, Tolusso LK, Swarr DT. Perinatal outcomes of
20parents fetuses and infants diagnosed with Trisomy 13 or Trisomy 18.
18. Sifrim A, Hitz MP, Wilsdon A, et al; INTERVAL Study; UK10K J Pediatr. 2022;247:116–123.e5. PubMed doi: 10.1016/j.jpeds.
Consortium; Deciphering Developmental Disorders Study. 2022.04.010
Distinct genetic architectures for syndromic and nonsyndromic 34. Oliveira CS, Alves C. The role of the SHOX gene in the
congenital heart defects identified by exome sequencing. Nat pathophysiology of Turner syndrome. Endocrinol Nutr. 2011;
Genet. 2016;48(9):1060–1065. PubMed doi: 10.1038/ng.3627 58(8):433–442. PubMed doi: 10.1016/j.endonu.2011.06.005
19. Akiel M. The genetic architecture behind congenital heart 35. Alam S, Claxton JNS, Thomas AS, et al. 20-year surgical
disease: a review of genetic and epigenetic factors. J Nature Sci outcomes for Turner syndrome patients: data from the Pediatric
Med. 2022;5(3):210–220. doi: 10.4103/jnsm.jnsm_126_21 Cardiac Care Consortium. Pediatrics. 2021;147(3):401. doi: 10.
20. Prendiville T, Jay PY, Pu WT. Insights into the genetic structure 1542/peds.147.3MA4.401a
of congenital heart disease from human and murine studies on 36. Gravholt CH, Andersen NH, Conway GS, et al; International
monogenic disorders. Cold Spring Harb Perspect Med. 2014;4(10): Turner Syndrome Consensus Group. Clinical practice guidelines
a013946. PubMed doi: 10.1101/cshperspect.a013946 for the care of girls and women with Turner syndrome:
21. Zaidi S, Choi M, Wakimoto H, et al. De novo mutations in Proceedings from the 2016 Cincinnati International Turner
histone-modifying genes in congenital heart disease. Nature. Syndrome Meeting. Eur J Endocrinol. 2017;177(3):G1–G70.
2013;498(7453):220–223. PubMed doi: 10.1038/nature12141 PubMed doi: 10.1530/EJE-17-0430
22. Priyanka P, Vyas V, Deora S, Nag VL, Singh K. Epidemiology, 37. McDonald-McGinn DM, Hain HS. Emanuel BS, Zackai EH.
etiology and clinical associations of congenital heart disease 22q11.2 Deletion syndrome. University of Washington, Seattle.
identified during congenital rubella syndrome surveillance. Updated May 9, 2024. Accessed June 24, 2024. https://www.
J Trop Pediatr. 2022;68(6):fmac089. PubMed doi: 10.1093/ ncbi.nlm.nih.gov/books/NBK1523/
tropej/fmac089 38. Guris DL, Duester G, Papaioannou VE, Imamoto A. Dose-
23. Wu L, Li N, Liu Y. Association between maternal factors and risk dependent interaction of Tbx1 and Crkl and locally aberrant
of congenital heart disease in offspring: a systematic review and RA signaling in a model of del22q11 syndrome. Dev Cell.
meta-analysis. Matern Child Health J. 2023;27(1):29–48. PubMed 2006;10(1):81–92. PubMed doi: 10.1016/j.devcel.2005.12.002
doi: 10.1007/s10995-022-03538-8 39. Yutzey KE. DiGeorge syndrome, Tbx1, and retinoic acid
24. Maduro C, Castro LF, Moleiro ML, Guedes-Martins L. signaling come full circle. Circ Res. 2010;106(4):630–632.
Pregestational diabetes and congenital heart defects. Rev Bras PubMed doi: 10.1161/CIRCRESAHA.109.215319
Ginecol Obstet. 2022;44(10):953–961. PubMed doi: 10.1055/ 40. Krauser AF, Ponnarasu S, Schury MP. Holt-Oram syndrome.
s-0042-1755458 StatPearls Publishing. Updated August 14, 2023. Accessed June
25. Choudhury TZ, Garg V. Molecular genetic mechanisms of 24, 2024. https://www.ncbi.nlm.nih.gov/books/NBK513339/
congenital heart disease. Curr Opin Genet Dev. 2022;75:101949. 41. Spiridon MR, Petris AO, Gorduza EV, Petras AS, Popescu R,
PubMed doi: 10.1016/j.gde.2022.101949 Caba L. Holt-Oram syndrome with multiple cardiac abnormalities.
26. Russell MW, Chung WK, Kaltman JR, Miller TA. Advances in Cardiol Res. 2018;9(5):324–329. PubMed doi: 10.14740/cr767w
the understanding of the genetic determinants of congenital 42. Morris CA. Williams syndrome. University of Washington,
heart disease and their impact on clinical outcomes. J Am Heart Seattle. Updated April 13, 2023. Accessed June 24, 2024.
Assoc. 2018;7(6):e006906. PubMed doi: 10.1161/JAHA.117. https://www.ncbi.nlm.nih.gov/books/NBK1249/
006906
43. Li FF, Chen WJ, Yao D, et al. Clinical phenotypes study of 231
27. Conway SJ, Firulli B, Firulli AB. A bHLH code for cardiac children with Williams syndrome in China: a single-center
morphogenesis. Pediatr Cardiol. 2010;31(3):318–324. doi: 10. retrospective study. Mol Genet Genomic Med. 2022;10(12):e2069.
1007/s00246-009-9608-x PubMed doi: 10.1002/mgg3.2069

e84 NeoReviews
44. Wat MJ, Shchelochkov OA, Holder AM, et al. Chromosome 60. Udine M, Donofrio MT. The role of the neonatologist in fetuses
8p23.1 deletions as a cause of complex congenital heart defects diagnosed with congenital heart disease. Neoreviews. 2023;24(9):
and diaphragmatic hernia. Am J Med Genet A. 2009;149A(8): e553–e568. PubMed doi: 10.1542/neo.24-9-e553
1661–1677. PubMed doi: 10.1002/ajmg.a.32896 61. Grace MR, Hardisty E, Dotters-Katz SK, Vora NL, Kuller JA.
45. Usman N, Sur M. CHARGE syndrome. StatPearls Publishing. Cell-free DNA screening: complexities and challenges of clinical
Updated March 6, 2023. Accessed June 24, 2024. https://www. implementation. Obstet Gynecol Surv. 2016;71(8):477–487.
ncbi.nlm.nih.gov/books/NBK559199/# PubMed doi: 10.1097/OGX.0000000000000342
46. Meisner JK, Martin DM. Congenital heart defects in CHARGE: 62. American College of Obstetricians and Gynecologists’
the molecular role of CHD7 and effects on cardiac phenotype Committee on Practice Bulletins—Obstetrics; Committee on
and clinical outcomes. Am J Med Genet C Semin Med Genet. Genetics; Society for Maternal-Fetal Medicine. Screening for
2020;184(1):81–89. PubMed doi: 10.1002/ajmg.c.31761 fetal chromosomal abnormalities: ACOG practice bulletin,
47. Deardorff MA, Noon SE, Krantz ID. Cornelia de Lange syndrome. number 226. Obstet Gynecol. 2020;136(4):e48–e69. PubMed
University of Washington, Seattle. Updated October 15, 2020. doi: 10.1097/AOG.0000000000004084
Accessed June 24, 2024. https://www.ncbi.nlm.nih.gov/books/ 63. Dar P, Jacobsson B, MacPherson C, et al. Cell-free DNA
NBK1104/ screening for trisomies 21, 18, and 13 in pregnancies at low and
48. Chatfield KC, Schrier SA, Li J, et al. Congenital heart disease in high risk for aneuploidy with genetic confirmation. Am J Obstet
Cornelia de Lange syndrome: phenotype and genotype analysis. Gynecol. 2022;227(2):259 e1-259 e14.
Am J Med Genet A. 2012;158A(10):2499–2505. PubMed doi: 10. 64. Nassr AA, Hessami K, D’Alberti E, et al. Obstetrical outcomes
1002/ajmg.a.35582 following amniocentesis performed after 24 weeks of gestation:
49. Chea S, Kreger J, Lopez-Burks ME, MacLean AL, Lander AD, a systematic review and meta-analysis. Prenat Diagn. 2023;
Calof AL. Gastrulation-stage gene expression in Nipbl+/− mouse 43(11):1425–1432. PubMed doi: 10.1002/pd.6435
embryos foreshadows the development of syndromic birth 65. American College of Obstetricians and Gynecologists’
defects. Sci Adv. 2024.10(12). doi: 10.1126/sciadv.adl4239 Committee on Practice Bulletins—Obstetrics; Committee on
50. Roberts AE. Noonan syndrome. University of Washington, Seattle. Genetics; Society for Maternal-Fetal Medicine. Practice Bulletin
Updated February 17, 2022. Accessed June 24, 2024. https:// No. 162: prenatal diagnostic testing for genetic disorders. Obstet
www.ncbi.nlm.nih.gov/books/NBK1124/ Gynecol. 2016;127(5):e108–e122. PubMed doi: 10.1097/AOG.
0000000000001405
51. Hebron KE, Hernandez ER, Yohe ME. The RASopathies: from
pathogenetics to therapeutics. Dis Model Mech. 2022;15(2): 66. Skari H, Malt UF, Bjornland K, et al. Prenatal diagnosis of
dmm049107. PubMed doi: 10.1242/dmm.049107 congenital malformations and parental psychological distress—
a prospective longitudinal cohort study. Prenat Diagn. 2006;
52. Linglart L, Gelb BD. Congenital heart defects in Noonan
26(11):1001–1009. PubMed doi: 10.1002/pd.1542
syndrome: diagnosis, management, and treatment. Am J Med
Genet C Semin Med Genet. 2020;184(1):73–80. PubMed doi: 10. 67. Mustafa HJ, Cross SN, Jacobs KM, et al. Preterm birth of infants
1002/ajmg.c.31765 prenatally diagnosed with congenital heart disease,
characteristics, associations, and outcomes. Pediatr Cardiol.
53. Gilbert MA, Bauer RC, Rajagopalan R, et al. Alagille syndrome
2020;41(5):972–978. PubMed doi: 10.1007/s00246-020-02345-8
mutation update: comprehensive overview of JAG1 and
NOTCH2 mutation frequencies and insight into missense 68. Levy PT, Thomas AR, Wethall A, Perez D, Steurer M, Ball MK.
variant classification. Hum Mutat. 2019;40(12):2197–2220. Rethinking congenital heart disease in preterm neonates.
PubMed doi: 10.1002/humu.23879 Neoreviews. 2022;23(6):e373–e387. PubMed doi: 10.1542/neo.23-
6-e373
54. Spinner NB, Loomes KM, Krantz ID, Gilbert MA. Alagille
syndrome. University of Washington, Seattle. Updated January 4, 69. Jepson BM, Metz TD, Miller TA, et al. Pregnancy loss in major
2024. Accessed June 24, 2024. https://www.ncbi.nlm.nih.gov/ fetal congenital heart disease: incidence, risk factors and timing.
books/NBK1273/ Ultrasound Obstet Gynecol. 2023;62(1):75–87. PubMed doi: 10.
1002/uog.26231
55. Turnpenny PD, Ellard S. Alagille syndrome: pathogenesis,
diagnosis and management. Eur J Hum Genet. 2012;20(3): 70. Divanovic A, Bowers K, Michelfelder E, et al. Intrauterine fetal
251–257. PubMed doi: 10.1038/ejhg.2011.181 demise after prenatal diagnosis of congenital heart disease:
assessment of risk. Prenat Diagn. 2016;36(2):142–147. PubMed
56. Ye S, Wang C, Xu Z, et al. Impaired human cardiac cell
doi: 10.1002/pd.4755
development due to NOTCH1 deficiency. Circ Res. 2023;
132(2):187–204. PubMed doi: 10.1161/CIRCRESAHA.122.321398 71. Madrigal VN, Feltman DM, Leuthner SR, et al. Bioethics for
neonatal cardiac care. Pediatrics. 2022;150(Suppl 2):e2022056415N.
57. Niessen K, Karsan A. Notch signaling in cardiac development.
Circ Res. 2008;102(10):1169–1181. PubMed doi: 10.1161/ 72. Chenni N, Lacroze V, Pouet C, et al. Fetal heart disease and
CIRCRESAHA.108.174318 interruption of pregnancy: factors influencing the parental
decision-making process. Prenat Diagn. 2012;32(2):168–172.
58. McElhinney DB, Krantz ID, Bason L, et al. Analysis of
PubMed doi: 10.1002/pd.2923
cardiovascular phenotype and genotype-phenotype correlation in
individuals with a JAG1 mutation and/or Alagille syndrome. 73. Nell S, Wijngaarde CA, Pistorius LR, et al. Fetal heart disease:
Circulation. 2002;106(20):2567–2574. PubMed doi: 10.1161/01. severity, associated anomalies and parental decision. Fetal Diagn
CIR.0000037221.45902.69 Ther. 2013;33(4):235–240. PubMed doi: 10.1159/000346564

59. van Velzen CL, Clur SA, Rijlaarsdam ME, et al. Prenatal 74. Costello JM, Kim F, Polin R, Krishnamurthy G. Double
detection of congenital heart disease—results of a national jeopardy: prematurity and congenital heart disease—what’s
screening programme. BJOG. 2016;123(3):400–407. PubMed known and why it’s important. World J Pediatr Congenit Heart
doi: 10.1111/1471-0528.13274 Surg. 2022;13(1):65–71. PubMed doi: 10.1177/21501351211062606

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e85

 75. Mamalis M, Koehler T, Bedei I, et al. Comparison of the results 88. Gelb B, Brueckner M, Chung W, et al; Pediatric Cardiac
of prenatal and postnatal echocardiography and postnatal cardiac Genomics Consortium. The Congenital Heart Disease Genetic
MRI in children with a congenital heart defect. J Clin Med. Network Study: rationale, design, and early results. Circ Res.
2023;12(10):3508. PubMed doi: 10.3390/jcm12103508 2013;112(4):698–706. PubMed doi: 10.1161/CIRCRESAHA.111.
76. Rosen O, Marion RW, Samanich J.Common congenital 300297
anomalies. In: McInerny TK, Adam HM, Campbell DE, et al, 89. Cocomello L, Taylor K, Caputo M, Cornish RP, Lawlor DA.
eds. Textbook of Pediatric Care. Second ed. American Academy of Health and well-being in surviving congenital heart disease
Pediatrics; 2017. patients: an umbrella review with synthesis of best evidence.
Front Cardiovasc Med. 2022;9:870474. PubMed doi: 10.3389/
77. Perry DJ, Mullen CR, Carvajal HG, Brar AK, Eghtesady P.
fcvm.2022.870474
Familial screening for left-sided congenital heart disease: what is
the evidence? what is the cost? Diseases. 2017;5(4):29. PubMed 90. Webbe JWH, Duffy JMN, Afonso E, et al. Core outcomes in
doi: 10.3390/diseases5040029 neonatology: development of a core outcome set for neonatal
research. Arch Dis Child Fetal Neonatal Ed. 2020;105(4):425–431.
78. Ison HE, Griffin EL, Parrott A, et al. Genetic counseling for
PubMed doi: 10.1136/archdischild-2019-317501
congenital heart disease—practice resource of the National
Society of Genetic Counselors. J Genet Couns. 2022;31(1):9–33. 91. Stout KK, Broberg CS, Book WM, et al; American Heart
PubMed doi: 10.1002/jgc4.1498 Association Council on Clinical Cardiology, Council on
Functional Genomics and Translational Biology, and Council on
79. Manickam K, McClain MR, Demmer LA, et al; ACMG Board of Cardiovascular Radiology and Imaging. Chronic heart failure in
Directors. Exome and genome sequencing for pediatric patients congenital heart disease: a scientific statement from the
with congenital anomalies or intellectual disability: an evidence- American Heart Association. Circulation. 2016;133(8):770–801.
based clinical guideline of the American College of Medical PubMed doi: 10.1161/CIR.0000000000000352
Genetics and Genomics (ACMG). Genet Med. 2021;23(11):
2029–2037. PubMed doi: 10.1038/s41436-021-01242-6 92. Villaseca-Rojas Y, Varela-Melo J, Torres-Castro R, et al.
Exercise capacity in children and adolescents with congenital
80. Mitchell AL. Congenital anomalies. In: Martin RJ, Fanaroff AA, heart disease: a systematic review and meta-analysis. Front
Walsh MC, eds. Fanaroff and Martin’s Neonatal-Perinatal Cardiovasc Med. 2022;9:874700. PubMed doi: 10.3389/fcvm.
Medicine: Diseases of the Fetus and Infant. 12th edition. Elsevier; 2022.874700
2020:504–528.
93. Raissadati A, Haukka J, Pätilä T, Nieminen H, Jokinen E.
81. Pinto NM, Nelson R, Puchalski M, Metz TD, Smith KJ. Cost- Chronic disease burden after congenital heart surgery: a 47-year
effectiveness of prenatal screening strategies for congenital heart population-based study with 99% follow-up. J Am Heart Assoc.
disease. Ultrasound Obstet Gynecol. 2014;44(1):50–57. PubMed 2020;9(9):e015354. PubMed doi: 10.1161/JAHA.119.015354
doi: 10.1002/uog.13287
94. Zhang Y, Ai F, Zheng J, Peng B. Associations of GATA4 genetic
82. Geddes GC, Basel D, Frommelt P, Kinney A, Earing M. Genetic mutations with the risk of congenital heart disease: a meta-
testing protocol reduces costs and increases rate of genetic analysis. Medicine (Baltimore). 2017;96(18):e6857. PubMed
diagnosis in infants with congenital heart disease. Pediatr Cardiol. doi: 10.1097/MD.0000000000006857
2017;38(7):1465–1470. PubMed doi: 10.1007/s00246-017-1685-7
95. Afouda BA. Towards understanding the gene-specific roles of
83. Gilner J, Rajkovic A, Kuller JA. Molecular genetic technology. In: GATA factors in heart development: does GATA4 lead the way?
Resnik R, Lockwood CJ, Moore TR, Greene MF, Copel JA, Silver Int J Mol Sci. 2022;23(9):5255. PubMed doi: 10.3390/
RM eds. Creasy and Resnik’s Maternal-Fetal Medicine: Principles ijms23095255
and Practice. Eighth ed. Elsevier; 2019.
96. Sissaoui S, Yu J, Yan A, et al. Genomic characterization of
84. Smeekens SP, Leferink M, Yntema HG, Kamsteeg EJ. Maternal endothelial enhancers reveals a multifunctional role for NR2F2
cell contamination in postnatal umbilical cord blood samples in regulation of arteriovenous gene expression. Circ Res.
implies a low risk for genetic misdiagnoses. Prenat Diagn. 2020;126(7):875–888. PubMed doi: 10.1161/CIRCRESAHA.119.
2024;44(11):1304–1309. PubMed doi: 10.1002/pd.6595 316075
85. Musunuru K, Hershberger RE, Day SM, et al; American Heart 97. Al Turki S, Manickaraj AK, Mercer CL, et al; UK10K
Association Council on Genomic and Precision Medicine; Consortium. Rare variants in NR2F2 cause congenital heart
Council on Arteriosclerosis, Thrombosis and Vascular Biology; defects in humans. Am J Hum Genet. 2014;94(4):574–585.
Council on Cardiovascular and Stroke Nursing; and Council on PubMed doi: 10.1016/j.ajhg.2014.03.007
Clinical Cardiology. Genetic testing for inherited cardiovascular
diseases: a scientific statement from the American Heart 98. Cao C, Li L, Zhang Q, et al. Nkx2.5: a crucial regulator of cardiac
Association. Circ Genom Precis Med. 2020;13(4):e000067. development, regeneration and diseases. Front Cardiovasc Med.
PubMed doi: 10.1161/HCG.0000000000000067 2023;10:1270951. PubMed doi: 10.3389/fcvm.2023.1270951

86. Miller DT, Lee K, Gordon AS, et al; ACMG Secondary Findings 99. González-Castro TB, Tovilla-Zárate CA, López-Narvaez ML, et al.
Working Group. Recommendations for reporting of secondary Association between congenital heart disease and NKX2.5 gene
findings in clinical exome and genome sequencing, 2021 update: polymorphisms: systematic review and meta-analysis. Biomarkers
a policy statement of the American College of Medical Genetics Med. 2020;14(18):1747–1757. PubMed doi: 10.2217/bmm-2020-
and Genomics (ACMG). Genet Med. 2021;23(8):1391–1398. 0190
PubMed doi: 10.1038/s41436-021-01171-4 100. Valer JA, Sánchez-de-Diego C, Pimenta-Lopes C, Rosa JL,
87. Kwak JH, Lee SW, Cha HR, et al. Long-term observational Ventura F. ACVR1 function in health and disease. Cells. 2019;
outcomes after total correction of congenital heart disease in 8(11):1366. PubMed doi: 10.3390/cells8111366
Korean patients with Down syndrome: a national cohort study. 101. Bleyl SB, Saijoh Y, Bax NA, et al. Dysregulation of the PDGFRA
Children (Basel). 2022;9(9):1329. PubMed doi: 10.3390/ gene causes inflow tract anomalies including TAPVR: integrating
children9091329 evidence from human genetics and model organisms. Hum

e86 NeoReviews
 Mol Genet. 2010;19(7):1286–1301. PubMed doi: 10.1093/hmg/ Accessed June 29, 2024. https://www.ncbi.nlm.nih.gov/books/
ddq005 NBK52787/
102. El-Rass S, Eisa-Beygi S, Khong E, et al. Disruption of pdgfra 112. Rauen KA. Cardiofaciocutaneous syndrome. University of
alters endocardial and myocardial fusion during zebrafish Washington, Seattle. Updated February 9, 2023. Accessed June
cardiac assembly. Biol Open. 2017;6(3):348–357. PubMed 29, 2024. https://www.ncbi.nlm.nih.gov/books/NBK1186/#
103. Tan HL, Glen E, Töpf A, et al. Nonsynonymous variants 113. Gelb BD. Char syndrome. University of Washington, Seattle.
in the SMAD6 gene predispose to congenital cardiovascular Updated May 21, 2020. Accessed June 29, 2024. https://www.
malformation. Hum Mutat. 2012;33(4):720–727. PubMed ncbi.nlm.nih.gov/books/NBK1106/
doi: 10.1002/humu.22030 114. Gripp KW, Weaver KN. HRAS-related Costello syndrome. University
104. Luyckx I, Verstraeten A, Goumans MJ, Loeys B. SMAD6- of Washington, Seattle. Updated December 21, 2023. Accessed
deficiency in human genetic disorders. NPJ Genom Med. 2022; June 29, 2024. https://www.ncbi.nlm.nih.gov/books/NBK1507/
7(1):68. PubMed doi: 10.1038/s41525-022-00338-5 115. Siwik ES, Zahka KG, Wiesner GL, Limwongse C. Cardiac
105. Durst R, Sauls K, Peal DS, et al. Mutations in DCHS1 cause disease in Costello syndrome. Pediatrics. 1998;101(4 Pt 1):
mitral valve prolapse. Nature. 2015;525(7567):109–113. PubMed 706–709. PubMed doi: 10.1542/peds.101.4.706
doi: 10.1038/nature14670 116. Jacquin C, Landais E, Poirsier C, et al. 1p36 deletion syndrome:
106. Basu R, Hazra S, Shanks M, Paterson DI, Oudit GY. Novel review and mapping with further characterization of the
mutation in exon 14 of the sarcomere gene MYH7 in familial phenotype, a new cohort of 86 patients. Am J Med Genet A.
left ventricular noncompaction with bicuspid aortic valve. 2023;191(2):445–458. PubMed doi: 10.1002/ajmg.a.63041
Circ Heart Fail. 2014;7(6):1059–1062. PubMed doi: 10.1161/ 117. Cox DM, Butler MG. The 15q11.2 BP1-BP2 microdeletion
CIRCHEARTFAILURE.114.001666 syndrome: a review. Int J Mol Sci. 2015;16(2):4068–4082.
107. Postma AV, van Engelen K, van de Meerakker J, et al. Mutations PubMed doi: 10.3390/ijms16024068
in the sarcomere gene MYH7 in Ebstein anomaly. Circ 118. Barry KK, Tsaparlis M, Hoffman D, et al. From genotype to
Cardiovasc Genet. 2011;4(1):43–50. PubMed doi: 10.1161/ phenotype—a review of Kabuki syndrome. Genes (Basel).
CIRCGENETICS.110.957985 2022;13(10):1761. PubMed doi: 10.3390/genes13101761
108. Pannu H, Tran-Fadulu V, Papke CL, et al. MYH11 mutations 119. Stevens CA. Rubinstein-Taybi syndrome. University of
result in a distinct vascular pathology driven by insulin-like Washington, Seattle. Updated November 9, 2023. Accessed
growth factor 1 and angiotensin II. Hum Mol Genet. 2007; June 29, 2024.
16(20):2453–2462. PubMed doi: 10.1093/hmg/ddm201
120. Mosaic trisomy 9. National Center for Advancing Translation
109. Endicott SJ, Basu B, Khokha M, Brueckner M. The NIMA-like Sciences, National Institute of Health. Updated June 2024.
kinase Nek2 is a key switch balancing cilia biogenesis and Accessed June 29, 2024. https://rarediseases.info.nih.gov/
resorption in the development of left-right asymmetry. diseases/43/mosaic-trisomy-9
Development. 2015;142(23):4068–4079. PubMed
121. Jacobsen syndrome. National Center for Advancing Translation
110. Hills CB, Kochilas L, Schimmenti LA, Moller JH. Ellis-van Sciences, National Institute of Health. Updated June 2024.
Creveld syndrome and congenital heart defects: presentation of Accessed June 29, 2024.
an additional 32 cases. Pediatr Cardiol. 2011;32(7):977–982.
122. Tatton-Brown K, Cole TR, Rahman N. Sotos syndrome.
PubMed doi: 10.1007/s00246-011-0006-9
University of Washington, Seattle. Updated December 1, 2022.
111. Guo R, Haldeman-Englert CR. 1q21.1 Recurrent deletion. Accessed June 29, 2024. https://www.ncbi.nlm.nih.gov/books/
University of Washington, Seattle. Updated February 1, 2024. NBK1479/

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e87

 NEOREVIEWS QUIZ

NEO
QUIZ
1. Rapid advancement and expanded availability of genetic testing has increased
the identification of genetic changes linked to structural congenital heart disease
(CHD). About 20%-30% of infants with CHD have an associated genetic cause,
with chromosomal abnormalities being the most commonly identified genetic
factor. Up to what percent of these patients have a chromosomal abnormality?
A. <1%
B. 5%
C. 10%
D. 15%
E. 20%
2. The human heart is the first functional organ in utero and its formation
follows a complex multistage development process that occurs early in
REQUIREMENTS: Learners can
gestation. Cardiogenesis starts with the primary heart tube being formed take NeoReviews quizzes and
around day 20 after fertilization and ends with cardiac looping which divides claim credit online only at:
the heart tube into 4 chambers with distinct circulations. At which week of https://publications.aap.org/
gestation is the process of cardiac formation completed? neoreviews.

A. 3rd week
To successfully complete 2025
B. 5th week NeoReviews articles for AMA PRA
C. 8th week Category 1 Credit™, learners must
D. 11th week demonstrate a minimum
E. 15th week performance level of 60% or
higher on this assessment. If you
3. A term infant is admitted to the neonatal intensive care unit (NICU) for further score less than 60% on the
management of cleft lip and palate. Further evaluation demonstrates hypo- assessment, you will be given
additional opportunities to
calcemia, thymic aplasia, and a structural heart defect. Given this constellation
answer questions until an overall
of findings, which of the following cardiac defects would be expected? 60% or greater score is achieved.
A. Atrioventricular canal defect
B. Bicuspid aortic valve This journal-based CME activity is
C. Coarctation of the aorta available through Dec. 31, 2027,
however, credit will be recorded
D. Total anomalous pulmonary venous return
in the year in which the learner
E. Transposition of the great arteries completes the quiz.
4. It is known that select monogenic pathogenic variants are associated with
cardiovascular malformation. In particular, GATA4 is a transcription factor known
to regulate genes involved in embryogenesis and myocardial differentiation.
Of the following possible phenotypes, which is NOT regulated by GATA4?
A. Atrial septal defect
B. Hypoplastic left heart syndrome 2025 NeoReviews is approved for
a total of 10 Maintenance of
C. Pulmonary valve stenosis
Certification (MOC) Part 2 credits
D. Tetralogy of Fallot by the American Board of
E. Ventricular septal defect Pediatrics (ABP) through the AAP
MOC Portfolio Program.
5. An infant born at 38 weeks’ gestation is admitted to the NICU for evaluation of
NeoReviews subscribers can claim
structural heart disease. In consultation with genetics, it is determined that a up to 10 ABP MOC Part 2 points
test looking to detect a single nucleotide variant would be best. Which of the upon passing 30 quizzes (and
following studies is best to detect this type of underlying genetic abnormality? claiming full credit for each quiz)
per year. Subscribers can start
A. Chromosomal analysis
claiming MOC credits as early as
B. Chromosomal microarray October 2025. To learn how to
C. Fluorescence in situ hybridization claim MOC points, go to: https://
D. Targeted gene sequencing publications.aap.org/journals/
E. Whole exome sequencing pages/moc-credit.

e88 NeoReviews
 ARTICLE

Effects of Assisted Reproductive

Technology on Genetics, Obstetrics,
and Neonatal Outcomes
Lateia Taylor, MD,1 Alexis Hood, MD,1 Francesca Mancuso, MD,2 Sofia Horan, MS,3 Zachary Walker, MD3,4

EDUCATIONAL GAPS

This literature review aims to evaluate adverse outcomes related to the use
of assisted reproductive technology, particularly neonatal genetics, imprint-
ABBREVIATIONS
ing disorders, abnormal placentation, and birth defects. Ethical considera-
tions, neonatal intensive care unit admission rates, and peripartum aHR adjusted hazard ratio
aOR adjusted odds ratio
morbidity are also addressed. Our goal is to provide a current perspective ART assisted reproductive
on limitations and improvements with assisted reproductive technology technology
and their associated pregnancies. AS Angelman syndrome
ASRM American Society for
Reproductive Medicine
BWS Beckwith-Wiedemann
OBJECTIVES After completing this article, readers should be able to: syndrome
CDC Centers for Disease Control
1. Describe the perinatal and obstetric outcomes related to the use of and Prevention
ICSI intracytoplasmic sperm
assisted reproductive technology. injection
IVF in vitro fertilization
2. Explain the neonatal genetic conditions associated with assisted repro-
MOSART Massachusetts Outcomes
ductive technology. Study of Assisted
Reproductive Technology
3. Identify the ethical considerations and long-term outcomes related to
NICU neonatal intensive care unit
assisted reproductive technology. OR odds ratio
PGT preimplantation genetic
testing
PGT-A preimplantation genetic
ABSTRACT testing for aneuploidy
PGT-M preimplantation genetic
The prevalence of infertility has increased in the United States over the past
testing for monogenic
decade with 1 in 5 reproductive-aged women suffering from this diagnosis. disorders
PGT-SR preimplantation genetic
The use of assisted reproductive technology (ART) to achieve pregnancy has testing for structural
correspondingly steadily increased. After examining the outcomes of ART rearrangement
PR prevalence ratio
births, clear trends of increased preterm birth rate, higher-order multiples, PWS Prader-Willi syndrome
RSS Russell-Silver syndrome
and imprinting disorders have been established among ART-related out-
SART Society for Assisted
comes. However, the relationship between ART and birth defects, abnormal Reproductive Technology

1
AUTHOR DISCLOSURE: Dr Walker receives payment from UpToDate. Dr Mancuso has traveled University of Chicago School of Medicine,
with the support of Indiana University. Drs Hood, Horan, and Taylor have disclosed no financial Chicago, Illinois; 2Indiana University School
relationships relevant to this article. This commentary does not contain a discussion of an of Medicine, Indianapolis, Indiana;
3
unapproved/investigative use of a commercial product/device. Brigham and Women’s Hospital, Boston,
Massachusetts; and 4Harvard Medical
Accepted for Publication Date: October 11, 2024
School, Boston, Massachusetts
https://doi.org/10.1542/neo.26-2-017
Copyright © 2025 American Academy of Pediatrics

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e89

 placentation, and stillbirth require further investigation. This review aims to highlight current literature surrounding
ART and its relationship with key obstetrical outcomes, neonatal outcomes, and medical genetics.

INTRODUCTION outcomes compared the subfertile population with non-sub-

Over the past decade, infertility rates have risen among repro- fertile populations, which is an inappropriate comparison
ductive-aged adults. The World Health Organization states group given underlying health conditions associated with
that 1 in 6 adults experience infertility worldwide.1 In the many women with subfertility (eg, polycystic ovarian syn-
United States, 1 in 5 reproductive-aged women are unable drome, premature ovarian insufficiency, genetic disorders)
to achieve a pregnancy within 12 months of trying to con- are confounders and not always addressed in studies, which
ceive.2 In addition, 1 in 4 women of reproductive age have may lead to selection bias or recruitment bias. Therefore, it is
difficulty getting pregnant or carrying a pregnancy to term.2 difficult to interpret the true associations between ART and
Correlating with rising infertility rates among US women is neonatal outcomes.3 The purpose of this review is to provide
an equivalent increase in the frequency of infants born as a a narrative summary about the association between ART,
result of assisted reproductive technology (ART). The medical genetics, and obstetrical and neonatal outcomes
Centers for Disease Control and Prevention (CDC) reported (Table 1).
97 128 births from ART in 2021, which is approximately 2%
of all infants born in the United States.3 FEDERAL REPORTING AUTHORITY AND STATE
Unfortunately, adverse outcomes have been reported for REGULATIONS
infants conceived by ART. Studies examining singleton preg- The Fertility Clinic Success Rate and Certification Act was
nancies as a result of ART cycles demonstrated an increased passed by Congress in 1992 requiring that all ART cycles per-
incidence of preterm birth (10.9% [95% CI, 10.0–11.8]), low formed in the United States be reported to the CDC via the
birth weight (8.7% [95% CI, 7.4–10.2]), small-for-gestational- National ART Surveillance System. The establishment of this
age status (1.1% [95% CI, 0.9–1.3]), and congenital malforma- system has allowed for large-scale regulation and analysis of
tions (5.7% [95% CI, 4.7–6.9]).4 In 2021, the CDC reported success rates as well as study of infant outcomes from ART
that of the singleton infants born from single-gestation cycles. Reporting requirements for ART clinics are updated
pregnancies, 17.8% were born preterm and 7.9% had low regularly via Federal Register Notices, ensuring ongoing
birth weight.3 However, most studies examining adverse regulation of ART practices, consistent data collection, and

TABLE 1. Summary of Key Findings

Topic Summary Statement
Multiple IVF pregnancies with higher gestations are associated with a higher risk of preterm birth and low birth weight when
gestations compared with IVF singletons (aOR, 11.84 [95% CI, 10.56–13.27]; and aOR, 10.68 [95% CI, 9.45–12.08], respectively).
Prematurity There has been an increased risk of prematurity (aOR, 1.43 [95% CI, 1.11–1.83]) with use of donor oocytes.
Genetics The use of ART has been associated with increased incidence of sex chromosome aneuploidies and imprinting disorders.
However, there are mixed reports on the effects of ART on de novo mutations, which require further evaluation.
Imprinting Children conceived via IVF, or IVF/ICSI, appear to be at a higher risk of any imprinting disorder than children conceived
disorders naturally (OR 3.67 [95% CI, 1.39–9.74]).
Beckwith-Wiedemann syndrome is the most common imprinting disorder associated with ART (relative risk, 5.2 [95% CI,
1.6–7.4]).
Birth defects Most studies indicate an increased risk of birth defects with IVF/ICSI, although the overall risk remains low (approximately
3.6% vs 3% in the general population).
Stillbirth Most studies have shown that there is an increased risk of stillbirth (defined as intrauterine death occurring at or above
20 weeks’ gestation) with ART pregnancies compared with natural conception (OR, 1.82 [95% CI, 1.37–2.42]).
Peripartum Studies have shown that ART pregnancies are associated with abnormal placentation, need for cesarean section (elective
morbidity and emergent), and postpartum hemorrhage.
NICU admission There are mixed reports on the effects of ART on NICU admissions, which require further studies to determine any
associations.
Long-term There is an increased risk of childhood obesity associated with ART conception (aHR, 1.14 [95% CI, 1.06–1.23]).
outcomes There is also an increased risk of type 1 diabetes in ART-conceived pregnancies from frozen-embryo transfers compared
with natural conception (aHR, 1.41 [95% CI, 1.05–1.89]).
However, several systematic reviews have found no differences on language development, behavior, social functioning,
educational outcomes, or psychological disturbances for ART-conceived pregnancies.

Abbreviations: aHR, adjusted hazard ratio; aOR, adjusted odds ratio; ART, assisted reproductive technology; ICSI, intracytoplasmic sperm injection;
IVF, in vitro fertilization; NICU, neonatal intensive care unit; OR, odds ratio.

e90 NeoReviews
assurance of the continued integrity of ART. While a small TABLE 2. Recommendations for the Limit to the
number of clinics do not report to the CDC, 453 clinics cur- Number of Embryos to Transfer
rently report data to the National ART Surveillance System, Age
capturing more than 95% of all ART cycles in the United
Prognosis <35 y 35–37 y 38–40 y 41–42 y
States.3,5 The Fertility Clinic Success Rate and Certification
Cleavage-stage embryos
Act has also mandated a regulatory model for embryology
Euploida 1 1 1 1
laboratory certification at the state level. Other favorableb 1 1 ≤3 ≤4
In conjunction with CDC efforts, the Society for Assisted Embryos not euploida ≤2 ≤3 ≤4 ≤5
b
or favorable
Reproductive Technology (SART) organization further Blastocysts
upholds standards of ART. More than 95% of ART cycles Euploida 1 1 1 1
in 2021 were completed at SART-affiliated in vitro fertiliza- Other favorableb 1 1 ≤2 ≤3
Embryos not euploida ≤2 ≤2 ≤3 ≤3
tion (IVF) clinics. The primary objectives of SART include or favorableb
reporting IVF outcomes, setting guidelines for best practices
Justification for transferring additional embryos beyond recom-
and quality assurances in the field of ART, and advocating for mended limits should be clearly documented in the patient’s
patients. SART is the only medical organization to imple- medical record.
a
Demonstrated euploid embryos, best prognosis.
ment advertising guidelines to regulate accurate clinic self- b
Other favorable = any 1 of these criteria: fresh cycle (expectation of 1 or
reporting of successful IVF outcomes, allowing for patients more high-quality embryos available for cryopreservation or previous
live birth after a prior transfer with sibling embryo[s]); frozen embryo
to make informed choices. transfer cycle (availability of vitrified day 5 or day 6 blastocysts,
euploid embryos, first FET cycle, or previous live birth after an in vitro
fertilization cycle).
Adapted with permission from the American Society for Reproductive
ART AND MULTIPLE GESTATIONS/PREMATURITY
Medicine.6
Historically, the use of ART adversely impacted perinatal out-
comes due to an increase in multiple gestations. In 2021, the
IVF singletons. The Massachusetts Outcomes Study of
American Society for Reproductive Medicine (ASRM) issued
Assisted Reproductive Technology (MOSART) conducted
guidelines to promote singleton gestations and reduce the
an analysis on maternal-child health using clinical IVF data
likelihood of twin gestation and higher-order gestations
between 2004 and 2008 from the SART Clinical Online
(>3 or more fetuses in 1 pregnancy) (Table 2). Multiple ges-
Reporting System longitudinally linked to Massachusetts
tations have increased risks for complications such as still-
vital records and administrative data.7 IVF pregnancies with
birth, preterm birth, and low-birth-weight infants.6
higher-order gestations were associated with a higher risk of
Although the incidence of higher-order gestations has sig-
preterm birth and low birth weight when compared with IVF
nificantly declined, the incidence of twin gestations remains
singletons (adjusted odds ratio [aOR], 11.84 [95% CI, 10.56–
relatively higher with ART.6 Luke et al assessed that 21% of
13.27]; and aOR, 10.68 [95% CI, 9.45–12.08], respectively).7
twins and 52% of higher-order multiples are due to non-IVF
In addition to preterm birth and low birth weight, there are
ART (eg, ovulation induction, artificial insemination, and
increased risks for pregnancy-induced hypertension (aOR,
intrauterine insemination).7 The decline in higher-order ges-
1.43 [95% CI, 1.14–1.78]) and prematurity (aOR, 1.43 [95%
tations via IVF is attributed to changes in SART guidelines
CI, 1.11–1.83]) with use of donor oocytes.7 While the factors
preferencing single-embryo transfers whenever possible.
underlying these associations are not known, practitioners
Improved methodologies in IVF, such as use of preimplan-
can consider incorporating this information during consul-
tation genetic testing (PGT), improved vitrification tech-
tations for multiple-gestation pregnancies occurring as a
niques, and development of culture media allowing for
result of ART.
blastocyst transfers, has yielded improving rates of singleton
gestations.7 In an ASRM Committee Opinion issued in 2021,
IVF programs are encouraged to track prognostic factors, ART AND GENETICS
such as the patient’s age, prognosis, and age of the donor Reporting on the downstream effects of ART on neonatal
oocyte.6 This aids to guide clinicians on the number of genetic disease has historically focused on imprinting disor-
embryos to be transferred to achieve a successful pregnancy, ders, while the risks of ART association with other genetic
with the goal of mitigating associated adverse outcomes with conditions affecting neonates have not been comprehen-
multiple gestations.6 sively evaluated. A retrospective cohort study that compared
Twins and higher-order gestations conceived via IVF are the percentage of neonates conceived with or without ART
at a higher risk of adverse perinatal outcomes compared with vs the likelihood of finding a genetic diagnosis for their

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e91

 symptoms discovered the diagnostic yield between ART-con- offspring. PGT-A also allows any person considering IVF to
ceived pregnancies was comparable to that of naturally con- reduce their risks of an aneuploid pregnancy and the possible
ceived neonates (10.1% vs 13.2%; OR, 0.74 [95% CI, 0.53– associated birth defects or genetic syndromes. Patients at risk
1.02]).8 The incidence of de novo variants was also similar of passing on single-gene disorders or chromosomal condi-
between ART- and naturally conceived neonates (75.9% [n = tions can elect PGT-M or PGT-SR to reduce the risk of pass-
41/54] vs 64.4% [n = 112/174]; OR, 0.89 [95% CI, 0.62– ing a genetic condition to their offspring. In these ways, ART
1.30]).8 Wang et al also evaluated risks associated with has a protective effect against the risk of offspring inheriting
ART and germline de novo variants.9 The authors found that certain genetic conditions.13,14 A Swedish study comparing
offspring conceived through ART had significantly more de outcomes and childhood health of pregnancies conceived
novo variants than those conceived naturally, even after via IVF with PGT vs IVF without PGT showed no significant
adjusting for parental age at conception.9 The underlying increased risk of adverse effects from PGT, indicating the
cause of parental infertility was associated with an increased biopsy of the trophectoderm performed during PGT does
risk of de novo variants, and most of the de novo variants not affect outcomes. Primary outcomes assessed were pre-
were of paternal origin, suggesting that the ART procedures term birth and low birth weight. Secondary outcomes
themselves may not have been the cause of the increased fre- assessed were for early childhood health including asthma,
quency of de novo variants.9 allergic disorders, sepsis, hypothyroidism, attention defi-
From a chromosomal pT techniques on aneuploidy rates cit/hyperactivity disorder, autism spectrum disorders, affec-
is an area of ongoing investigation. Kochanski et al reported tive disorders, schizophrenia, intellectual disabilities,
increased frequency of sex chromosome aneuploidy; how- cerebral palsy, epilepsy, and mortality from birth through
ever, the authors do not account for the possibility of parental end of follow-up in the study.15
sex chromosome abnormalities.10 Their study highlighted Genetic counseling can be challenging due to the com-
that ART can enable propagation of existing mutations. plexity of hereditary risk factors pursuant to IVF. Patients
For example, ART may aid a male with a microdeletion in should be informed of the increased risk for imprinting dis-
the AZF region with associated oligozoospermia to conceive, orders when ART is used; however, it should also be made
yet all male offspring would be expected to inherit the del- clear that this risk is still much lower than 1%. Although
eterious microdeletion.10 From a culture medium perspec- the use of ART is ethically complex, counselors and providers
tive, the impact of embryo culture and other laboratory should appropriately inform their patients on possible risks
techniques on aneuploidy lacks concrete evidence.11 In a associated with ART while respecting their right to reproduc-
study evaluating karyotypes of products of conception, abnor- tive autonomy.16
mal karyotypes did not correlate to the method of conception
(ie, ART vs naturally conceived pregnancies).12
When discussing ART and genetics, the option of preim- ART AND IMPRINTING DISORDERS
plantation genetic testing for aneuploidy (PGT-A), mono- Much of the discussion regarding the effects of ART on
genic disorders (PGT-M), and structural rearrangements genetics and genetic disorders has revolved around potential
(PGT-SR) must be considered. PGT is performed by increased risks of imprinting disorders in children conceived
obtaining a biopsy of a small sample of cells from the tro- via IVF. The timing of ART manipulations, such as ovarian
phectoderm of a blastocyst and testing this sample for either stimulation, intracytoplasmic sperm injection (ICSI), and
chromosomal abnormalities or single-gene conditions. embryo culture, overlap with the timing of epigenetic
Testing methodologies vary based on the laboratory, but in changes during the critical periods of fertilization and
general, next-generation sequencing and/or single-nucleo- implantation. During this period, changes in DNA methyla-
tide variant analysis are used to detect chromosomal abnor- tion levels are occurring, and the expression and impact of
malities; additionally, linkage analysis and/or direct imprinted genes, particularly in more common imprinting
detection are used to screen for single-gene conditions. disorders (Beckwith-Wiedemann syndrome [BWS], Russell-
The utility of PGT for polygenic risk scores and PGT for Silver syndrome [RSS], Angelman syndrome [AS], and
whole-exome sequencing is still being investigated, and they Prader-Willi syndrome [PWS]), have been investigated in
are not commonly used in IVF clinics currently. Patients the setting of ART.17,18
undergoing IVF can screen for chromosomal abnormalities A systematic review of DNA methylation levels and
before a transfer by using PGT-A. This allows patients at imprinting disorders in children conceived via ART con-
higher risk of aneuploidy (eg, patients with Turner syndrome cluded that children conceived via IVF, or ICSI, appear to
or advanced oocyte age) to reduce risk of aneuploidy in their be at a higher risk of any imprinting disorder than children

e92 NeoReviews
conceived naturally (odds ratio [OR], 3.67 [95% CI, 1.39– were conceived naturally.24,25 Aforementioned, limited evi-
9.74]).19 However, no significant association of altered dence also suggests ICSI may contribute to epigenetic errors
DNA methylation in other individual imprinted genes was and imprinting disorders. It is theorized that ICSI limits the
reported.19 Furthermore, recent evidence on specific ability for natural selection mechanisms because embryos are
imprinting disorders suggests that BWS after ART is particu- subject to environmental stressors that could lead to epige-
larly elevated compared with other imprinting disorders such netic changes, such as imprinting defects.24,26
as RSS, AS, and PWS (relative risk, 5.2 [95% CI, 1.6–7.4]).20 In conclusion, data on the relationship between imprint-
While this review did not find a statistically significant corre- ing disorders and ART are varied but overall tend to support
lation for RSS, AS, or PWS, the authors attributed overall an increased risk of imprinting disorders, particularly BWS,
lower incidence rates of these conditions as a potential limi- in pregnancies conceived with ART vs those conceived nat-
tation. They also reported that while BWS did have higher urally. It is important to note that causality cannot be inferred
prevalence in ART-conceived pregnancies, the study did at this time, as the current literature does not account for
not correct for fertility problems among the parents.20 imprinting risk that may come with subfertility, parental
In a 2007 analysis conducted by Doornbos et al that cor- age, and other factors. Additional studies should be com-
rected for fertility problems among parents of children pleted to further characterize this risk.
affected by BWS, AS, or PWS vs controls, the relative risk
was the same, suggesting subfertility could play a role in
the increased incidence of imprinting disorders in ART- ART AND BIRTH DEFECTS
conceived pregnancies.21 Multiple conflicting studies exist on the association between
The investigation by Johnson et al22 of the association ART and birth defects. A study conducted in Western
between BWS and ART-conceived pregnancies focused on Australia, using registry data from 1993–1997, found that
evaluating pregnancies with omphalocele and positive prena- infants conceived with ICSI or IVF had twice the risk of
tal testing for BWS compared with those with omphalocele major birth defects compared with infants born from nonas-
and negative BWS testing and found a 20-fold (P <.001) sisted conception, including IVF, IVF/ICSI, ovulation induc-
overrepresentation of positive BWS cases conceived via tion, and intrauterine insemination.27 However, an analysis
IVF compared with the rate of ART pregnancies in the of the South Australian Birth Defects Registry found no sig-
United States. However, this study was likely confounded nificant increase in major birth defects in IVF pregnancies
by ascertainment bias, given their population focused on after adjusting for parental characteristics, although a signifi-
pregnancies affected with omphalocele, which is a prenatal cant difference was observed in IVF/ICSI pregnancies.28 An
ultrasonogram finding known to be associated with BWS; analysis conducted in Massachusetts compared singletons
thus, prenatal centers may have been more likely to request and multiple-gestation livebirths with respect to association
BWS testing in the setting of an IVF pregnancy.22 Hattori of nonchromosomal birth defects in ART (ART-exposed),
et al23 conducted a nationwide epidemiological study in subfertile (ART-unexposed), and fertile (ART-unexposed)
Japan evaluating the association of ART with 4 common populations.29 A higher prevalence of nonchromosomal birth
imprinting disorders (BWS, RSS, AS, and PWS). The authors defects was noted in ART births (199.1 per 10 000) compared
found a 4.46-fold increased risk of BWS, 8.91-fold increase of with fertile births (139.9 per 10 000). The adjusted prevalence
RSS, 3.44-fold increase of PWS, and no statistically significant ratio (PR) for ART-conceived infants was 1.5 (95% CI, 1.3–1.6).
risk increase for AS (1.32-fold). Unique methylation patterns On the other hand, 6183 of the 445 080 neonates born to fertile
were observed in patients with RSS, leading the authors to mothers had birth defects, with a prevalence rate of 138.9 per
conclude a distinct period of vulnerability to epigenetic 10 000 live births. After adjusting for age, the PR of birth
changes exists immediately after fertilization, which is fur- defects for ART-conceived infants was 1.4 (95% CI, 1.3–1.6).
ther exacerbated by techniques such as IVF, ICSI, and culture No significant difference was seen when comparing the age-
mediums, ultimately contributing to imprinting disorders. adjusted PRs for mothers exposed to ART with mothers who
The inheritance pattern of BWS and AS are genetically hetero- have subfertility (PR, 1.2 [95% CI, 1.1–1.4]) (Table 3).29
geneous. They can be caused by other inheritance patterns A large US cohort study (2004–2015) using data from
aside from imprinting defects, such as sequence variants, the SART Clinical Online Reporting System linked to state
deletions, and uniparental disomy. Reviews have concluded birth defect registries found that singletons conceived via
BWS and AS conceived via IVF are more frequently associ- IVF with or without ICSI had an increased risk of major con-
ated with imprinting defects as the underlying genetic etiol- genital malformations, with male-factor infertility further
ogy when compared with children with BWS and AS who exacerbating risk, compared with children conceived without

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e93

 TABLE 3. Prevalence Rates and Age-Adjusted PRs for Nonchromosomal Birth Defects by Maternal Fertility
Exposure Status
Prevalence Rate per 10 000 Live Births

Subfertile ARTa Exposed

ARTa Exposed Subfertile Fertile Prevalence Prevalence
Birth defect (n = 17 829) (n = 9431) (n = 445 080) Ratiob (95% CI) Ratiob (95% CI)
Overall c,d 199.1 171.8 138.9 1.2 (1.1–1.4) 1.4 (1.3–1.6)
Cardiac Defectd 63.9 47.7 38.6 1.2 (0.9–1.6) 1.6 (1.3–1.9)
Conotruncal/Aortic arch 12.9 6.4 6.6 1.0 (0.4–2.2) 1.9 (1.3–3.0)
Tetralogy of Fallot 9.5 3.0 3.2 (1.9–5.5)
Left-Sided obstruction 6.2 6.2 0.9 (0.5–1.7)
Right-Sided obstruction 9.5 9.5 6.9 1.3 (0.7–2.9) 1.3 (0.8–2.1)
Pulmonary valve stenosis 8.4 8.5 5.6 1.4 (0.7–2.9) 1.4 (0.8–2.4)
Septal heart defects 35.9 26.5 20.5 1.2 (0.8–1.8) 1.7 (1.3–2.2)
Atrial septal defecte 24.1 14.8 14.0 1.0 (0.6–1.7) 1.6 (1.2–2.2)
Ventricular septal defectf 14.6 11.7 8.0 1.4 (0.8–2.6) 1.8 (1.2–2.7)
Non-cardiac Defect 145.8 133.6 109.1 1.2 (1.0–1.5) 1.4 (1.2–1.5)
Central nervous system 11.2 12.0 1.0 (0.6–1.6)
Respiratory defects 6.2 3.3 1.8 (1.0–3.4)
Orofacial 17.4 25.4 15.7 1.6 (1.1–2.4) 1.1 (0.8–1.6)
Cleft lip with/without cleft palate 10.1 9.5 7.0 1.4 (0.7–2.7) 1.4 (0.9–2.4)
Gastrointestinal 20.8 17.0 14.1 1.2 (0.7–2.0) 1.5 (1.1–2.1)
Genitourinary 47.1 44.5 32.9 1.3 (0.9–1.8) 1.3 (1.1–1.7)
Hypospadias, 2nd or 3rd degreeg 45.8 25.1 23.8 1.0 (0.6–1.8) 1.8 (1.3–2.5)
Obstructive genitourinary defect 15.7 14.8 12.0 1.2 (0.7–2.1) 1.3 (0.9–1.9)
Musculoskeletal 54.4 40.3 41.1 1.0 (0.8–1.4) 1.4 (1.2–1.8)
Club foot 14.0 9.5 11.5 0.9 (0.5–1.8) 1.4 (0.9–2.1)
Craniosynostosis 7.9 7.4 4.0 1.8 (0.8–3.7) 1.9 (1.1–3.3)
Polydactyly/Syndactyly 14.0 19.1 12.9 1.6 (1.0–2.5) 1.2 (0.8–1.8)

Abbreviations: ART, assisted reproductive technology.

Prevalence rates reported per 10,000 live births. Prevalence estimates not calculated for case counts less than 6.
a
Assisted reproductive technology.
b
Adjusted for maternal age (<35 years, ≥35 years). Fertile group is referent.
c
Any defect collected as part of surveillance by the Massachusetts Birth Defects Monitoring Program as described in Supplemental Table 1 [29].
Excludes cases with a Mendelian gene syndrome or chromosomal defect.
d
Excludes patent ductus arteriosus.
e
Does not include primum type.
f
Does not include canal type or isolated muscular type.
g
Prevalence per 10,000 male live births.
Printed with permission from Liberman RF, Getz KD, Heinke D, et al. Assisted reproductive technology and birth defects: effects of subfertility and
multiple births. Birth Defects Res. 2017;109(14):1144–1153.29

ART (non-IVF/ICSI: aOR, 1.18 [95% CI, 1.05–1.32]; IVF/ICSI ART AND STILLBIRTH
without male-factor infertility: aOR, 1.30 [95% CI, 1.16–1.45]; Current literature shows an increased risk of perinatal death
IVF/ICSI with male-factor infertility: aOR, 1.42 [95% CI, in ART pregnancies. A systematic review and meta-analysis
1.28–1.57]).30 Non-IVF/ICSI–conceived singletons were also found a higher risk of stillbirths (defined as intrauterine
at higher risk for cardiovascular defects (aOR, 1.2 [95% CI,
death occurring at or after 20 weeks’ gestation) in ART sin-
1.03–1.40]).30 Additionally, when comparing ART-conceived
gleton pregnancies (OR, 1.82 [95% CI, 1.37–2.42]) compared
singleton births, the use of ICSI was associated with
with natural conceptions.32 One study found a significantly
increased risk of major nonchromosomal birth defects
greater risk of stillbirth in ART singletons born before 28
(aOR, 1.18 [95% CI, 1.03–1.35]).30
weeks’ gestation, although no difference was found after
In summary, most studies indicate an increased risk of
birth defects with IVF/ICSI, although the overall risk 28 weeks’ gestation.33 Interestingly, ART twins had a lower
remains low (approximately 3.6% vs 3% in the general pop- stillbirth risk compared with naturally conceived twins until
ulation). The Society of Maternal Fetal Medicine recom- 40 weeks’ gestation.33 In comparison with pregnancies con-
mends that a fetal echocardiogram can be considered for ceived with ART and/or infertility treatment (eg, ovulation
pregnancies conceived via IVF with ICSI to allow for early induction, artificial insemination, or intrauterine insemina-
detection of congenital malformations (Grade 2C, weak rec- tion), the lowest stillbirth rate was seen at 38 weeks’ gestation
ommendation/low-quality evidence).31 with progressively increasing stillbirth risk seen for infants

e94 NeoReviews
FIGURE 1. Comparison of rate of infant deaths or neonatal morbidities vs rate of stillbirths and infant deaths or neonatal morbidities in the
subsequent week of gestation in term pregnancies conceived with infertility treatment or assisted reproductive technology (ART).34

born after 38 weeks’ gestation (Figure 1).34 Investigations greater need of respiratory support during NICU admission.
into the association of stillbirth and ART are limited by the Wang et al found that late-preterm infants conceived via ART
overall low incidence of stillbirths resulting in a smaller sam- had a higher risk of NICU admission (OR, 2.08 [95% CI, 1.1–
ple size and lower statistical power. Further research is 4.7]) and required more aggressive respiratory support (OR,
needed to determine causal factors and ascertain delivery 2.53 [95% CI, 1.12–5.70]) compared with natural concep-
timing for ART-conceived pregnancies. tions.44 The study stratified ART conceptions into IVF and
non-IVF fertility treatments. It demonstrated that noninva-
sive fertility treatments with pharmacologic agents such as
ART AND PERIPARTUM MORBIDITY
selective estrogen receptor modulators, aromatase inhibi-
Pregnancies conceived via ART are at higher risk for abnor- tors, and gonadotropins have an increased risk of NICU
mal placentation (placenta accreta spectrum, placenta previa, admission (OR, 3.70 [95% CI, 1.3–10.7]) compared with non-
or vasa previa).35–37 Studies linking these associations are assisted conceptions.44 Furthermore, upon NICU admis-
confounded by type of embryo transfer, with frozen-embryo sion, infants conceived with fertility treatments are more
transfers associated with higher risk of anatomic, inflamma- likely to need supplemental respiratory support, including
tory, and vascular malperfusion abnormalities within the pla- continuous positive airway pressure, intermittent mechani-
centa.38,39 The MOSART study found that abnormal cal ventilation, or surfactant replacement therapy, compared
placentation was among the strongest contributors to pre- with naturally conceived infants. Al-Hathlol et al found no
term birth in ART treatment.40 ART singleton pregnancies detectable relationship with neonatal outcomes and duration
also have higher cesarean section rates, with a 1.9-fold of NICU stay among very low-birth-weight preterm infants
increase compared with natural conceptions. This includes conceived by IVF in comparison with neonates of unassisted
a 1.91-fold increase in elective and a 1.38-fold increase in conception.45 As data on ART and NICU admissions are lim-
emergent cesarean section.41,42 Postpartum hemorrhage ited, continued research is needed in this area.
and blood loss are also higher in IVF/ICSI pregnancies.43
Early intervention, such as use of uterotonics at 500 mL of
ART AND LONG-TERM OUTCOMES
estimated blood loss, may help reduce these risks.
Concerns about adverse cardiometabolic outcomes in chil-
dren conceived via ART have been raised46–48, although
ART AND NEONATAL INTENSIVE CARE UNIT large cohort studies show no significant differences in
ADMISSION cardiovascular disease (adjusted hazard ratio [aHR], 1.02
ART is associated with preterm birth and increased neonatal [95% CI, 0.86–1.22]) or type 2 diabetes (aHR, 1.31 [95%
intensive care unit (NICU) admissions. Current data are con- CI, 0.82–2.09]) between ART- and naturally conceived chil-
flicting with respect to association of ART conception with dren.49 A small increase in obesity has been associated with

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e95

 ART conception (aHR, 1.14 [95% CI, 1.06–1.23]).12 There conditions.58 Finally, as previously noted, ASRM promotes
has been an increased risk of type 1 diabetes seen in ART- elective single-embryo transfer to minimize the risk of multi-
conceived pregnancies from frozen-embryo transfer com- ple gestations due to the associated increases in adverse
pared with fresh-embryo transfers (aHR, 1.52 [95% CI, obstetrical and perinatal outcomes of multiple gestations.6
1.08–2.14]) and frozen-embryo transfers compared with Shared decision-making and thorough counseling regarding
natural conception (aHR, 1.41 [95% CI, 1.05–1.89]).50 risk are critical in these challenging ethical scenarios.
Previously, the risk of cerebral palsy was found to be
higher among pregnancies conceived through ART than CONCLUSIONS
natural conception (aOR, 2.76 [95% CI, 2.03–3.67]).14
Over the past decade, ART guidelines have evolved to priori-
However, recent studies have shown that the risk has
tize patient safety and optimize neonatal outcomes to adjust
decreased (aOR, 1.39 [95% CI, 1.01–1.87]) due to the decrease
for rising use and success rates of ART. Further research
in ART multiples and has been shown to be no longer asso-
is needed to assess the relationship between ART and
ciated with ART singleton pregnancies (aOR, 1.11 [95% CI,
adverse perinatal outcomes. The literature suggests ART
0.98–1.24]).51 Several systematic reviews have found no
may increase the risks of rare imprinting disorders in a preg-
differences on language development, behavior, or social
nancy, but IVF with PGT can reduce the risk of many other
functioning for ART-conceived pregnancies.52–54 Further-
more common genetic conditions. Recent improvements in
more, educational outcomes and age-related development
accessing ART and perinatal outcome data will allow physi-
were equivalent between groups.54
cians to improve counseling of their patients on short-term
The long-term impact on mental health for children born
and long-term risks associated with ART-conceived pregnan-
from ART must be considered as well. Previously, there was
cies for themselves and their future neonate.
concern that children born from ART would have a higher
prevalence of psychological disorders. Recent studies of chil-
dren born from ART show no major psychological dif-
ferences compared with naturally conceived children.55,56 American Board of Pediatrics
Specifically in the examination of reproductive donation, Neonatal-Perinatal Content
comparisons of families formed through donor gametes or Specification
gestational carriers vs families formed through natural con- • Recognize abnormalities of the umbilical cord, fetal
ception showed no difference in adjustment problems, self- membranes, and placenta
esteem, or psychological well-being by age 14 years.57 In con- • Understand pregnancy physiology
trast, another study from Sweden showed a lower incidence
of emotional and behavioral problems in children born to
families who conceived using donor sperm or egg.56 While References
the evidence above is reassuring, further longitudinal studies
1. World Health Organization. 1 in 6 people globally affected by
are warranted to understand the long-term impact beyond
infertility: WHO. Published April 4, 2023. Accessed February
adolescence. 20, 2024. https://www.who.int/news/item/04-04-2023-1-in-6-
people-globally-affected-by-infertility.
2. Centers for Disease Control and Prevention. Infertility:
ETHICAL CONSIDERATIONS AND CHALLENGES frequently asked questions. Published May 15, 2024. Accessed
February 20, 2024. https://www.cdc.gov/reproductivehealth/
ART raises ethical concerns due to the inherent risks of fer- infertility/.
tility treatment, including venous thromboembolism, multi- 3. Centers for Disease Control and Prevention. 2021 National ART
ple gestation, preterm birth, and preeclampsia. These risks summary. Published January 11, 2024. Updated September 11,
are further increased in patients with baseline comorbidities, 2024. Accessed February 20, 2024. https://www.cdc.gov/art/
reports/2021/summary.html#:~:text=Based%20on%20the%
such as an inherited thrombophilia, psychiatric disorders,
20ART%20cycles,and%2097%2C128%20live%20born%
and obesity.58 ASRM advises reproductive endocrinologists 20infants
to counsel patients on these risks and obtain consultations 4. Qin JB, Sheng XQ, Wu D, et al. Worldwide prevalence of
when needed. An example of this includes vascular Ehlers- adverse pregnancy outcomes among singleton pregnancies after
in vitro fertilization/intracytoplasmic sperm injection: meta-
Danlos syndrome, which carries greater risk of maternal
analysis. Arch Gynecol Obstet. 2017;295(2):285–301. PubMed
mortality and a 50% chance of having an affected off- doi: 10.1007/s00404-016-4250-3
spring. Providers should also discuss PGT-M and gestational 5. American Society for Reproductive Medicine. Oversight of
carrier options for high-risk patients with complex genetic assisted reproductive technology. Published 2010. Updated 2021.

e96 NeoReviews
 Accessed February 20, 2024. https://www.asrm.org/advocacy- Update. 2015;21(4):555-557]. Hum Reprod Update. 2014;20(6):
and-policy/media-and-public-affairs/oversite-of-art/. 840–852. PubMed doi: 10.1093/humupd/dmu033
6. Practice Committee of the American Society for Reproductive 20. Vermeiden JP, Bernardus RE. Are imprinting disorders more
Medicine and the Practice Committee for the Society for prevalent after human in vitro fertilization or intracytoplasmic
Assisted Reproductive Technologies. Guidance on the limits to sperm injection? Fertil Steril. 2013;99(3):642–651. PubMed
the number of embryos to transfer: a committee opinion. Fertil doi: 10.1016/j.fertnstert.2013.01.125
Steril. 2021;116(3):651–654. PubMed doi: 10.1016/j.fertnstert. 21. Doornbos ME, Maas SM, McDonnell J, Vermeiden JP,
2021.06.050 Hennekam RC. Infertility, assisted reproduction technologies
7. Luke B. Pregnancy and birth outcomes in couples with infertility and imprinting disturbances: a Dutch study. Hum Reprod.
with and without assisted reproductive technology: with an 2007;22(9):2476–2480. PubMed doi: 10.1093/humrep/dem172
emphasis on US population-based studies. Am J Obstet Gynecol. 22. Johnson JP, Beischel L, Schwanke C, et al. Overrepresentation of
2017;217(3):270–281. PubMed doi: 10.1016/j.ajog.2017.03.012 pregnancies conceived by artificial reproductive technology in
8. Huang Z, Xiao F, Xiao H, et al. Comparison of genetic profiles prenatally identified fetuses with Beckwith-Wiedemann
of neonates in intensive care units conceived with or without syndrome. J Assist Reprod Genet. 2018;35(6):985–992. PubMed
assisted reproductive technology. JAMA Netw Open. 2023;6(4): doi: 10.1007/s10815-018-1228-z
e236537. PubMed doi: 10.1001/jamanetworkopen.2023.6537 23. Hattori H, Hiura H, Kitamura A, et al. Association of four
9. Wang C, Lv H, Ling X, et al. Association of assisted reproductive imprinting disorders and ART. Clin Epigenetics. 2019;11(1):21.
technology, germline de novo mutations and congenital heart PubMed doi: 10.1186/s13148-019-0623-3
defects in a prospective birth cohort study. Cell Res. 2021;31(8): 24. Fauser BC, Devroey P, Diedrich K, et al; Evian Annual
919–928. PubMed doi: 10.1038/s41422-021-00521-w Reproduction (EVAR) Workshop Group 2011. Health outcomes
10. Kochanski A, Merritt TA, Gadzinowski J, Jopek A. The impact of children born after IVF/ICSI: a review of current expert
of assisted reproductive technologies on the genome and opinion and literature. Reprod Biomed Online. 2014;28(2):
epigenome of the newborn. J Neonatal Perinatal Med. 2013;6(2): 162–182. PubMed doi: 10.1016/j.rbmo.2013.10.013
101–108. PubMed doi: 10.3233/NPM-1366812 25. Manipalviratn S, DeCherney A, Segars J. Imprinting disorders
11. Swain JE. Controversies in ART: can the IVF laboratory and assisted reproductive technology. Fertil Steril. 2009;91
influence preimplantation embryo aneuploidy? Reprod Biomed (2):305–315. PubMed doi: 10.1016/j.fertnstert.2009.01.002
Online. 2019;39(4):599–607. PubMed doi: 10.1016/j.rbmo.2019. 26. Sciorio R, Tramontano L, Rapalini E, et al. Risk of genetic and
06.009 epigenetic alteration in children conceived following ART: is it
12. Li G, Jin H, Niu W, et al. Effect of assisted reproductive time to return to nature whenever possible? Clin Genet. 2023;
technology on the molecular karyotype of missed abortion 103(2):133–145. PubMed doi: 10.1111/cge.14232
tissues. Biosci Rep. 2018;38(5):BSR20180605. PubMed 27. Hansen M, Kurinczuk JJ, Bower C, Webb S. The risk of major
doi: 10.1042/BSR20180605 birth defects after intracytoplasmic sperm injection and in vitro
13. Lu Y, Liu L, Zhang P, Sun Y, Ma C, Li Y. Risk of birth defects fertilization. N Engl J Med. 2002;346(10):725–730. PubMed
in children conceived with assisted reproductive technology: doi: 10.1056/NEJMoa010035
a meta-analysis. Medicine (Baltimore). 2022;101(52):e32405. 28. Davies MJ, Moore VM, Willson KJ, et al. Reproductive
PubMed doi: 10.1097/MD.0000000000032405 technologies and the risk of birth defects. N Engl J Med.
14. Sánchez-Pavón E, Mendoza H, García-Ferreyra J. Trisomy 21 2012;366(19):1803–1813. PubMed doi: 10.1056/NEJMoa1008095
and assisted reproductive technologies: a review. JBRA Assist 29. Liberman RF, Getz KD, Heinke D, et al. Assisted reproductive
Reprod. 2022;26(1):129–141. PubMed doi: 10.5935/1518-0557. technology and birth defects: effects of subfertility and multiple
20210047 births. Birth Defects Res. 2017;109(14):1144–1153. PubMed
15. Ginström Ernstad E, Hanson C, Wånggren K, et al. doi: 10.1002/bdr2.1055
Preimplantation genetic testing and child health: a national 30. Luke B, Brown MB, Wantman E, et al. The risk of birth defects
register-based study. Hum Reprod. 2023;38(4):739–750. PubMed with conception by ART. Hum Reprod. 2021;36(1):116–129.
doi: 10.1093/humrep/dead021 PubMed doi: 10.1093/humrep/deaa272
16. Roy MC, Dupras C, Ravitsky V. The epigenetic effects of assisted 31. Ghidini A, Gandhi M, McCoy J, Kuller JA; Society for Maternal-
reproductive technologies: ethical considerations. J Dev Orig Fetal Medicine (SMFM). Electronic address: [email protected];
Health Dis. 2017;8(4):436–442. PubMed doi: 10.1017/ Publications Committee. Society for Maternal-Fetal Medicine
S2040174417000344 Consult Series #60: management of pregnancies resulting from
17. Uyar A, Seli E. The impact of assisted reproductive technologies in vitro fertilization. Am J Obstet Gynecol. 2022;226(3):B2–B12.
on genomic imprinting and imprinting disorders. Curr Opin PubMed doi: 10.1016/j.ajog.2021.11.001
Obstet Gynecol. 2014;26(3):210–221. PubMed doi: 10.1097/GCO. 32. Sarmon KG, Eliasen T, Knudsen UB, Bay B. Assisted
0000000000000071 reproductive technologies and the risk of stillbirth in singleton
18. Wilkins-Haug L. Assisted reproductive technology, congenital pregnancies: a systematic review and meta-analysis. Fertil Steril.
malformations, and epigenetic disease. Clin Obstet Gynecol. 2021;116(3):784–792. PubMed doi: 10.1016/j.fertnstert.2021.04.
2008;51(1):96–105. PubMed doi: 10.1097/GRF.0b013e318161d25a 007
19. Lazaraviciute G, Kauser M, Bhattacharya S, Haggarty P, 33. Henningsen AA, Wennerholm UB, Gissler M, et al. Risk of
Bhattacharya S. A systematic review and meta-analysis of DNA stillbirth and infant deaths after assisted reproductive
methylation levels and imprinting disorders in children technology: a Nordic study from the CoNARTaS group. Hum
conceived by IVF/ICSI compared with children conceived Reprod. 2014;29(5):1090–1096. PubMed doi: 10.1093/humrep/
spontaneously [published correction appears in Hum Reprod deu031

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e97

 34. Hamilton I, Martin N, Liu J, DeFranco E, Rossi R. Gestational children born after in vitro fertilization: follow-up study. J Clin
age and birth outcomes in term singleton pregnancies conceived Endocrinol Metab. 2008;93(5):1682–1688. PubMed doi: 10.1210/
with infertility treatment. JAMA Netw Open. 2023;6(8):e2328335. jc.2007-2432
PubMed doi: 10.1001/jamanetworkopen.2023.28335 47. Meister TA, Rimoldi SF, Soria R, et al. Association of assisted
35. Violette CJ, Mandelbaum RS, Matsuzaki S, Ouzounian JG, reproductive technologies with arterial hypertension during
Paulson RJ, Matsuo K. Assessment of abnormal placentation in adolescence. J Am Coll Cardiol. 2018;72(11):1267–1274. PubMed
pregnancies conceived with assisted reproductive technology. Int doi: 10.1016/j.jacc.2018.06.060
J Gynaecol Obstet. 2023;163(2):555–562. PubMed doi: 10.1002/ 48. Liu H, Zhang Y, Gu HT, et al. Association between assisted
ijgo.14850 reproductive technology and cardiac alteration at age 5 years.
36. Allen C, Bowdin S, Harrison RF, et al. Pregnancy and perinatal JAMA Pediatr. 2015;169(6):603–605. PubMed doi: 10.1001/
outcomes after assisted reproduction: a comparative study. jamapediatrics.2015.0214
Ir J Med Sci. 2008;177(3):233–241. PubMed doi: 10.1007/ 49. Norrman E, Petzold M, Gissler M, et al. Cardiovascular disease,
s11845-008-0172-9 obesity, and type 2 diabetes in children born after assisted
37. Romundstad LB, Romundstad PR, Sunde A, von Düring V, reproductive technology: a population-based cohort study. PLoS
Skjaerven R, Vatten LJ. Increased risk of placenta previa in Med. 2021;18(9):e1003723. PubMed doi: 10.1371/journal.pmed.
pregnancies following IVF/ICSI; a comparison of ART and non- 1003723
ART pregnancies in the same mother. Hum Reprod. 2006;21(9): 50. Norrman E, Petzold M, Clausen TD, et al. Type 1 diabetes in
2353–2358. PubMed doi: 10.1093/humrep/del153 children born after assisted reproductive technology: a register-
38. Hayashi M, Nakai A, Satoh S, Matsuda Y. Adverse obstetric and based national cohort study. Hum Reprod. 2020;35(1):221–231.
perinatal outcomes of singleton pregnancies may be related to PubMed doi: 10.1093/humrep/dez227
maternal factors associated with infertility rather than the type 51. Pinborg A, Wennerholm UB, Bergh C. Long-term outcomes for
of assisted reproductive technology procedure used. Fertil Steril. children conceived by assisted reproductive technology. Fertil
2012;98(4):922–928. PubMed doi: 10.1016/j.fertnstert.2012. Steril. 2023;120(3):449–456. PubMed doi: 10.1016/j.fertnstert.
05.049 2023.04.022
39. Volodarsky-Perel A, Ton Nu TN, Orvieto R, et al. The impact of 52. Middelburg KJ, Heineman MJ, Bos AF, Hadders-Algra M.
embryo vitrification on placental histopathology features and Neuromotor, cognitive, language and behavioural outcome in
perinatal outcome in singleton live births. Hum Reprod. 2022; children born following IVF or ICSI-a systematic review. Hum
37(10):2482–2491. PubMed doi: 10.1093/humrep/deac167 Reprod Update. 2008;14(3):219–231. PubMed doi: 10.1093/
40. Stern JE, Farland LV, Hwang SS, et al. Assisted reproductive humupd/dmn005
technology or infertility: what underlies adverse outcomes? 53. Bay B, Mortensen EL, Kesmodel US. Assisted reproduction and
Lessons from the Massachusetts Outcome Study of Assisted child neurodevelopmental outcomes: a systematic review. Fertil
Reproductive Technology. F S Rev. 2022;3(4):242–255. PubMed Steril. 2013;100(3):844–853. PubMed doi: 10.1016/j.fertnstert.
doi: 10.1016/j.xfnr.2022.06.003 2013.05.034
41. Lodge-Tulloch NA, Elias FTS, Pudwell J, et al. Caesarean section 54. Kennedy AL, Vollenhoven BJ, Hiscock RJ, et al. School-age
in pregnancies conceived by assisted reproductive technology: a outcomes among IVF-conceived children: a population-wide
systematic review and meta-analysis. BMC Pregnancy Childbirth. cohort study. PLoS Med. 2023;20(1):e1004148. PubMed
2021;21(1):244. PubMed doi: 10.1186/s12884-021-03711-x doi: 10.1371/journal.pmed.1004148
42. Pandey S, Shetty A, Hamilton M, Bhattacharya S, Maheshwari A. 55. Hart R, Norman RJ. The longer-term health outcomes for
Obstetric and perinatal outcomes in singleton pregnancies children born as a result of IVF treatment. Part II–mental health
resulting from IVF/ICSI: a systematic review and meta-analysis. and development outcomes. Hum Reprod Update. 2013;19
Hum Reprod Update. 2012;18(5):485–503. PubMed doi: 10.1093/ (3):244–250. PubMed doi: 10.1093/humupd/dmt002
humupd/dms018
56. Widbom A, Sydsjö G, Lampic C. Psychological adjustment in
43. Tang D, Cheng Y, Feng X, Li X, Coyte PC. The use of IVF/ICSI disclosing and non-disclosing heterosexual-couple families
and risk of postpartum hemorrhage: a retrospective cohort study following conception with oocytes or spermatozoa from identity-
of 153,765 women in China. Front Public Health. release donors. Reprod Biomed Online. 2022;45(5):1046–1053.
2023;11:1016457. PubMed doi: 10.3389/fpubh.2023.1016457 PubMed doi: 10.1016/j.rbmo.2022.06.011
44. Wang ET, Sundheimer LW, Spades C, Quant C, Simmons CF, 57. Golombok S, Ilioi E, Blake L, Roman G, Jadva V. A longitudinal
Pisarska MD. Fertility treatment is associated with stay in the study of families formed through reproductive donation: Parent-
neonatal intensive care unit and respiratory support in late adolescent relationships and adolescent adjustment at age 14.
preterm infants. J Pediatr. 2017;187:309–312. PubMed Dev Psychol. 2017;53(10):1966–1977. PubMed doi: 10.1037/
doi: 10.1016/j.jpeds.2017.05.020 dev0000372
45. Al-Hathlol K. Relationship between in vitro fertilization and 58. Ethics Committee of the American Society for Reproductive
neonatal outcomes in very low birth weight preterm infants. Am Medicine. Electronic address: [email protected]. Provision of
J Perinatol. 2018;35(11):1113–1118. PubMed doi: 10.1055/s-0038- fertility services for women at increased risk of complications
1641590 during fertility treatment or pregnancy: an Ethics Committee
46. Ceelen M, van Weissenbruch MM, Vermeiden JP, van Leeuwen opinion. Fertil Steril. 2022;117(4):713–719. PubMed doi: 10.1016/
FE, Delemarre-van de Waal HA. Cardiometabolic differences in j.fertnstert.2021.12.030

e98 NeoReviews
 NEOREVIEWS QUIZ

NEO
QUIZ

1. Infertility rates have increased in recent years. In the United States, data
indicate that 1 in 5 women of reproductive age is unable to conceive within
12 months of trying. Infants conceived via assisted reproductive technology
(ART) are at increased risk of preterm delivery and small-for-gestational-age
status. According to a 2021 Centers for Disease Control and Prevention (CDC)
report, what proportion of infants born in the United States are born via ART?
A. 2%.
B. 6%.
C. 10%.
D. 14%
E. 18%.
REQUIREMENTS: Learners can
2. Guidelines to decrease the risk of higher-order pregnancies after ART were take NeoReviews quizzes and
published in 2021 by the American Society for Reproductive Medicine. While claim credit online only at:
the incidence of higher-order pregnancies has declined, the incidence of twin https://publications.aap.org/
gestations has remained high. What is the proportion of twin pregnancies neoreviews.
due to non-in vitro fertilization (IVF) ART?
To successfully complete 2025
A. 9%. NeoReviews articles for AMA PRA
B. 14%. Category 1 Credit™, learners must
demonstrate a minimum
C. 21%.
performance level of 60% or
D. 29%. higher on this assessment. If you
E. 34%. score less than 60% on the
assessment, you will be given
3. The risk of adverse perinatal outcomes is increased in IVF pregnancies with
additional opportunities to
higher-order gestation compared with IVF singleton pregnancies. These answer questions until an overall
include increased risk of preterm birth and low birth weight. Which of the 60% or greater score is achieved.
following statements also represents an adverse perinatal outcome in higher-
order IVF pregnancies compared with singleton IVF pregnancies? This journal-based CME activity is
available through Dec. 31, 2027,
A. Increased risk of abruption. however, credit will be recorded
B. Increased risk of fetal growth restriction. in the year in which the learner
C. Increased risk of gestational diabetes. completes the quiz.

D. Increased risk of pregnancy-induced hypertension.

E. Increased risk of polyhydramnios.
4. In a systematic review, the risk of imprinting disorders in children conceived
via ART was found to be increased. Which of the following imprinting
disorder was recently found to be at a particularly increased risk?
2025 NeoReviews is approved for
A. Russell-Silver syndrome. a total of 10 Maintenance of
Certification (MOC) Part 2 credits
B. Angelman syndrome.
by the American Board of
C. Prader-Willi syndrome. Pediatrics (ABP) through the AAP
D. Transient neonatal diabetes mellitus. MOC Portfolio Program.
E. Beckwith-Wiedemann syndrome. NeoReviews subscribers can claim
up to 10 ABP MOC Part 2 points
5. While the risk remains low overall, studies indicate an increased risk of birth upon passing 30 quizzes (and
defects after IVF via intracytoplasmic sperm injection (ICSI). Which of the claiming full credit for each quiz)
following intervention is recommended for pregnancies conceived via IVF/ICSI? per year. Subscribers can start
claiming MOC credits as early as
A. Fetal brain magnetic resonance imaging (MRI). October 2025. To learn how to
B. Fetal echocardiogram. claim MOC points, go to: https://
C. Weekly nonstress test starting at 34 weeks of gestation. publications.aap.org/journals/
D. Early screening for gestational diabetes before 24 weeks’ gestation. pages/moc-credit.
E. Increased folic acid intake to 4000 μg daily.

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e99

 ARTICLE

Applications of Metabolomics and

Lipidomics in the Neonatal Intensive
Care Unit
Jonathan D. Reiss, MD,1 Samson J. Mataraso, BS,2,4 Lindsay F. Holzapfel, MD,3 Ivana Marić, PhD,1
Maya M. Kasowski, MD, PhD,4,5 Camilia R. Martin, MD,6 Jonathan Z. Long, PhD,7 David K. Stevenson, MD,1,4
Gary M. Shaw, DrPH,1 on behalf of the Stanford Metabolic Health Center

EDUCATIONAL GAPS

Clinicians caring for newborns should understand the translational rel-

evance of the metabolome and lipidome and the potential for identification
of novel mechanistic pathways and biomarker(s) for common disease out-
comes such as bronchopulmonary dysplasia and necrotizing enterocolitis.

OBJECTIVES After completing this article, readers should be able to:

ABBREVIATIONS

BPD bronchopulmonary dysplasia 1. Describe commonly used nomenclature for terms related to evaluation
HIE hypoxic-ischemic and measurement of the metabolome and lipidome.
encephalopathy
IVH intraventricular hemorrhage 2. Recognize the potential impact of exposures on the neonatal metabo-
LASSO least absolute shrinkage and
lome and lipidome.
selection operator
MS mass spectrometry 3. Characterize aspects of biomarker(s) identification for common neonatal
MS/MS tandem mass spectrometry
NEC necrotizing enterocolitis
and infantile disorders.
NMR nuclear magnetic resonance 4. Describe technical and analytic considerations and challenges for metab-
ROP retinopathy of prematurity
SCFA short chain fatty acids. olomic and lipidomic investigations.

1
Department of Pediatrics, Division of AUTHOR DISCLOSURE: Dr Martin works under a grant, has received honorarium, has traveled
Neonatology, Stanford University School of with the support of Reckitt/Mead Johnson and Baxter, and has given expert testimony with the
Medicine, Palo Alto, California; support of Abbott Nutrition. They have been a part of a data safety monitoring board or
2
Department of Anesthesiology, advisory board for LactaLogics, Vitara, and Plakous. Drs Reiss, Mataraso, Holzapfel, Maric,
Perioperative and Pain Medicine, Stanford Kasowski, Long, Stevenson, and Shaw have disclosed no financial relationships relevant to this
University School of Medicine, Stanford, article. This article does not contain a discussion of an unapproved/investigative use of a
California; 3Department of Pediatrics, commercial product/device.
Division of Neonatology, McGovern Medical
Accepted for Publication Date: October 30, 2024
School, University of Texas Health Science
Center at Houston, Houston, Texas; https://doi.org/10.1542/neo.26-2-011
4
Metabolic Health Center, Stanford Copyright © 2025 American Academy of Pediatrics
University, Palo Alto, California;
5
Department of Pathology, Stanford
University School of Medicine, Palo Alto,
California; 6Division of Neonatology,
Department of Pediatrics, Weill Cornell
Medicine, New York, New York; and
7
Department of Pathology, Chemistry,
Engineering and Medicine for Human
Health, Stanford University School of
Medicine, Stanford, California

e100 NeoReviews
ABSTRACT
The metabolome and lipidome comprise the thousands of molecular compounds in an organism. Molecular com-
pounds consist of the upstream metabolic components of intracellular reactions or the byproducts of cellular path-
ways. Molecular and biochemical perturbations are associated with disorders in newborns and infants. The diagnosis
of inborn errors of metabolism has relied on targeted metabolomics for several decades. Newer approaches offer the
potential to identify novel biomarkers for common diseases of the newborn and infant. They may also elucidate novel
predictive or diagnostic measures for a variety of health trajectories. Here, we review the relevance of the metabolome
and lipidome for common disorders and highlight challenges and opportunities for future investigations.

INTRODUCTION delivery. This is particularly beneficial in neonatal intensive

Newborns represent a vulnerable and understudied popula- care units (NICUs), where precise and personalized nutri-
tion because of organ underdevelopment and associated tional support can aid in growth, development, prevention
enzymatic and metabolic immaturity.1 Molecular medicine of future disease, and repair from injury.
and systems biology approaches including metabolomics Fundamentally, investigations interrogating the neonatal
and lipidomics represent an objective method to identify metabolome and lipidome also advance general knowledge
health and disease states.2–5 Translating molecular medicine of developmental biology. Molecular biomarkers can provide
approaches by incorporating metabolomic and lipidomic benchmark and foundational developmental patterns for
data are critical for furthering biologic, clinical, and therapeu- healthy newborns. They may also augment the utility of rela-
tic insights. The metabolome is the comprehensive set tively nonspecific clinical definitions through incorporation
of extra- and intracellular small-molecule (more than of objective molecular markers or patterns of disease for out-
1500 Da) substrates, intermediates, and end products (ie, comes and associated phenotypes that remain poorly defined.
amino acids, sugars, nucleotides, organic acids, lipids) that Through incorporation of objective molecular markers,
can be measured within a biological sample.2,3,6 The metab- researchers can subset nonspecific clinical definitions into
olome provides a snapshot of the unique metabolic state of more precisely defined metabolic categories. Most neonatal out-
an individual patient. This may permit an understanding come definitions still rely heavily on nonspecific operational
of both normal metabolic pathways and deviations that definitions that do not always precisely define pathobiology.1
increase susceptibility to developmental and/or acquired dis- This review will highlight general considerations, chal-
orders. The lipidome, a distinct field of its own, encompasses lenges, and opportunities for metabolomics and lipidomics
a chemically diverse cohort of nonpolar hydrocarbons that as applied to neonates and infants. Definitions for tech-
play a uniquely critical role in neonatal health.7,8 Lipids are niques, approaches, and available databases are highlighted
essential for a number of activities, including cell membrane in Tables 1 and 2. We will provide a broad overview of metab-
formation, organogenesis, second messenger signaling, olomics and lipidomics investigations in neonates and
energy storage, and intercellular communication.7–10 infants, outline considerations for the interested investigator
Metabolomic and lipidomic profiling holds the potential to and clinician alike, and highlight challenges and future
identify preclinical molecular alterations that signify suscep- opportunities for translational studies in the NICU. We refer
tibility to disease. Many serious conditions that manifest in interested readers to the many outstanding publications that
childhood, adolescence, and adulthood can be traced to meta- cover preprocessing and analytic workflows, which will not
bolic abnormalities present in mothers and their offspring.11 be covered in this review.5,11,13–19
Early intervention by identification and detection of alterations
in individualized metabolic and lipidomic data may signifi- TECHNICAL CONSIDERATIONS
cantly alter the course of these conditions, potentially reducing Metabolomics and lipidomics systematically identify and
their clinical impact or mitigating their biologic effects. This potentially quantify the diverse range of compounds present
principle serves as the underlying foundation of state-spon- within a biological sample, providing a biochemical snapshot
sored newborn screening programs nationally.12 From a clini- of the metabolic state of an organism (Figure 1A). Sample
cal perspective, comprehensive metabolomic and lipidomic processing may involve various techniques, including
profiling may facilitate the creation of targeted nutritional nuclear magnetic resonance (NMR) spectroscopy and mass

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e101

 TABLE 1. Definitions of Instruments and Terms Used in Metabolomics and Lipidomics Research
Instrument/Term Definition Characteristics
a
MS Measures the mass-to-charge ratio of ions, enabling Extremely sensitive and can detect compounds in very
molecular identification and quantification low concentrations
Adaptable for both targeted and untargeted studies
Targeted MSa Quantitatively analyzes a priori–selected metabolites High precision and accuracy
or lipids
Untargeted MSa Identifies all present compounds without prior Often used for exploratory hypothesis-generating
knowledge of what may be present. Comprehensive studies
approach designed to capture a diverse array of
compounds.
NMR spectroscopya Applies a magnetic field and radiofrequency pulses to Unlike MS, does not require the ionization of samples
a sample to detect the energy changes of certain and is nondestructive
atomic nuclei (ie, 1H or 13C) Highly reproducible and quantitative
Generally less sensitive than MS and less commonly
used in untargeted studies due to its lower
sensitivity and the complex data interpretation it
requires
a
LC-MS Combines the separation capabilities of LC with the Adaptable for both targeted and untargeted
analysis capabilities of spectrometry approaches, providing extensive coverage and
Used for analyzing complex biological samples detailed structural insights
containing biomolecules that vary in size and
polarity such as in lipidomics studies
Allows for separation of lipids prior to their ionization
and detection, improving the specificity and
sensitivity of the analysis
a
GC-MS Hybrid analytical method that is especially suited for Incredibly sensitive and capable of detecting
the analysis of volatile and semi-volatile compounds compounds at very low concentrations
Often used for the analysis of fatty acids, sterols, and Requirement for compound volatility often
organic acids necessitates derivatization of samples, which can
The GC component separates compounds based on complicate sample preparation
their volatility and interaction with the column
material followed by their detection using MS
Annotated compounds Compounds for which structural or functional Can be readily identified and quantified in biological
information is already known and catalogued in samples using reference standards or by matching
available databases experimental data with existing data (ie, mass,
retention time and spectral patterns) in
comprehensive metabolite or lipid libraries
Unannotated compounds Compounds that have not been previously identified Represent a significant portion of the metabolites or
or for which there is no available reference lipids detected in typical untargeted analyses
information in existing databases Pose both a challenge and an opportunity for
Identification of unannotated compounds generally researchers
follows a multistep process involving both Identifying these unknown compounds is crucial for
advanced analytical techniques and computational discovering new biomarkers or biochemical
tools pathways but requires sophisticated techniques and
approaches

Abbreviations: GC, gas chromatography; LC, liquid chromatography; MS, mass spectrometry; NMR, nuclear magnetic resonance.
a
The choice between these instruments and techniques largely depends on the specific objectives of the scientific question. For instance, LC-MS is
preferred in lipidomics due to its ability to handle the diverse chemistry of lipid molecules, whereas GC-MS might be chosen for metabolomics
involving volatile organic compounds. NMR, despite its lower sensitivity, provides valuable quantitative data for targeted analysis without
derivatization or ionization, largely preserving the sample specimen. Each analytical technique used in targeted and untargeted metabolomics
and lipidomics has strengths and weaknesses. MS provides high sensitivity and is versatile for both targeted and untargeted studies. NMR
offers high reproducibility and structural information. LC-MS and GC-MS provide powerful combinations of separation and detection
capabilities. The choice of method depends on the specific requirements of the study, including the nature of the sample, the types of
metabolites or lipids of interest, and the desired level of molecular characterization.

spectrometry (MS), to analyze the complex chemical compo- eliminate large molecules (ie, DNA, RNA, and proteins)
sition of cells, tissues, or biofluids. The processing of while retaining hydrophobic and hydrophilic small-molecule
samples involves several steps to ensure accuracy and repro- metabolites and lipid compounds. High-throughput analyti-
ducibility. Initially, biological samples are collected and cal platforms, primarily MS and NMR, are employed to detect
stored, often in −80 °C, to prevent degradation. Samples and quantify metabolites and lipids. In MS-based metabolo-
undergo preparation protocols that may include centrifuga- mics, samples are run through liquid or gas chromatography
tion, filtration, or derivatization, depending on the analytical and ionized, allowing the mass-to-charge ratios of the metab-
technique to be used. The ultimate goal of these steps is to olites to be measured via mass spectrometry. Fragmentation

e102 NeoReviews
TABLE 2. Databases That Provide Compound Matching and Identificationa
Database Description Characteristics
MassBank of North America (MoNA) An extensive public repository of mass spectra It provides an open-access platform for
https://mona.fiehnlab.ucdavis.edu/ for small molecules, including metabolites, researchers to search and match experimental
contaminants, synthetic molecules, and mass spectra against a broad library of
biological macromolecules reference spectra
Human Metabolome Database Contains detailed information about small Specifically designed for human metabolic
(HMDB) molecule metabolites found in the human research
https://hmdb.ca/ body Useful for linking metabolomic profiles to human
Includes chemical, clinical, and molecular health
biology/biochemistry data
METLIN Metabolite database specifically developed for Often used for both identification and structural
https://metlin.scripps.edu/ metabolomics by providing tandem mass characterization of metabolites in biological
landing_page.php? spectrometry data for thousands of samples
pgcontent=mainPage compounds across a variety of conditions
LipidMaps Categorizes lipids and provides detailed Focuses on lipids
https://www.lipidmaps.org/ molecular information including mass spectral Provides comprehensive data on lipid structures
data, which is crucial for lipidomics studies and their biological functions
PubChem Hosted by the National Center for Biotechnology Includes a vast amount of information on
https://pubchem.ncbi.nlm.nih.gov/ Information chemical structures, identifiers, chemical and
A free database of chemical molecules and their physical properties, biological activities, patents,
activities against biological assays health, safety, toxicity data, and analytical
spectra
ChemSpider Owned by the Royal Society of Chemistry Serves as a chemical search engine that
https://www.chemspider.com/ Free chemical structure database provides access aggregates and indexes chemical structures
to over 63 million chemicals, properties, and and their associated information into a single
associated information searchable repository
GoIm Metabolome Database (GMD) Database specializes in gas chromatography/ Particularly useful for metabolomics studies that
http://gmd.mpimp-golm.mpg.de/ mass spectrometry data involve GC-MS, providing reference spectra,
retention indices, and metabolite profiles
National Institute of Standards and Provides a wide range of data on chemical and Particularly useful for matching and identifying
Technology Chemistry WebBook physical properties of pure compound compounds based on their mass spectra
https://webbook.nist.gov/
chemistry/

Abbreviation: GC-MS, gas chromatography/mass spectrometry.

a
Databases listed provide compound matching and identification. They provide extensive libraries of compound structures, spectra, and other
relevant data that facilitate the identification of both known and unknown compounds. These databases are integral to the workflows in
metabolomics and lipidomics, enabling researchers to identify unknown compounds, understand their functions, and link molecular profiles to
biological pathways and disease states. Each database may specialize in different types of data or analytical approaches. Investigators will often
utilize multiple databases to confirm compound identities and curate as much information as possible for a given molecule.

enables an additional dimension of identification, as metab- metabolic or signaling pathways and model interactions
olites have unique fragmentation patterns after collision with between individual molecules as well as between different
high-energy particles. The resulting data are processed pathways with distinct biologic function. Advanced machine
through bioinformatics pipelines to identify and quantify learning methods including supervised and unsupervised
(relative or absolute concentrations) the metabolites, typically approaches may be used for feature selection and predictive
involving peak detection, deconvolution, and normalization modeling. Validation and reproducibility techniques often
steps. The processed data are then analyzed using computa- employ training and test cohorts with cross-validation and
tional methods to interpret the metabolic signals and to iden- external validation approaches. Thorough reporting and
tify significant changes related to the biological condition documentation of methodologies and workflows are crucial
under study.2,4,18,20 for transparency and reproducibility. These steps, while
Computational methods, including differential, multi- adaptable to specific requirements, form the foundation of
variate, and machine learning techniques, identify signifi- transforming high-throughput biological data into meaning-
cant differences and patterns in the high-dimensional ful insights.2,21–23 The above approaches can be used for a
biologic data (Figure 1B). Annotation and identification focus variety of biological samples. Note, because of their chemical
on matching molecular features to known databases or infer- structures, metabolomic workflows interrogate mostly water-
ring structures of novel compounds. Univariate analyses are soluble polar compounds, whereas lipidomics focuses
used to identify statistically significant associations followed mostly on hydrophobic nonpolar compounds.24 Although
by multiple hypothesis testing to control the false discovery a wide range of chemical diversity exists among lipid classes,
rate. Pathway and network analyses map features to many individual compounds share structural similarities

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e103

 FIGURE 1. Overview of omics approaches and workflows. (A) The sequential layers of omics technologies, starting from genomics (DNA
sequencing) to transcriptomics (messenger RNA analysis), proteomics (protein profiling), and metabolomics (metabolite identification). The
arrows originating from metabolomics to the different layers signify feedback mechanisms, in which changes in metabolite levels can
influence gene expression, protein activity, and messenger RNA level. (B) Workflow for untargeted metabolomics in the discovery of disease
biomarkers for a hypothetical retrospective case-control study design. (1) Study design involves selecting healthy individuals and diseased
patients. (2) Sample collection encompasses obtaining biological samples such as blood, stool, or urine. (3) Pretreatment includes extraction
protocols to prepare the samples for analysis. (4) Data acquisition utilizes mass spectrometry to generate metabolic profiles. (5) Statistical
analysis is performed to identify statistically significant metabolites. (6) Biomarker identification focuses on pinpointing potential biomarkers
from the data. (7) Pathway analysis integrates further analysis and database searches to understand metabolic pathways. (8) Biological
interpretation involves validating the potential biomarkers through additional studies, aiding in the comprehensive understanding of disease
mechanisms and potential therapeutic targets. Figure created at BioRender.com.
Abbreviations: BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage; NEC, necrotizing enterocolitis; ROP, retinopathy of
prematurity.

with permutations in double bond location or carbon chain technologies and data analysis methods aim to progressively
length.7 address these limitations.25–28
Despite progress over the last 2 decades, challenges and
limitations exist with current workflows. The complexity of
the metabolome and lipidome and the vast diversity of METABOLOMICS AND LIPIDOMICS DRIVE
metabolites require sophisticated analytical and computa- FUNDAMENTAL BIOLOGIC PROCESSES
tional tools, which can be resource intensive. Moreover, Metabolite and lipid compounds play fundamental roles in
the sensitivity of compounds to preanalytical and analytical human biology. They serve as major structural components
conditions necessitates rigorous standardization and quality of cellular membranes and heavily influence energy storage,
control measures that are not always uniform across labora- signaling, and overall metabolic processes.7 Owing to their
tories, core facilities, or institutions. The reproducibility and biologic immaturity, preterm neonates often face challenges
generalizability of study findings remain some of the greatest in achieving and maintaining a homeostatic balance of vari-
challenges of demonstrating widescale translational validity. ous compounds (ie, acylcarnitines, amino acids, free fatty
This is compounded by cost and resource considerations acids, triglycerides) that are critical for their growth and
that often result in relatively small study sizes. Despite development. This leaves them vulnerable to biochemical
these challenges, the continued advancements in analytical imbalances that can be measured.29 For instance, essential

e104 NeoReviews
FIGURE 2. Lipid classes illustrating known relationships and mechanistic pathways. All lipid species are light blue. Metabolites are pink. Figure
created at BioRender.com.
Abbreviations: CE, cholesterol esters; CER, ceramides; DAG, diacylglycerols; DCER, dihydroceramides; FFA, free fatty acids; HCER,
hexosylceramides; LCER, lactosylceramides; LPC, lysophosphatidylcholines; LPE, lysophosphatidylethanolamines; PC, phosphatidylcholines; PE,
phosphatidylethanolamines; SM, sphingomyelins; TAG, triacylglycerols; TCA, tricarboxylic acid.

and nonessential amino acids have diverse and critical met- have specific and diverse roles in ongoing developmental bio-
abolic functions including peptide and protein formation, logic processes (Figure 2).
nitric oxide production, and organogenesis. Branched chain
(leucine, isoleucine, and valine) and aromatic amino acids
(ie, phenylalanine, tyrosine, histidine, tryptophan) have METABOLOMICS AND LIPIDOMICS: CLINICAL
highly conserved precursor roles in neurotransmitter pro- CONSIDERATIONS
duction, protein folding, and organ development.30 Metabolomic and lipidomic studies include 2 key principles
Lipids, specifically phospholipids such as phosphatidyl- important for translational discovery: (1) determining novel
choline and phosphatidylglycerol, are essential components biologic insights related to disease and (2) identifying
of pulmonary surfactant.31 Targeted lipidomics can assess molecular biomarkers associated with prognosis and estab-
phospholipid levels, enabling timely surfactant therapy to lished disease.2 These principles are related but also distinct.
improve lung function and decrease morbidity and mortal- The study of inborn errors of metabolism (IEMs) remains the
ity.32 Sphingolipids, including sphingomyelin, play key roles best demonstrated application of metabolomics to date
in cell membrane structure and immune signaling.33 (detailed below). Beyond IEMs, most studies examining
Abnormal sphingolipid metabolism is linked with respiratory metabolomics and lipidomics for neonatal and infantile
distress syndrome and bronchopulmonary dysplasia outcomes have considerable limitations, including small
(BPD).34–36 Cholesterol is vital for membrane structure and samples sizes, sampling from limited time points, and spec-
synthesis of steroid hormones and bile acids, both essential imens obtained from a single biofluid. These issues have lim-
processes for nervous system development.37,38 Arachid- ited the overall reproducibility of findings.
onic acid and docosahexaenoic acid are critical for brain Furthermore, certain factors are known to impact the
and retina development.7,39 Note that many compounds have metabolome and lipidome. Gestational age, weight, sex, nutri-
pleiotropic effects on various developmental processes and tional status, and medications affect metabolite and lipid mea-
are not simply one-dimensional actors. For instance, eicosa- surements.22,29,44–47 However, findings are often compound
noids, derived from arachidonic acid, mediate inflammatory dependent. For instance, many studies have demonstrated
responses significant in conditions such as BPD, retinopathy significant correlation between gestational age and metabo-
of prematurity, and periventricular leukomalacia.7 However, lites including 3-hydroxyisobutyrate, acetate, acetoacetate,
under certain conditions, they are also growth factors impor- acetone, formate, glucose, and valine.48,49 Lipid species such
tant for cellular division and growth.40 Triglycerides and free as free fatty acids, diacylglycerols, triglycerides, and others are
fatty acids are major energy sources essential for preterm all affected by age, weight, and nutritional considerations.7,8
infants’ energy storage and cell-cell signaling.41,42 They are Accounting for these factors in clinical studies is necessary
also intricately linked with immune signaling, inflammation, but often constrained by limited sample sizes and incomplete
and toll-like receptor 4 activation.43 Thus, these compounds metadata. Thus, few studies to date have incorporated

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e105

 adjustment, stratification, or the advanced epidemiologic or urea cycle amino acids, sphingolipids, putragenic amines
machine learning procedures necessary to isolate the biologic (putrescine), and the specific amino acids alanine and histi-
effect of a given metabolite level on a clinical outcome.17 dine.60–64 As with most neonatal molecular studies, investi-
The goal of most translational metabolomic and lipidomic gations of NEC to date have relied on sample cohorts
studies is to characterize a clinical outcome or disease state from single centers while using a single time point for data
using molecular patterns and/or biomarker(s). In newborn analysis.59 Results suggest the absence of a single molecular
medicine, outside of IEMs, there are several use cases in marker with sufficient sensitivity and specificity to inform
which omics approaches have shown robust associations clinical care; however, combinations of selected molecular
with neonatal disease. features have illustrated reasonable predictive power for
NEC (ie, area under the curve > 0.8).59,61,63,65–70 The driving
Bronchopulmonary Dysplasia factors of NEC pathobiology remains unclear; it is unknown
Accumulating evidence demonstrates alterations in the whether this process is driven by or simply associated with
metabolism of glucose, lipids, and amino acids in premature dysbiotic colonization patterns and microbial metabolite dis-
infants that develop BPD.50 Premature infants exhibit high turbances. Future studies would benefit from prospective
metabolic rates necessary for organogenesis and repair from longitudinal human sampling potentially incorporating
injury.51 BPD is defined principally by (1) alveolar arrest and multiple biofluid matrices (ie, blood, stool, urine) to fully
(2) localized hyperimmune response to injurious exposures characterize the microbial and metabolomic alterations asso-
(ie, hypoxia and hyperoxia).52 Numerous experimental and ciated with NEC onset and progression.
human-based omics studies suggest that abnormal metabo-
lism of glucose and oxygen may lead to impaired cellular Hypoxic-Ischemic Encephalopathy
growth, apoptotic mechanisms, and abnormal repair mech- A limited number of studies have investigated the metabo-
anisms.50,53 Recent studies demonstrate specific alterations lome for infants with hypoxic-ischemic encephalopathy
in a range of species including sphingolipids, phosphatidyl- (HIE). Studies to date have demonstrated associations with
cholines, triglycerides, urea cycle amino acids (ie, arginine, 3-hydroxybutyrate, butyrate, various acylcarnitines (acetylcar-
citrulline), and others.49,50,54,55 This growing evidence sug- nitine, palmitoyolcarnitine, hexadecenoylcarnitine, stearol-
gests that BPD may be characterized beyond traditional def- carnitine), glycerol, succinate, O-phosphocholine, leucine,
initions to include the functional metabolic abnormalities kynureine, and 3-hydroxydodecanoic acid.71 Most studies
that result from immaturity. While most studies to date have have relied on serum umbilical cord blood or blood spots.71,72
relied on sampling at a single time point to predict BPD Future investigations may determine (1) metabolomic and
occurrence at 36 weeks postmenstrual age, future studies lipidomic signals that correspond with HIE severity and
should incorporate longitudinal metabolomic and lipidomic (2) metabolomic patterns associated with response to thera-
analyses for established BPD. Longitudinal sampling is criti- peutic hypothermia.
cal to elucidating the multifactorial components that drive
Intraventricular Hemorrhage
BPD pathobiology. Defining metabolomic and lipidomic
The literature on neonatal intraventricular hemorrhage
measurements at the time of diagnosis is needed to define
(IVH) indicates several metabolites and compounds associ-
referent molecular signatures for established disease.
ated with the condition. Amino acid alterations in alanine,
arginine, asparagine, glutamine, lysine, valine, proline,
Necrotizing Enterocolitis
taurine, and malate have been implicated in IVH compared
The prediction of medical and surgical NEC remains elusive
to controls.73 Organic acids such as lactate, malate, pyruvate,
for clinicians in the NICU. Diagnosis of medical NEC
kynurenate, and hippuric acid were also found to differenti-
(ie, Bell stage II, limited mucosal injury NEC) has inherent
ate between IVH and control cases.73 Compared to other dis-
subjectivity. Recent evidence suggests that NEC develops
orders related to prematurity, there is a relative paucity of
from a multifactorial process, including a dysbiotic microbial
omics studies that have examined IVH.
state.56–59 Preterm dysbiosis, through gut colonization with
Enterobacter cloacae, Klebsiella pneumoniae, and related taxa of
the Gammaproteobacteria class, is most strongly associated TARGETED METABOLOMICS FOR INBORN ERRORS
with alterations in specific microbial metabolites found in OF METABOLISM
stool including short-chain fatty acids, secondary bile The realm of metabolomic and lipidomic studies for
acids, and additional markers.56,60 These include free carni- acquired neonatal conditions remains largely exploratory
tine, short-chain acylcarnitines, long-chain acylcarnitines, and hypothesis generating. However, newborn metabolic

e106 NeoReviews
screening for IEMs is an established and robust approach with available linkages to maternal and neonatal clinical
that unites biology and clinical actionability. The newborn records, investigators have leveraged this data to evaluate
screen is a critical public health program aimed at the early thousands of patients rather than the few dozen or hun-
identification of IEMs by measuring molecular byproducts of dred(s) typical of many untargeted approaches. This
defined metabolic pathways. approach also potentially overcomes reproducibility issues
Early detection of IEMs prompts interventions intended incumbent to many of the untargeted approaches historically
to prevent the effects of the mutated metabolic pathway used. Analyses often rely on complex regression and/or
and consequent complications, including death. IEMs are machine learning methodologies, interrogating acylcarni-
typically monogenic conditions that lead to dysfunction in tines, and amino acids—the principle analytes on the new-
specific enzymes or proteins needed for endogenous born screen. Disorders evaluated include acquired
metabolism.12 Without proper treatment, this group of disor- disorders of prematurity—BPD, NEC, sepsis, and mortal-
ders leads to an accumulation of toxic substances or deficits ity.63,74–77 They also include term diagnoses such as
in critical compounds, potentially resulting in acute toxicity, persistent pulmonary hypertension of the newborn and
severe developmental issues, lifelong disability, or death. HIE.72,78,79 There is also a growing recognition that the new-
Conditions such as phenylketonuria, maple syrup urine dis- born screen may reflect common maternal conditions during
ease, and medium-chain acyl-CoA dehydrogenase deficiency pregnancy such as hypertensive disorders of pregnancy or
are among the few dozen diseases tested for in the standard diabetes.75,79,80 For instance, infants born to mothers with
newborn screening panel. hypertensive disorders of pregnancy have demonstrated
The methodology employed in screening for IEMs is alterations in short-chain acylcarnitines compared to con-
based on targeted metabolomics. This approach focuses on trols.77 Moreover, infants born to mothers with diabetes
measuring a few dozen metabolites from whole blood col- (any form) were found to have alterations in long-chain acyl-
lected on a filter paper from a heel prick.12 Newborn screen- carnitines, again compared to controls.77 Early detection of
ing programs have revolutionized the early detection of amino acid and acylcarnitine abnormalities may reflect the
inborn errors of metabolism through the application of tar- molecular conditions necessary for inflammatory and/or oxi-
geted and sequential tandem mass spectrometry (MS/MS). dative injury to occur. Elevations in long-chain acylcarnitines
The precision and specificity of this method make it excep- are strongly associated with inflammatory pathways.80 For
tionally useful for detecting the subtle metabolic changes diseases with overlapping pathobiology rooted in maladap-
indicative of rare metabolic disorders.12 The ability of MS/ tive responses such as NEC, BPD, and retinopathy of
MS to detect a wide range of metabolic abnormalities from prematurity, these approaches have the potential to reveal
a minimal sample volume has made it an indispensable tool individualized levels of risk across various populations.
in newborn screening.12 This application of MS is arguably
the most impactful molecular screening measure in all of
medicine on a population scale to screen for rare disorders, TIMING AND LOCATION OF SAMPLE COLLECTION
as it facilitates early diagnosis and intervention. Thus, the The timing of sample collection in omics studies is crucial for
integration of MS/MS into newborn screening programs accurately interpreting biochemical alterations in relation to
offers a powerful use case to safeguard the health of a specific outcome. Samples collected prior to the onset of
newborns. clinical sequelae may reflect underlying biochemical changes
that predispose to disease. Samples obtained during active
disease (ie, established BPD) can reveal ongoing metabolic
NEWBORN SCREENING FOR COMPLEX disturbances that reflect disease activity. Analyses at different
PHENOTYPES stages can distinguish between progressive, active, and estab-
Although the newborn screen is primarily utilized in clinical lished states. They can also aid in determining normal bio-
practice to screen for IEMs, newer investigations have exam- logic variation over time—necessary when evaluating
ined its potential for predicting complex phenotypes. We and compounds that have never been characterized in the neona-
other investigative groups have interrogated the newborn tal population. These temporal dynamics are also crucial for
screen as a predictor for acquired disorders of prematurity understanding metabolic and lipidomic trajectories between
and other multifactorial disorders. In many cases, this active and quiescent disease states while informing targeted
approach hypothesizes that a complex collection or pattern therapeutic interventions and management strategies.
of metabolites may inform the prediction of a later outcome. Longitudinal analyses can also considerably increase statisti-
Given that the newborn screen is a population screening tool cal power when compared to cross-sectional studies.81

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e107

 The choice of sampling location is also critical, as it directly inhaled or systemic steroids with sampling from blood or
influences the type of compounds detected, which in turn urine before and after medication administration. Lewis et al
affect interpretation. Different sample types—blood, serum, measured blood and urine metabolomic response to
plasma, tracheal aspirates, urine, stool, and tissue—each pro- dexamethasone for preterm infants at risk for BPD.88
vide unique insights into the organism’s metabolic and lipido- Serum gluconic acid sharply decreased in response to dexa-
mic status, reflecting various physiological and pathological methasone administration, with a median fold change of
states. Blood, serum, and plasma are among the most com- 0.007 across time. In metabolite set enrichment analyses,
monly used sample types, owing to their relative accessibility ammonia recycling and malate-aspartate shuttle pathways
and the rich information they contain about systemic metabo- were enriched when comparing before and after treatment.
lism. These biofluids are particularly valuable for diagnosing In a follow-up validation study, investigators observed
and monitoring systemic diseases and for understanding over- changes in urine citrulline and serum trans-4-hydroxypro-
all metabolic homeostasis.3,4,6,21 However, they may not reveal line levels that showed similar results to their original inves-
localized perturbations in metabolic processes for organ-spe- tigation.89 Citrulline is a key urea cycle metabolite important
cific processes. Urine and stool samples offer complementary for endogenous nitric oxide, providing a vasodilatory effect in
dimensions, reflecting excretion processes. Urine studies can peripheral and pulmonary vasculature. Trans-4-hydroxypro-
reveal information regarding filtering and excretion proc- line has been previously associated with pulmonary fibrosis
esses.82 Stool samples can offer information on local micro- and and/or lung injury.90 More recently, Ballard et al evalu-
bial activity, immune regulation, and the influence of these ated blood metabolomics in a pilot trial of budesonide in sur-
factors on systemic health.83 Tracheal aspirates can be useful factant.91 They observed 90 distinct metabolites increased or
for respiratory metabolism, lung diseases, or systemic condi- decreased in a time- and dose-dependent manner, with an
tions with pulmonary manifestations.34,53,84–86 Tissue sam- overrepresentation in lipid and amino acid pathways. How-
ples, including biopsies from specific organs or tumors, ever, when comparing their results directly with Lewis et al,
offer the most specific and localized information but are dif- there were no significant changes for the majority of detect-
ficult to obtain, owing to the invasive methods required for col- able metabolites. One metabolite, pantothenate, was signifi-
lection. Interpreting results in the context of the distinct cantly increased; however, Lewis et al reported a 4-fold
source is critical for appropriate biologic and translational decrease. Follow-up studies may consider further evaluating
interpretation. pantothenate for its association with systemic steroid admin-
istration. Finally, Torgeson et al compared the urine metab-
olome in infants receiving hydrocortisone as part of the of the
TOWARD ACTIONABLE Trial of Late Surfactant (TOLSURF).92 Of the 1145 urinary
PHARMACOMETABOLOMICS metabolites detected, 245 metabolites significantly changed
Pharmacometabolomics is an emerging field that combines over time, with cortisol derivatives increasing 2-fold follow-
the principles of pharmacology and metabolomics. This dis- ing hydrocortisone therapy.92 The highlighted studies are
cipline focuses on studying metabolomic profiles that can key first steps in this relatively new field. Future studies must
predict or explain drug responses at an individual level. evaluate both established and novel therapies beyond
For neonates, developmental differences (ie, enzymatic steroids. Prime targets may include exogenous surfactant,
maturation), genetic polymorphisms, epigenetic marks, caffeine, and antibiotics.
and environmental factors create a unique constellation of
factors that need to be considered when interpreting pharma-
cokinetic and pharmacodynamic data.87 Traditional dosing METABOLOMICS AND THE MICROBIOME
strategies in neonates are often extrapolated from adult data, The relationship between metabolomics, beneficial com-
adjusted for body weight or surface area, which can lead to mensal organisms, and alterations in the microbiome is
suboptimal dosing. Pharmacometabolomics can improve an increasingly relevant area for newborn health.56
upon suboptimal dosing by identifying metabolic signa- Fundamental areas of interest include (1) understanding
ture(s) that predict how a neonate may respond to a specific the developmental timing and establishment of the micro-
drug, leading to safer and more effective dosing. These biome in the setting of varied environmental prenatal and
approaches may also help in discerning patterns that predict postnatal exposures, (2) determining commensal vs patho-
safety or efficacy. genic influence, and (3) defining dysbiosis in terms of its
There have been a limited number of pharmacometabolo- impact on endogenous and exogenous metabolites. Many
mic investigations in neonates. Studies have examined data (although not all) suggest that the fetus resides in a

e108 NeoReviews
sterile in-utero environment.56 Colonization occurs via pas- Besides SCFAs, secondary bile acids are additional micro-
sage through the birth canal during a vaginal delivery with bial metabolites produced in the gut through the action of gut
initial gut colonization that includes Streptococci, microbiota on primary bile acids.96 Primary bile acids,
Lactobacilli, and Enterobacteriaceae.56 The subsequent devel- synthesized in the liver from cholesterol, are secreted into
opment of a rich gut microbiota predominant in commensal the intestine, where they are modified by gut bacteria, par-
Bacteroides and Bifidobacteria species and related organisms ticularly by Clostridium, Bacteroides, and Bifidobacterium spe-
is linked with early changes in stool patterns, from sterile cies, into secondary bile acids such as deoxycholic acid and
meconium to the soft semi-formed consistency typified after lithocholic acid.93 The production of secondary bile acids also
feeding is firmly established. Microbial metabolites such as affects gut ecology, resulting in homeostatic control of sys-
short-chain fatty acids (SCFAs) and bile acids are directly temic bilirubin and bile acid metabolism (eg, hyperbilirubi-
linked to the fermentation patterns represented by the colo- nemia) as well as also shaping the ecology of the gut-
nizing gut microbes and thus may serve as early molecular colonizing microbes.93 Disruption in these tightly controlled
patterns mediating clinical changes.93,94 processes can cause a buildup of cytotoxic levels of hydropho-
SCFAs are a group of short carbon chain (typically 2–6 bic bile acids within enterocytes and may lead to NEC. Thus,
carbons) metabolites (ie, acetate, propionate, butyrate) gener- secondary bile acids play complex roles in host metabolism
ated by gut microbial fermentation of complex carbohy- and health. While they aid in the digestion and absorption of
drates.93 SCFAs supply energy to colonocytes and regulate dietary fats and fat-soluble vitamins, perturbations have
immune responses while maintaining the integrity of the been linked to clinical sequelae including NEC and brain
gut barrier. Clinical outcomes are linked with the relative injury.100–103 The intersection of metabolomics and the
abundance of SFCA species. Recent work demonstrates microbiome offers tremendous potential in advancing our
changes in specific SCFAs associated with decreased risk understanding of neonatal health and disease. In analyzing
for disorders such as BPD and NEC.49,95 SCFAs are pro- how microbial communities alter host metabolites and how
duced in part by Bifidobacterium species that metabolize these metabolites in turn affect microbial composition, there
human milk oligosaccharides from human milk. may be the ability to therapeutically manipulate these
Interestingly, premature infants have decreased levels of interactions in favor of anti-inflammatory and pro-growth
commensal Bifidobacterium and Bacteroides organisms com- trajectories.
pared to term infants96 and increased pathogenic bacteria
including Klebsiella, Enterobacteriaceae, Staphylococcus,
Streptococcus, and others. These colonization patterns reflect COMPUTATIONAL AND MACHINE LEARNING
a multitude of factors representing those occurring second- APPROACHES
arily to NICU exposures such as widespread perinatal antibi- The complexity of metabolomic and lipidomic data often
otic usage, prevalence of human breast milk feeding, necessitates the use of advanced computational methods
minimal initial enteral feeding, and reliance on total parental for analysis. Generally, bioinformatic pipelines are used to
nutrition. Bifidobacterium species play a crucial role in process the data into intensity values for various metabolites
metabolizing prebiotic human milk oligosaccharides to pro- and lipids (both annotated and unknown). This tabular data
duce an abundance of the SCFA acetate and lactate. These (in which rows represent samples and columns represent
metabolites provide essential ecologic service to the newborn intensity values for various species) is optimal for analysis
gut by lowering the gut pH, thus shaping the balance of col- by standard machine learning approaches. In supervised
onizing commensals (strict anaerobes) and potential patho- machine learning, this data can be used alongside labeled
gens (microaerophilic microbes).56,97 This relationship is outcome data (eg, annotations for each sample indicating
critical for the establishment of a eubiotic (high in anaerobes if the newborn had an outcome of interest) to create predic-
fermenting human milk oligosaccharides) state while tive models. Unsupervised approaches (ie, those that do not
displacing dysbiotic microbes (facultative anaerobes, ie, gam- require labeled outcomes) can be used to reduce the complex-
maproteobacteria) that have been most closely associated ity of the data, removing noise and helping to visualize and
with devastating diseases such as NEC.97,98 A recent cluster analytes into groups that may reflect biological
U.S. Food and Drug Administration letter published in meaning.
September 2023 to halt the clinical administration of Owing to the high dimensionality of omics data, often
Bifidobacterium and other multi-strain probiotics has with relatively small sample sizes, methods designed to ana-
currently limited clinical and translational work in this lyze high-dimensional data tend to be the most suitable and
area.99 offer the best performance. For example, least absolute

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e109

 shrinkage and selection operator (LASSO) is a form of regu- underlying mechanisms for established therapeutic inter-
larized regression, which introduces a penalty for each fea- ventions and pharmacotherapies in humans remain
ture that is used in the final model.104 The resulting unknown in up to 25% of cases.110 The evolution of clinical
models often use a relatively small number of analytes. An trials beyond the limitations of clinical outcome data alone is
important aspect of supervised machine learning is to split important for furthering biologic and clinical insights.
the data into training and validation sets. The training set Cost considerations often dictate the ability to pursue con-
is used to develop the model, and the validation set is used current biologic sampling. However, recent illustrative
to estimate its performance on unseen data. This process examples highlight the potential for examining both biologic
is generally repeated multiple times with different train-val- and clinical endpoints.111,112 In the Bilirubin Neurotoxicity
idation splits in a process called cross-validation.105 Models and Neurodevelopmental Impairment in Extremely
trained via regularized supervised machine learning Preterm Infants trial led by Dr Lindsay Holzapfel (Clinical
approaches such as LASSO often generalize better to unseen Trials number NCT04584983), daily blood samples were
data. Furthermore, by computing feature importance (ie, a obtained from extremely preterm infants to measure
measure of the contribution of each input variable to the unbound bilirubin and unbound free fatty acid profiles from
model’s prediction), these models can lead to hypotheses infants randomized to receive usual vs reduced dosing of
for novel biomarkers. lipid emulsions.111 Clinical outcomes measured neurotoxic-
More advanced computational methods are also being ity through brainstem auditory evoked response testing.
applied to neonatal metabolomics and lipidomics research. Small volume blood sampling measured free fatty acid pro-
Deep learning approaches, such as convolutional neural net- files. The results of this study may shed light on the relation-
works, are currently under exploration for their ability to cap- ship between lipid emulsion dosing, free fatty acid profiles,
ture complex, nonlinear relationships in high-dimensional and the presence or absence of neurotoxicity.
data in maternal and child health. For example, De The High-Dose Erythropoietin for Asphyxia and
Francesco et al used a multitask deep learning model to pre- Encephalopathy trial evaluated plasma inflammatory media-
dict 24 neonatal outcomes incorporating longitudinal mater- tors in infants with moderate or severe HIE.112 Notably,
nal and neonatal data.106 Shen et al used convolutional erythropoietin administration did not confer a protective
neural networks to analyze pseudo-images that represented effect. However, concurrent blood sampling enabled a
metabolomics data, showing an improved ability to predict secondary analysis of erythropoietin’s effect on systemic
gestational age compared to traditional bioinformatic inflammation and predictive performance for neurodevelop-
pipelines.107 Deep learning approaches also enable the inte- mental impairment. The study found that erythropoietin did
gration of heterogeneous data types, allowing the simultane- not significantly alter concentrations of measured bio-
ous analysis of metabolomics, lipidomics, clinical data, and markers by postnatal day 4. However, 6 plasma analytes were
other data modalities.108 Furthermore, deep learning found to modestly increase the predictive power (area under
approaches are often flexible with respect to the ways in the curve from 0.73, 95% CI, 0.70–0.75 to 0.79, 95% CI,
which they combine data modalities. Data can be combined 0.77–0.81) for death or neurodevelopment impairment at
before machine learning modeling and used as inputs to 2 years compared to clinical data alone. These results dem-
train a single machine learning algorithm called early fusion. onstrate feasibility and the potential utility for measuring bio-
Individual models can also be trained on each modality sep- logic and clinical outcomes in clinical trials.
arately and combined using a meta-learner (which learns the
best way to combine predictions from each individual
model); this approach is called late fusion (sometimes called CONCLUSION
stack generalization).109 As these computational approaches Metabolomic and lipidomic investigations have the potential
evolve, they promise to help enhance our understanding of to advance precision and individualized medicine ap-
neonatal biology and ultimately improve clinical care. proaches in the NICU. Untargeted and targeted approaches
can characterize biochemical patterns associated with a vari-
ety of important clinical outcomes. In time, they may aug-
BIOLOGIC SAMPLING IN CLINICAL TRIALS ment or even replace reliance on imprecise clinical
Most human-based metabolomic and lipidomic investiga- definitions. Importantly, longitudinal sampling may charac-
tions rely on retrospective case-control study designs. To terize novel developmental trajectories and aid in identifying
advance translational medicine, there is a critical need to mechanistic and metabolic pathways that drive complex phe-
incorporate biologic sampling within clinical trials. The notypes of disease. A combination of traditional and

e110 NeoReviews
advanced machine learning methods can be used to account 7. Martin CR. Lipids and fatty acids in the preterm infant, part 1:
for high-dimensional omics data. Results must be inter- basic mechanisms of delivery, hydrolysis, and bioavailability.
Neoreviews. 2015;16(3):e160–e168. doi: 10.1542/neo.16-3-e160
preted in the context of sample location and timing of collec-
8. Martin CR. Lipids and fatty acids in the preterm infant, part 2:
tion. Incorporation of clinical context data and the reliance clinical considerations. Neoreviews. 2015;16(3):e169–e180.
on the knowledge and acumen of practicing providers is par- doi: 10.1542/neo.16-3-e169
amount. Ultimately, leveraging interdisciplinary expertise is 9. Hornburg D, Wu S, Moqri M, et al. Dynamic lipidome
critical to ensure the reproducibility and rigor of findings. alterations associated with human health, disease and ageing.
Nat Metab. 2023;5(9):1578–1594. PubMed doi: 10.1038/s42255-
Future studies may examine manipulation of key metabolic
023-00880-1
pathways to aid in prevention and/or treatment of common
10. Tabassum R, Ruotsalainen S, Ottensmann L, et al. Lipidome-
neonatal and infant diseases. and genome-wide study to understand sex differences in
circulatory lipids. J Am Heart Assoc. 2022;11(19):e027103.
PubMed doi: 10.1161/JAHA.122.027103
11. Fanos V, Pintus R, Dessì A. Clinical metabolomics in
American Board of Pediatrics neonatology: from metabolites to diseases. Neonatology. 2018;
113(4):406–413. PubMed doi: 10.1159/000487620
Neonatal-Perinatal Content 12. Kronn D. Navigating newborn screening in the NICU: a user’s
Specification guide. Neoreviews. 2019;20(5):e280–e291. PubMed doi: 10.1542/
neo.20-5-e280
• Demonstrate proper assessment of fetal well-being
• Understand technical considerations and data science 13. Antonucci R, Atzori L, Barberini L, Fanos V. Metabolomics: the
“new clinical chemistry” for personalized neonatal medicine.
opportunities in metabolomic and lipidomic studies in
Minerva Pediatr. 2010;62(3)(suppl 1):145–148. PubMed
the neonatal intensive care unit
14. Ali A, Davidson S, Fraenkel E, et al. Single cell metabolism:
• Recognize the potential for novel mechanistic and bio-
current and future trends. Metabolomics. 2022;18(10):77. PubMed
marker development for common disorders in term
doi: 10.1007/s11306-022-01934-3
and preterm neonates
15. Bardanzellu F, Fanos V. How could metabolomics change
pediatric health? Ital J Pediatr. 2020;46(1):37. PubMed
doi: 10.1186/s13052-020-0807-7

Acknowledgments 16. Chen C, Gonzalez FJ, Idle JR. LC-MS-based metabolomics in

The authors would like to thank Samuel Lancaster, Frank drug metabolism. Drug Metab Rev. 2007;39(2-3):581–597.
PubMed doi: 10.1080/03602530701497804
Wong, Denver Bradley, Kevin Contrepois, Jonathan A.
17. Chu SH, Huang M, Kelly RS, et al; Consortium of Metabolomics
Bernstein, Tina Cowan, Nima Aghaeepour, Karl G.
Studies Statistics Working Group. Integration of metabolomic
Sylvester, and Michael P. Snyder at the Stanford Metabolic
and other omics data in population-based study designs: an
Healthcare Center. epidemiological perspective. Metabolites. 2019;9(6):117. PubMed
doi: 10.3390/metabo9060117
18. D’Alessandro A, ed. High-Throughput Metabolomics: Methods and
References Protocols. Humana; 2019.
1. Noto A, Fanos V, Dessì A. Metabolomics in newborns. Adv Clin 19. Alseekh S, Aharoni A, Brotman Y, et al. Mass spectrometry-
Chem. 2016;74:35–61. PubMed doi: 10.1016/bs.acc.2015.12.006 based metabolomics: a guide for annotation, quantification and
2. Xia J, Broadhurst DI, Wilson M, Wishart DS. Translational best reporting practices. Nat Methods. 2021;18(7):747–756.
biomarker discovery in clinical metabolomics: an introductory PubMed doi: 10.1038/s41592-021-01197-1
tutorial. Metabolomics. 2013;9(2):280–299. PubMed doi: 10. 20. Giera M, ed. Clinical Metabolomics: Methods and Protocols.
1007/s11306-012-0482-9 Humana; 2018.
3. Johnson CH, Ivanisevic J, Siuzdak G. Metabolomics: beyond 21. Pinu FR, Beale DJ, Paten AM, et al. Systems biology and multi-
biomarkers and towards mechanisms. Nat Rev Mol Cell Biol. omics integration: viewpoints from the metabolomics research
2016;17(7):451–459. PubMed doi: 10.1038/nrm.2016.25 community. Metabolites. 2019;9(4):76. PubMed doi: 10.3390/
4. Johnson CH, Gonzalez FJ. Challenges and opportunities of metabo9040076
metabolomics. J Cell Physiol. 2012;227(8):2975–2981. PubMed 22. Psychogios N, Hau DD, Peng J, et al. The human serum
doi: 10.1002/jcp.24002 metabolome. PLoS One. 2011;6(2):e16957. PubMed doi: 10.1371/
5. Beger RD, Dunn W, Schmidt MA, et al; for “Precision Medicine journal.pone.0016957
and Pharmacometabolomics Task Group”-Metabolomics Society 23. Chong J, Wishart DS, Xia J. Using MetaboAnalyst 4.0 for com-
Initiative. Metabolomics enables precision medicine: “A White prehensive and integrative metabolomics data analysis. Curr Protoc
Paper, Community Perspective”. Metabolomics. 2016;12(10): Bioinformatics. 2019;68(1):e86. PubMed doi: 10.1002/cpbi.86
149. PubMed doi: 10.1007/s11306-016-1094-6 24. Wang R, Li B, Lam SM, Shui G. Integration of lipidomics and
6. Wishart DS. Emerging applications of metabolomics in drug metabolomics for in-depth understanding of cellular mechanism
discovery and precision medicine. Nat Rev Drug Discov. 2016; and disease progression. J Genet Genomics. 2020;47(2):69–83.
15(7):473–484. PubMed doi: 10.1038/nrd.2016.32 PubMed doi: 10.1016/j.jgg.2019.11.009

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e111

 25. Contrepois K, Liang L, Snyder M. Can metabolic profiles be used 40. Umamaheswaran S, Dasari SK, Yang P, Lutgendorf SK, Sood
as a phenotypic readout of the genome to enhance precision AK. Stress, inflammation, and eicosanoids: an emerging
medicine? Clin Chem. 2016;62(5):676–678. PubMed doi: perspective. Cancer Metastasis Rev. 2018;37(2-3):203–211. PubMed
10.1373/clinchem.2015.251181 doi: 10.1007/s10555-018-9741-1
26. Contrepois K, Mahmoudi S, Ubhi BK, et al. Cross-platform 41. Macfarlane DP, Forbes S, Walker BR. Glucocorticoids and fatty
comparison of untargeted and targeted lipidomics approaches on acid metabolism in humans: fuelling fat redistribution in the
aging mouse plasma. Sci Rep. 2018;8(1):17747. PubMed metabolic syndrome. J Endocrinol. 2008;197(2):189–204.
doi: 10.1038/s41598-018-35807-4 PubMed doi: 10.1677/JOE-08-0054
27. Ahadi S, Zhou W, Schüssler-Fiorenza Rose SM, et al. Personal 42. Santoro K, Martin CR. Lipids and long chain polyunsaturated
aging markers and ageotypes revealed by deep longitudinal fatty acids in preterm infants. Clin Perinatol. 2022;49(2):381–391.
profiling. Nat Med. 2020;26(1):83–90. PubMed doi: 10.1038/ PubMed doi: 10.1016/j.clp.2022.02.007
s41591-019-0719-5 43. Rogero MM, Calder PC. Obesity, inflammation, Toll-like
28. Ghaemi MS, DiGiulio DB, Contrepois K, et al. Multiomics receptor 4 and fatty acids. Nutrients. 2018;10(4):432. PubMed
modeling of the immunome, transcriptome, microbiome, doi: 10.3390/nu10040432
proteome and metabolome adaptations during human 44. Wilson K, Hawken S, Potter BK, et al. Accurate prediction of
pregnancy. Bioinformatics. 2019;35(1):95–103. PubMed gestational age using newborn screening analyte data. Am J
doi: 10.1093/bioinformatics/bty537 Obstet Gynecol. 2016;214(4):513.e1–513.e9. PubMed doi: 10.1016/j.
29. Wilson K, Hawken S, Ducharme R, et al. Metabolomics of ajog.2015.10.017
prematurity: analysis of patterns of amino acids, enzymes, 45. Contrepois K, Chen S, Ghaemi MS, et al; Alliance for Maternal
and endocrine markers by categories of gestational age. and Newborn Health Improvement (AMANHI); Global Alliance
Pediatr Res. 2014;75(2):367–373. PubMed doi: 10.1038/pr. to Prevent Prematurity and Stillbirth (GAPPS). Prediction of
2013.212 gestational age using urinary metabolites in term and preterm
30. Newgard CB, An J, Bain JR, et al. A branched-chain amino acid- pregnancies. Sci Rep. 2022;12(1):8033. PubMed doi: 10.1038/
related metabolic signature that differentiates obese and lean s41598-022-11866-6
humans and contributes to insulin resistance. Cell Metab. 46. Leite DFB, Morillon A-C, Melo Júnior EF, et al. Examining the
2009;9(4):311–326. PubMed doi: 10.1016/j.cmet.2009.02.002 predictive accuracy of metabolomics for small-for-gestational-age
31. Agassandian M, Mallampalli RK. Surfactant phospholipid babies: a systematic review. BMJ Open. 2019;9(8):e031238.
metabolism. Biochim Biophys Acta. 2013;1831(3):612–625. PubMed doi: 10.1136/bmjopen-2019-031238
PubMed doi: 10.1016/j.bbalip.2012.09.010 47. Bahado-Singh RO, Yilmaz A, Bisgin H, et al. Artificial
32. Koussa S, Sood BG, Xin Y, Sharma A, Maddipati KR. Gastric intelligence and the analysis of multi-platform metabolomics
aspirate phosphatidylcholine species in preterm neonates data for the detection of intrauterine growth restriction. PLoS
receiving aerosolized surfactant. J Pediatr. 2023;263:113638. One. 2019;14(4):e0214121. PubMed doi: 10.1371/journal.pone.
PubMed doi: 10.1016/j.jpeds.2023.113638 0214121
33. Hannun YA, Obeid LM. Sphingolipids and their metabolism in 48. Nilsson AK, Tebani A, Malmodin D, et al. Longitudinal serum
physiology and disease. Nat Rev Mol Cell Biol. 2018;19(3):175–191. metabolomics in extremely premature infants: relationships with
PubMed doi: 10.1038/nrm.2017.107 gestational age, nutrition, and morbidities. Front Neurosci.
34. Hendricks-Muñoz KD, Xu J, Voynow JA. Tracheal aspirate VEGF 2022;16:830884. PubMed doi: 10.3389/fnins.2022.830884
and sphingolipid metabolites in the preterm infant with later 49. Frazer LC, Yakah W, Martin CR. Decreased acetic acid in the
development of bronchopulmonary dysplasia. Pediatr Pulmonol. stool of preterm infants is associated with an increased risk of
2018;53(8):1046–1052. PubMed doi: 10.1002/ppul.24022 bronchopulmonary dysplasia. Nutrients. 2022;14(12):2412.
35. Lee J, Yeganeh B, Ermini L, Post M. Sphingolipids as cell fate PubMed doi: 10.3390/nu14122412
regulators in lung development and disease. Apoptosis. 2015; 50. Yue L, Lu X, Dennery PA, Yao H. Metabolic dysregulation in
20(5):740–757. PubMed doi: 10.1007/s10495-015-1112-6 bronchopulmonary dysplasia: Implications for identification of
36. Thomas JM, Sudhadevi T, Basa P, Ha AW, Natarajan V, Harijith biomarkers and therapeutic approaches. Redox Biol.
A. The role of sphingolipid signaling in oxidative lung injury and 2021;48:102104. PubMed doi: 10.1016/j.redox.2021.102104
pathogenesis of bronchopulmonary dysplasia. Int J Mol Sci. 51. Bauer J, Werner C, Gerss J. Metabolic rate analysis of healthy
2022;23(3):1254. PubMed doi: 10.3390/ijms23031254 preterm and full-term infants during the first weeks of life. Am J
37. Fessler MB. A new frontier in immunometabolism. cholesterol Clin Nutr. 2009;90(6):1517–1524. PubMed doi: 10.3945/ajcn.
in lung health and disease. Ann Am Thorac Soc. 2017;14(suppl 5): 2009.28304
S399–S405. PubMed doi: 10.1513/AnnalsATS.201702-136AW 52. Thébaud B, Goss KN, Laughon M, et al. Bronchopulmonary
38. Kelishadi R, Barekatain B, Fatahi A. Comparison of serum dysplasia. Nat Rev Dis Primers. 2019;5(1):78. PubMed doi: 10.
triglyceride and cholesterol levels in premature neonates with or 1038/s41572-019-0127-7
without respiratory distress syndrome (RDS). Int J Pediatr. 53. Lal CV, Bhandari V, Ambalavanan N. Genomics, microbiomics,
2021;8893754. proteomics, and metabolomics in bronchopulmonary dysplasia.
39. Martin CR, Dasilva DA, Cluette-Brown JE, et al. Decreased Semin Perinatol. 2018;42(7):425–431. PubMed doi: 10.1053/j.
postnatal docosahexaenoic and arachidonic acid blood levels in semperi.2018.09.004
premature infants are associated with neonatal morbidities. 54. Liu G, Summer R. Cellular metabolism in lung health and
J Pediatr. 2011;159(5):743–749.e2. PubMed doi: 10.1016/j.jpeds. disease. Annu Rev Physiol. 2019;81(1):403–428. PubMed doi: 10.
2011.04.039 1146/annurev-physiol-020518-114640

e112 NeoReviews
55. Piersigilli F, Bhandari V. Metabolomics of bronchopulmonary 69. Wandro S, Osborne S, Enriquez C, Bixby C, Arrieta A, Whiteson
dysplasia. Clin Chim Acta. 2020;500:109–114. PubMed doi: K. The microbiome and metabolome of preterm infant stool are
10.1016/j.cca.2019.09.025 personalized and not driven by health outcomes, including
56. Valentine G, Prince A, Aagaard KM. The neonatal microbiome necrotizing enterocolitis and late-onset sepsis. MSphere. 2018;3
and metagenomics: what do we know and what is the future? (3):e00104–18. PubMed doi: 10.1128/mSphere.00104-18
Neoreviews. 2019;20(5):e258–e271. PubMed doi: 10.1542/neo.20- 70. Wilcock A, Begley P, Stevens A, Whatmore A, Victor S. The
5-e258 metabolomics of necrotising enterocolitis in preterm babies: an
57. Tobias J, Olyaei A, Laraway B, et al. Bifidobacterium longum exploratory study. J Matern Fetal Neonatal Med. 2016;29(5):758–
subsp. infantis EVC001 administration is associated with a 762. PubMed doi: 10.3109/14767058.2015.1017462
significant reduction in the incidence of necrotizing enterocolitis 71. Debuf MJ, Carkeek K, Piersigilli F. A metabolomic approach in
in very low birth weight infants. J Pediatr. 2022;244:64–71.e2. search of neurobiomarkers of perinatal asphyxia: a review of the
PubMed doi: 10.1016/j.jpeds.2021.12.070 current literature. Front Pediatr. 2021;9:674585. PubMed doi:
58. Pammi M, Cope J, Tarr PI, et al. Intestinal dysbiosis in preterm 10.3389/fped.2021.674585
infants preceding necrotizing enterocolitis: a systematic review 72. Wilson LA, Fell DB, Hawken S, et al. Association between
and meta-analysis. Microbiome. 2017;5(1):31. PubMed doi: 10. newborn screening analytes and hypoxic ischemic
1186/s40168-017-0248-8 encephalopathy. Sci Rep. 2019;9(1):15704. PubMed doi: 10.1038/
59. Agakidou E, Agakidis C, Gika H, Sarafidis K. Emerging s41598-019-51919-x
biomarkers for prediction and early diagnosis of necrotizing 73. Sarafidis K, Begou O, Deda O, et al. Targeted urine
enterocolitis in the era of metabolomics and proteomics. Front metabolomics in preterm neonates with intraventricular
Pediatr. 2020;8:602255. PubMed doi: 10.3389/fped.2020. hemorrhage. J Chromatogr B Analyt Technol Biomed Life Sci.
602255 2019;1104:240–248. PubMed doi: 10.1016/j.jchromb.2018.
60. Casaburi G, Wei J, Kazi S, et al. Metabolic model of necrotizing 11.024
enterocolitis in the premature newborn gut resulting from 74. Fell DB, Hawken S, Wong CA, et al. Using newborn screening
enteric dysbiosis. Front Pediatr. 2022;10:893059. PubMed doi: analytes to identify cases of neonatal sepsis. Sci Rep. 2017;7(1):
10.3389/fped.2022.893059 18020. PubMed doi: 10.1038/s41598-017-18371-1
61. Sinclair TJ, Ye C, Chen Y, et al. Progressive metabolic 75. Oltman SP, Rogers EE, Baer RJ, et al. Initial metabolic profiles
dysfunction and nutritional variability precedes necrotizing are associated with 7-day survival among infants born at 22-25
enterocolitis. Nutrients. 2020;12(5):1275. PubMed doi: 10.3390/ weeks of gestation. J Pediatr. 2018;198:194–200.e3. PubMed doi:
nu12051275 10.1016/j.jpeds.2018.03.032
62. Moschino L, Verlato G, Duci M, et al. The metabolome and the 76. Oltman SP, Rogers EE, Baer RJ, et al. Newborn metabolic
gut microbiota for the prediction of necrotizing enterocolitis and vulnerability profile identifies preterm infants at risk for
spontaneous intestinal perforation: a systematic review. mortality and morbidity. Pediatr Res. 2021;89(6):1405–1413.
Nutrients. 2022;14(18):3859. PubMed doi: 10.3390/nu14183859 PubMed doi: 10.1038/s41390-020-01148-0
63. Sylvester KG, Kastenberg ZJ, Moss RL, et al. Acylcarnitine 77. Reiss JD, Chang AL, Mayo JA, et al. Newborn screen metabolic
profiles reflect metabolic vulnerability for necrotizing panels reflect the impact of common disorders of pregnancy.
enterocolitis in newborns born premature. J Pediatr. Pediatr Res. 2022;92(2):490–497. PubMed doi: 10.1038/s41390-
2017;181:80–85.e1. PubMed doi: 10.1016/j.jpeds.2016.10.019 021-01753-7
64. Bosco A, Toto M, Pintus R, Fanos V, Dessì A. Human milk 78. McCarthy ME, Oltman SP, Baer RJ, et al. Newborn metabolic
sphingomyelins and metabolomics: an enigma to be discovered. profile associated with hyperbilirubinemia with and without
J Matern Fetal Neonatal Med. 2022;35(25):7649–7661. PubMed kernicterus. Clin Transl Sci. 2019;12(1):28–38. PubMed doi: 10.
doi: 10.1080/14767058.2021.1958314 1111/cts.12590
65. Morrow AL, Lagomarcino AJ, Schibler KR, et al. Early microbial 79. Steurer MA, Oltman S, Baer RJ, et al. Altered metabolites in
and metabolomic signatures predict later onset of necrotizing newborns with persistent pulmonary hypertension. Pediatr Res.
enterocolitis in preterm infants. Microbiome. 2013;1(1):13. 2018;84(2):272–278. PubMed doi: 10.1038/s41390-018-0023-y
PubMed doi: 10.1186/2049-2618-1-13 80. McCoin CS, Knotts TA, Adams SH. Acylcarnitines–old actors
66. Rusconi B, Jiang X, Sidhu R, Ory DS, Warner BB, Tarr PI. Gut auditioning for new roles in metabolic physiology. Nat Rev
sphingolipid composition as a prelude to necrotizing Endocrinol. 2015;11(10):617–625. PubMed doi: 10.1038/nrendo.
enterocolitis. Sci Rep. 2018;8(1):10984. PubMed doi: 10.1038/ 2015.129
s41598-018-28862-4 81. Piening BD, Zhou W, Contrepois K, et al. Integrative personal
67. Stewart CJ, Nelson A, Treumann A, et al. Metabolomic and omics profiles during periods of weight gain and loss. Cell Syst.
proteomic analysis of serum from preterm infants with 2018;6(2):157-170.e8. PubMed doi: 10.1016/j.cels.2017.12.013
necrotising entercolitis and late-onset sepsis. Pediatr Res. 82. Bouatra S, Aziat F, Mandal R, et al. The human urine
2016;79(3):425–431. PubMed doi: 10.1038/pr.2015.235 metabolome. PLoS One. 2013;8(9):e73076. PubMed doi: 10.1371/
68. Thomaidou A, Chatziioannou AC, Deda O, et al. A pilot case- journal.pone.0073076
control study of urine metabolomics in preterm neonates with 83. Karu N, Deng L, Slae M, et al. A review on human fecal
necrotizing enterocolitis. J Chromatogr B Analyt Technol Biomed metabolomics: methods, applications and the human fecal
Life Sci. 2019;1117:10–21. PubMed doi: 10.1016/j.jchromb.2019. metabolome database. Anal Chim Acta. 2018;1030:1–24. PubMed
04.019 doi: 10.1016/j.aca.2018.05.031

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e113

 84. Lal CV, Kandasamy J, Dolma K, et al. Early airway microbial 98. Pammi M, Hollister E, Neu J. Gut injury and the microbiome
metagenomic and metabolomic signatures are associated with in neonates. Clin Perinatol. 2020;47(2):369–382. PubMed
development of severe bronchopulmonary dysplasia. Am J doi: 10.1016/j.clp.2020.02.010
Physiol Lung Cell Mol Physiol. 2018;315:L810–L815. 99. Marks P, Prater D. Warning regarding use of probiotics in preterm
85. van Mastrigt E, Zweekhorst S, Bol B, et al. Ceramides in tracheal infants. U.S. Food and Drug Administration. Published
aspirates of preterm infants: marker for bronchopulmonary September 29, 2023. https://www.fda.gov/media/172606/
dysplasia. PLoS One. 2018;13(1):e0185969. PubMed doi: 10.1371/ download
journal.pone.0185969 100. Hulzebos CV, van Zoonen AGJF, Hulscher JBF, et al. Fecal bile
86. Verlato G, Simonato M, Giambelluca S, et al. Surfactant salts and the development of necrotizing enterocolitis in preterm
components and tracheal aspirate inflammatory markers in infants. PLoS One. 2017;12(1):e0168633. PubMed doi: 10.1371/
preterm infants with respiratory distress syndrome. J Pediatr. journal.pone.0168633
2018;203:442–446. PubMed doi: 10.1016/j.jpeds.2018.08.019 101. Knapp S, Kehring A, Stepp J, et al. Elevated coefficient of
87. Yeung CHT, Verstegen RHJ, Greenberg R, Lewis TR. variation in total fecal bile acids precedes diagnosis of
Pharmacokinetic and pharmacodynamic principles: unique necrotizing enterocolitis. Sci Rep. 2020;10(1):249. PubMed doi:
considerations for optimal design of neonatal clinical trials. Front 10.1038/s41598-019-57178-0
Pediatr. 2024;11:1345969. PubMed doi: 10.3389/fped.2023. 102. Gao T, Hu S, Xu W, et al. Targeted LC-MS/MS profiling of bile
1345969 acids reveals primary/secondary bile acid ratio as a novel
88. Lewis T, Chalise P, Gauldin C, Truog W. biomarker for necrotizing enterocolitis. Anal Bioanal Chem.
Pharmacometabolomics of respiratory phenotypic response to 2024;416(1):287–297. PubMed doi: 10.1007/s00216-023-05017-7
dexamethasone in preterm infants at risk for bronchopulmonary 103. Pristner M, Wasinger D, Seki D, et al. Neuroactive metabolites
dysplasia. Clin Transl Sci. 2019;12(6):591–599. PubMed doi: 10. and bile acids are altered in extremely premature infants with
1111/cts.12659 brain injury. Cell Rep Med. 2024;5(4):101480. PubMed
89. Stockard B, Gauldin C, Truog W, Lewis T. Pharmacometabolomics doi: 10.1016/j.xcrm.2024.101480
profiling of preterm infants validates patterns of metabolism 104. Tibshirani R. Regression shrinkage and selection via the lasso.
associated with response to dexamethasone treatment for J R Stat Soc Series B Stat Methodol. 1996;58(1):267–288.
bronchopulmonary dysplasia. Front Pediatr. 2022;10:898806. doi: 10.1111/j.2517-6161.1996.tb02080.x
PubMed doi: 10.3389/fped.2022.898806
105. Bates S, Hastie T, Tibshirani R. Cross-validation: what does it
90. Zhao YD, Yin L, Archer S, et al. Metabolic heterogeneity of estimate and how well does it do it? J Am Stat Assoc. 2024;
idiopathic pulmonary fibrosis: a metabolomic study. BMJ Open 119(546):1434–1445. PubMed doi: 10.1080/01621459.2023.
Respir Res. 2017;4(1):e000183. PubMed doi: 10.1136/bmjresp- 2197686
2017-000183
106. De Francesco D, Reiss JD, Roger J, et al. Data-driven
91. Ballard PL, Torgerson D, Wadhawan R, et al. Blood longitudinal characterization of neonatal health and morbidity.
metabolomics in infants enrolled in a dose escalation pilot trial Sci Transl Med. 2023;15(683):eadc9854. PubMed doi: 10.1126/
of budesonide in surfactant. Pediatr Res. 2021;90(4):784–794. scitranslmed.adc9854
PubMed doi: 10.1038/s41390-020-01343-z
107. Shen X, Shao W, Wang C, et al. Deep learning-based pseudo-
92. Torgerson D, Guardado M, Steurer M, Chapin C, Hernandez mass spectrometry imaging analysis for precision medicine.
RD, Ballard PL. The hydrocortisone-responsive urinary Brief Bioninform. 2022;23:bbac331.
metabolome of premature infants. Pediatr Res. 2023;94(4):1317–
108. Pammi M, Aghaeepour N, Neu J. Multiomics, artificial
1326. PubMed doi: 10.1038/s41390-023-02610-5
intelligence, and precision medicine in perinatology. Pediatr Res.
93. Krautkramer KA, Fan J, Bäckhed F. Gut microbial metabolites as 2023;93(2):308–315. PubMed doi: 10.1038/s41390-022-02181-x
multi-kingdom intermediates. Nat Rev Microbiol. 2021;19(2):77–
109. Steyaert S, Pizurica M, Nagaraj D, et al. Multimodal data fusion
94. PubMed doi: 10.1038/s41579-020-0438-4
for cancer biomarker discovery with deep learning. Nat Mach
94. Liu J, Tan Y, Cheng H, Zhang D, Feng W, Peng C. Functions Intell. 2023;5(4):351–362. PubMed doi: 10.1038/s42256-023-00633-5
of gut microbiota metabolites, current status and future
110. Gregori-Puigjané E, Setola V, Hert J, et al. Identifying
perspectives. Aging Dis. 2022;13(4):1106–1126. PubMed
mechanism-of-action targets for drugs and probes. Proc Natl
doi: 10.14336/AD.2022.0104
Acad Sci U S A. 2012;109(28):11178–11183. PubMed doi: 10.1073/
95. Alsharairi NA. Therapeutic potential of gut microbiota and its pnas.1204524109
metabolite short-chain fatty acids in neonatal necrotizing
111. Holzapfel LF, Arnold C, Tyson JE, et al. Effect of reduced versus
enterocolitis. Life (Basel). 2023;13(2):561. PubMed
usual lipid emulsion dosing on bilirubin neurotoxicity and
doi: 10.3390/life13020561
neurodevelopmental impairment in extremely preterm infants:
96. Arboleya S, Binetti A, Salazar N, et al. Establishment and study protocol for a randomized controlled trial. BMC Pediatr.
development of intestinal microbiota in preterm neonates. FEMS 2023;23(1):347. PubMed doi: 10.1186/s12887-023-04149-0
Microbiol Ecol. 2012;79(3):763–772. PubMed doi: 10.1111/j.1574-
112. Juul SE, Voldal E, Comstock BA, et al; HEAL consortium.
6941.2011.01261.x
Association of high-dose erythropoietin with circulating
97. Healy DB, Ryan CA, Ross RP, Stanton C, Dempsey EM. Clinical biomarkers and neurodevelopmental outcomes among neonates
implications of preterm infant gut microbiome development. with hypoxic ischemic encephalopathy: a secondary analysis of
Nat Microbiol. 2022;7(1):22–33. PubMed doi: 10.1038/s41564- the HEAL randomized clinical trial. JAMA Netw Open. 2023;6(7):
021-01025-4 e2322131. PubMed doi: 10.1001/jamanetworkopen.2023.22131

e114 NeoReviews
 INDEX OF SUSPICION IN THE NURSERY

Multicystic Lobar Lung Lesion in a

Preterm Neonate
Sarah E Diamond, MD,1 Sarah Perez, MD,1 Vikramaditya Dumpa, MD,1 Sateesh Jayappa, MD,2 Laura Gonzalez, MD,3
Evgeniya Pasternak, MD,3 Sidney Melvin Dassinger, MD,4 Indirapriya Avulakunta, MD1

CASE PRESENTATION
A female infant aged 24 weeks and 5 days gestation is born to a G3P1 mother aged
30 years old via cesarean section for breech presentation in the setting of preterm
labor. The mother receives a course of antenatal steroids. Pregnancy is complicated
by type 2 diabetes mellitus. The infant’s birth weight is 581 g (22.5 percentile for
weight on the Fenton growth chart), with proportional head circumference and
length. The infant is intubated at delivery, receives surfactant, and stabilizes on first
intention high-frequency oscillatory ventilation as per the center’s protocol. The ini-
tial chest radiograph at birth is consistent with respiratory distress syndrome. Due to
the increasing fraction of inspired oxygen (FiO2) requirement to a maximum of
0.85, a second dose of surfactant is given on the day of life 4. She is transitioned
to a high-frequency jet ventilator (HFJV) and receives a third dose of surfactant
on the day of life 9, given poor oxygenation on FiO2 of 1. Her oxygenation remains
challenging, and a chest radiograph demonstrates optimal endotracheal tube posi- ABBREVIATIONS
tion, multiple cystic lucencies in the right lower lobe with focal hyperinflation, and CLE Congenital lobar emphysema
associated mass effect with right upper lung collapse and mediastinal shift. An CPAM Cystic pulmonary airway
18-day course of intravenous dexamethasone is started on day 12 of life as the FiO2 malformation
CT Computed tomography
requirement remains high. She later develops a large, well-demarcated lucency in
FiO2 Fraction of inspired oxygen
the anterior midline chest representing pneumomediastinum, so HFJV settings are HFJV High-frequency jet ventilator
adjusted. The 4 sigh breaths were removed, and the positive end-expiratory pressure NICU Neonatal intensive care unit
PIE Pulmonary interstitial
decreased from 14 to 12 cm H2O, with subsequent resolution of pneumomediasti-
emphysema
num by the next day. Her oxygenation remains suboptimal with worsening cystic PMA Postmenstrual age

1
Address correspondence to: Indirapriya Avulakunta, MD, Division of Neonatology, Department of Division of Neonatology, Department of
Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, 4301 W Pediatrics, University of Arkansas for
Markham St, Little Rock, Arkansas, [email protected], 501-686-7000 Medical Sciences, Arkansas Children’s
Hospital, Little Rock, Arkansas; 2Department
AUTHOR DISCLOSURE: Dr Jayappa has attended meetings with the support of the University of
of Pediatric Radiology, University of
Arkansas. Drs Diamond, Perez, Dumpa, Gonzalez, Pasternak, Dassinger, and Avulakunta have
Arkansas for Medical Sciences, Arkansas
disclosed no financial relationships relevant to this article. This article does not contain a
Children’s Hospital, Little Rock, Arkansas;
discussion of an unapproved/investigative use of a commercial product/device. 3
Department of Pathology, University of
Accepted for Publication Date: October 9, 2024 Arkansas for Medical Sciences, Arkansas
https://doi.org/10.1542/neo.26-2-012 Children’s Hospital, Little Rock,
Arkansas; and 4Division of Pediatric
Copyright © 2025 American Academy of Pediatrics
Surgery, University of Arkansas for Medical
Sciences, Arkansas Children’s Hospital, Little
Rock, Arkansas

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e115

 FIGURE 1. Left (A): Frontal view of the chest radiograph on day 27 of life demonstrating right lower lung cystic lucencies with worsening of
focal lung hyperinflation and mass effect. Right (B): radiograph chest frontal view on day 33 of life, during left main bronchus intubation trial.
The tip of the endotracheal tube is seen in the left main stem bronchus (white arrow). There is hyperinflation of the left lung with some
residual scattered focal atelectasis. Right lung hyperinflation has decreased with a decrease in the size and number of multiple cystic lucencies.

changes with emphysematous blebs in her right lung and inotropic support, a computed tomography (CT) of the
(Figure 1A). The infant continued to be managed on HFJV chest with contrast is obtained, revealing a large right lower
over the next several days. Many interventions are attempted, lobe multicystic lesion, which the radiologist reports to be
including antibiotic treatment of possible pneumonia, repo- consistent with a type I CPAM (Figure 2). The following
sitioning, sedation, and paralysis, without sustained im- day, at 30 weeks and 1 day postmenstrual age (PMA) and
provement. A trial of left mainstem intubation (Figure 1B) weighing 1300 g, she underwent a right lower lobe lobectomy
is pursued for a few hours, which she did not tolerate with with a preoperative diagnosis of type 1 CPAM. A surgical
ensuing severe hypercarbia and needing a FiO2 of 1, prompt- specimen is sent for pathology review. The patient rapidly
ing retraction of the endotracheal tube from the left main improves postoperatively, and ventilator settings are weaned
stem bronchus. As the infant’s clinical condition is not im- as tolerated. She receives a 10-day course of dexamethas-
proving on different ventilator strategies, including a trial one to aid with extubation. She is successfully extubated
of single-lung ventilation, general surgery is consulted for (Figure 3), weaned progressively to room air by 36 weeks
possible lobectomy. She is transferred to the level IV neonatal PMA, and discharged home at 39 weeks PMA on room
intensive care unit (NICU) on the day of life 36. air, taking all oral feeds.
The patient is now 62 weeks PMA, thriving well, and is
healthy without any respiratory issues.
DISCUSSION
Differential Diagnosis Actual Diagnosis
The differential diagnosis of cystic lung lesions in this Histopathology confirmed the diagnosis of cystic PIE
premature infant includes severe cystic pulmonary inter- (Figure 4).
stitial emphysema (PIE) secondary to ventilator-associated
lung injury, cystic pulmonary airway malformation (CPAM), The Condition
and congenital lobar emphysema (CLE). Other differential PIE is a ventilator-associated acquired disease of preterm
diagnoses in an infant presenting with cystic lung dis- neonates caused by air leakage into the interstitial space and
ease include necrotizing pneumonia, pneumatocele, con- characterized by radiolucency along the perivascular sheaths.
genital diaphragmatic hernia, and cystic bronchopulmonary PIE causes ventilation/perfusion mismatch and compres-
dysplasia. sion of unaffected lung tissue and can lead to pneumothorax,
pneumomediastinum, and/or pneumopericardium.1,2
Progression Managing PIE can be complex, as increased support from
After transferring to the level IV NICU for surgical evalu- mechanical ventilation may worsen the cystic lesions, which
ation, the patient becomes critically ill and hypotensive, likely may compress the unaffected adjacent lung tissue, impairing
due to mediastinal compression by the significant cystic oxygenation and ventilation. Thus, it may be necessary to tol-
changes in the right lung. After aggressive fluid resuscitation erate hypercapnia while attempting to wean the mean airway

e116 NeoReviews
FIGURE 2. CT chest lung window axial (A) and coronal (B) images demonstrate multiple round, ovoid, and oblong-shaped cystic lucencies
involving the right lower lobe having an appearance similar to the cystic mass of type I CPAM. In the coronal image, the right lower lobe
bronchus is seen entering the hyperinflated multicystic lower lobe (arrowhead). The left lung is well expanded and shows some small focal
atelectasis. The endotracheal tube tip is in the lower thoracic trachea (white arrow). A nasogastric tube is seen in the stomach (black arrow).

pressure to prevent worsened distension. Positioning the intervention in cystic lung lesions in premature infants.
affected side of the chest down and using high-frequency In the future, we recommend considering early surgical con-
jet ventilation help decrease further distension and worsen- sultation and CT imaging to better delineate the extent of
ing of PIE. For the subset of patients whose cysts worsen and lung involvement. If severe diffuse cystic PIE involves a
coalesce, there may be a role for single-lung ventilation, as single lobe of the lung and is not responding to medical
described by Rastogi et al.3 In term infants, a trial of selective management, surgical resection of the affected lobe can be
bronchial blockade can be attempted to determine if single- curative.
lung ventilation can be tolerated before subjecting the infant
to lobectomy.4 In refractory cases, there are reports of surgi-
cal intervention with lobectomy.5,6 Histopathology provides a LESSONS FOR THE CLINICIAN
definitive diagnosis of the PIE, and resection may be curative • While rare, refractory PIE may present as a worsening
in the most severe cases. cystic lung disease that progresses to the point of hemo-
Based on this experience, we only had a definitive diagno- dynamic instability.
sis after resection. To our knowledge, there is no literature in • High-frequency ventilation and patient positioning are the
pediatric surgery regarding the optimal timing for surgical first lines of management for PIE.

FIGURE 3. Frontal view of the chest on day 53 of life. Patient with status post right lower lobectomy and extubation. There is complete
resolution of multicystic hyperinflation of the right lung. Mild asymmetric postsurgical right lung volume loss is seen. The left lung is well
expanded. Mild bilateral interstitial thickening of chronic lung diseases is present. Overall, lung aeration has improved.

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e117

 FIGURE 4. The histopathology slide shows airspace enlargement (asterisks) compared with the surrounding lung parenchyma alongside mild
fibrotic changes (arrows) consistent with PIE.

• In refractory cases of PIE, surgical consultation may be stabilisation were independent risks factors for pulmonary
warranted for potential lobectomy. interstitial emphysema in preterm infants. Acta Paediatr. 2018;
107(1):28–32. PubMed doi: 10.1111/apa.14048
2. Tachibana Y, Taniguchi H, Kondoh Y, et al. Pulmonary interstitial
emphysema is a risk factor for poor prognosis and a cause of air
leaks. Respir Investig. 2019;57(5):444–450. PubMed doi: 10.1016/j.
American Board of Pediatrics resinv.2019.03.008
3. Rastogi S, Gupta A, Wung JT, Berdon WE. Treatment of giant
Neonatal-Perinatal Content pulmonary interstitial emphysema by ipsilateral bronchial
Specification occlusion with a Swan-Ganz catheter. Pediatr Radiol. 2007;37(11):
1130–1134. PubMed doi: 10.1007/s00247-007-0597-8
• Recognize the clinical, laboratory, and imaging features
4. Sankaran D, Hirose S, Null DM, Ravula NR, Lakshminrusimha S.
of air leaks.
Novel use of a bronchial blocker in a challenging case of
• Know how to prevent and manage air leaks. congenital diaphragmatic hernia-a case report. Children (Basel).
• Know the appropriate management for an infant with 2021;8(12):1163. PubMed doi: 10.3390/children8121163
congenital malformations of the lung, including con- 5. Magarakis M, Nguyen DM, Macias AE, Rosenkranz ER.
genital pulmonary lymphangiectasia, and cystic lung Lobectomy with ECMO support in an infant who developed
diseases, such as CLE, cystic adenomatoid malforma- pulmonary interstitial emphysema following repair of hypoplastic
tion, and mediastinal tumors. aortic arch. Braz J Cardiovasc Surg. 2018;33(5):528–530. PubMed
doi: 10.21470/1678-9741-2018-0135
6. Ahluwalia JS, Rennie JM, Wells FC. Successful outcome of severe
unilateral pulmonary interstitial emphysema after bi-lobectomy in
References a very low birthweight infant. J R Soc Med. 1996;89(3):167P–168P.
PubMed doi: 10.1177/014107689608900315
1. Nuñez-Ramiro A, Aguar M, Cernada M, Parra-Llorca A, Vento M.
Oxygen needs during resuscitation and surfactant to achieve

e118 NeoReviews
 INDEX OF SUSPICION IN THE NURSERY

Term Infant With Apnea and

Seizure-Like Activity
Ina A. Lee, MS,1 Erin Von Klein, MD,2 Laura Petrauskas, MD,3 Gabriella L. Crane, MD,4 Kevin Louie, DO,2
Lyndy Wilcox, MD, MMHC3

PRESENTATION
The patient is a former 39-week gestational age girl born via spontaneous vaginal
delivery to a vaginal delivery to a mother, 35 years of age, gravida 7 para 5015.
Pregnancy and delivery are complicated by maternal herpes simplex virus (HSV)-2
(recurrent, with no lesions present at birth), concern for nuchal cord, meconium at
birth, and fetal decelerations. Antenatal imaging showed polyhydramnios but was
otherwise normal. Apgar scores are 3 at 1 minute, 6 at 5 minutes, and 7 at 10 minutes.
The infant is born at a level 1 nursery and requires continuous positive airway pres-
sure (CPAP) and supplemental oxygen after delivery. Due to hypoxia with the patient
on CPAP of 5 cm H2O and fraction of inspired oxygen 0.30, transfer is requested to a
higher level of care neonatal intensive care unit (NICU). There is no concern for
perinatal depression or hypoxic-ischemic encephalopathy (HIE) reported.
During transport, the infant has 2 desaturation events that resolve with stimu-
lation and increased supplemental oxygen. Upon presentation to the NICU, her ini-
tial examination is within normal limits. She subsequently develops recurrent apnea
ABBREVIATIONS
episodes associated with desaturation to 40%; during each episode, the patient is
noted to have tensed extremities and rhythmic flexion and extension movements. CPAP continuous positive airway
pressure
The NICU team is initially most concerned for seizures and consults neurology
NICU neonatal intensive care unit
for evaluation and placement of video electroencephalography (EEG). An EEG is HIE hypoxic-ischemic encephalopathy
ordered, and antimicrobials are broadened to include acyclovir for HSV coverage. EEG electroencephalography
ENT otolaryngology
The apnea episodes increase in frequency. Therefore, the team proceeds with
HSV herpes simplex virus
intubation to protect the patient’s airway. Intubation is difficult, requiring more MRI magnetic resonance imaging
than 3 attempts, with successful intubation by the supervising physician. CT computed tomography

1
AUTHOR DISCLOSURE: Dr Von Klein works under a grant from AHRQ National Research Service Vanderbilt University School of Medicine,
Award and has attended meetings with the support of the AAP. Drs Lee, Petrauskas, Crane, Nashville, Tennessee; 2Division of
Louie, and Wilcox have disclosed no financial relationships relevant to this article. This Neonatology, Department of Pediatrics,
commentary does not contain a discussion of an unapproved/investigative use of a commercial Vanderbilt University Medical Center,
product/device. Nashville, Tennessee; 3Division of Pediatric
Otolaryngology, Department of
Accepted for Publication Date: October 14, 2024
Otolaryngology-Head & Neck Surgery,
https://doi.org/10.1542/neo.26-2-013 Vanderbilt University Medical Center,
Copyright © 2025 American Academy of Pediatrics Nashville, Tennessee; and 4Division of
Pediatric Radiology & Radiological Sciences,
Department of Radiology & Radiological
Sciences, Vanderbilt University Medical
Center, Nashville, Tennessee

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e119

 DISCUSSION of mature fatty tissue, salivary glands, squamous epithelium
Differential Diagnosis with keratin pearls, and a focus of dental papillae with
The differential diagnosis for apnea and seizure-like-activity enamel epithelium and ameloblasts consistent with a mature
in the neonatal population is broad. Most common causes teratoma.
include infections, such as meningitis or sepsis, and neuro-
logic pathologies, such as HIE, mass-effect, bleeding, or The Condition
stroke. Additional etiologies can include genetic abnor- Oropharyngeal teratomas, also known as epignathus, are
malities such as in-born errors of metabolism, electrolyte a rare form of congenital teratoma originating from the
derangements, or upper airway obstruction, especially in the skull base often with attachments at the hard palate or
setting of syndromes like trisomy 21, Beckwith-Wiedemann, mandible.1,2 It is a germinal neoplasm consisting of tis-
or Treacher Collins. sues from all 3 germ layers. The incidence of epignathus
is estimated to affect between 1 in 35 000 to 1 in 200 000
Diagnosis live births.3 Depending on their location, these masses
The supervising physician notes a round, pink-colored mass may present with dysphagia, rhinorrhea, or nasal block-
along the posterior oropharynx during intubation, leading age; if large, they may cause respiratory obstruction and
to consultation of the pediatric otolaryngology (ENT) service cyanosis.4
for bedside laryngoscopy. The team performs a flexible laryn- Orofacial teratomas identified before birth are often large
goscopy, which visualized a mass posterior to the uvula and can be linked to polyhydramnios, hydrops fetalis, and
obstructing the choanae. preterm delivery, leading to a mortality rate of more than
Computed tomography (CT) demonstrated a large heter- 50%.5 The most serious postnatal complication is severe res-
ogenous naso-oral-pharyngeal mass containing a partially piratory distress caused by airway obstruction. Prenatal diag-
formed tooth, macroscopic fat, and a small amount of nosis can enable early recognition and anticipatory treatment
enhancing tissue. The mass measures 1.1 × 2.0 × 3.5 cm such as ex utero intrapartum treatment procedures in the
and shows remodeling of the smooth bone of the posterior most severe cases. However, smaller masses may go unde-
nasal cavity. In the meantime, the EEG returned as normal. tected in the prenatal period and may present unexpectedly
CT imaging was suggestive of an epignathus, an oropharyn- after delivery.
geal teratoma (Figure 1), particularly due to the presence of
a tooth. magnetic resonance imaging (MRI) was also Treatment and Management
obtained to better understand tissue attachments and bor- It is preferred to detect masses of the airway prenatally to
ders prior to surgery (Figure 2). The mass is removed by prepare for difficulties with airway at birth. In neonates
ENT (Figures 3 and 4). Pathology demonstrates a mixture with obstructive apneas, it is important to prioritize the

FIGURE 1. Coronal computed tomography (CT) (A) demonstrates a mass (*) occupying portions of the pharynx, which contains markedly
hypodense tissue, similar to subcutaneous fat, but with a left lateral soft tissue component containing a tooth (arrow). Endotracheal tube
passes beneath the mass. Sagittal CT (B) reveals that the mass (*) causes significant narrowing of the posterior nasopharynx and oropharynx.

e120 NeoReviews
FIGURE 2. On magnetic resonance imaging, sagittal T2-weighted sequence with fat saturation (A) allows clear delineation of the mass as
separate from the soft palate (arrow) and highlights the fatty nature of the mass. Coronal T1-weighted post-contrast sequence (B) better
defines the enhancing soft tissue component, appearing to arise from the left lateral wall of the pharynx (multiple arrows).

FIGURE 3. (A and B) Visualization of mass in the posterior oropharynx with a rigid 0-degree endoscope performed intraoperatively during
mass excision by the pediatric otolaryngology team.

ABCs—airway, breathing, and circulation. Every effort has healed from surgery and resumed normal breathing
should be made to stabilize the airway. In this case, the mass and feeding.
was noted on intubation. Performing a thorough and full
physical examination on all patients is critical. Once the diag- Patient Course
nosis of epignathus is determined, management requires Three days after admission, the patient is taken to the oper-
multidisciplinary care including NICU and ENT. Further ating room for removal of the mass. General anesthesia was
evaluations like flexible laryngoscopy and imaging such as administered. The mass was visualized, confirmed to be
CT and MRI must further delineate the lesion prior to attached to the left posterior pharyngeal wall, and removed.
surgical planning. Surgical excision should not be de- The patient is extubated to room air the following day. She
layed because while the lesions are benign, they may grow had no further episodes of apnea or abnormal movements;
quickly and cause further airway destruction and feeding the movements were thought to be secondary to discomfort
difficulties. There is low concern for recurrence. Scheduling associated with airway obstruction. Oncology is consulted
short-term follow-up is appropriate to ensure that the patient and out-patient follow-up every 3 months for surveillance

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e121

 • Prioritize airway stabilization in neonates with apneas.
Potential diagnostic material may be visually noted on
intubation.

American Board of Pediatrics

Neonatal–Perinatal Content
Specification
• Know the various causes of stridor in the newborn and
how to assess severity
• Know the clinical manifestations and approaches to
therapy of neck masses in the newborn infant

References
FIGURE 4. Gross pathology of mass after surgical excision by 1. Parajuli R, Thapa S, Maharjan S. Mature Nasopharyngeal
pediatric otolaryngology team. Teratoma in a Child. Case Rep Otolaryngol. 2015;2015:515474.
PubMed doi: 10.1155/2015/515474
2. Pellegrini V, Colasurdo F, Guerriero M. Epignathus with
is planned. Upon discharge, the patient has normal work of oropharynx destruction. Autops Case Rep. 2021;11:e2021293.
breathing on room air without noted apneic events since doi: 10.4322/acr.2021.293
excision. 3. Zhu P, Li XY. Management of oropharyngeal teratoma: Two case
reports and a literature review. J Int Med Res. 2021;49(2):
e2021293. PubMed doi: 10.1177/0300060521996873
LESSONS FOR CLINICIAN
4. Choudhury N, Ghosh T, Mukherjee M, Dutta M. Oropharyngeal
• Neonatal epignathus is a true congenital teratoma and may true teratoma. Indian J Pediatr. 2009;76(7):747–748. PubMed
doi: 10.1007/s12098-009-0146-6
present with prenatal polyhydramnios and obstructive
5. Bianchi B, Ferri A, Silini EM, Magnani C, Sesenna E. Congenital
apneas in the neonatal period.
cervical teratoma: a case report. J Oral Maxillofac Surg. 2010;
• Consider obstructive pathologies in the differential diag- 68(3):667–670. PubMed doi: 10.1016/j.joms.2009.04.054
nosis for apnea even in non-syndromic infants.

e122 NeoReviews
 MATERNAL-FETAL CASE STUDIES

MATERNAL-FETAL
CASE STUDIES

Managing Fetal Anemia: A Case of

Parvovirus Infection in Pregnancy
Rodolfo Fernandez Criado, MD, Stephanie Ros Saposnik, MD

CASE
A gravida 2, para 1-0-0-1 woman aged 27 years with chronic hypertension and a pre-
vious cesarean delivery in Brazil presented to her scheduled anatomy ultrasonogram
for routine prenatal care at 20 weeks and 1 day’s gestation. On imaging, the fetus had
ascites and a small pericardial effusion diagnostic of fetal hydrops (Fig. 1). Middle
cerebral artery (MCA) Dopplers were performed and noted to be significantly
elevated, indicating fetal anemia (Fig. 2). This finding was reviewed with the patient.
Her medical and surgical histories were unremarkable, except that she reported hav-
ing experienced a flu-like illness about 3 to 4 weeks before her ultrasonogram, with
symptoms including coughing, sneezing, headaches, arthralgias in bilateral knees,
shortness of breath, and lower abdominal pain. The differential diagnosis included
an infectious, cardiac, or genetic etiology. The combination of her recent symptoma-
tology and ultrasonogram findings led to a leading differential diagnosis of parvo-
virus infection. Serum testing with parvovirus serologies was obtained. The
parvovirus IgM returned positive, confirming parvovirus infection.
At 20 weeks’ gestation, she was transferred to a tertiary care center where she
underwent a percutaneous umbilical blood sampling (PUBS) to confirm suspicion
of fetal anemia. The PUBS was performed without complication, and fetal anemia
was confirmed with a hematocrit of 9.7% (reference range, 35%–48%). The fetus
underwent an intrauterine blood transfusion with 15 cc of irradiated, O-negative,
cytomegalovirus-negative blood. Several hours after the procedure, she reported dif-
fuse abdominal pain and had decreased fetal movement. Bedside ultrasonogram
found absent cardiac activity, confirming intrauterine fetal demise.

Address correspondence to: Stephanie Ros Saposnik, MD, Women & Infants Hospital, Brown Women & Infants Hospital, Brown
University, 101 Dudley St, Providence, RI 02905. [email protected] University, Providence, Rhode Island
AUTHOR DISCLOSURE: Dr Ros Saposnik is on the board of directors for the Society for Maternal
Fetal Medicine. Dr Fernandez Criado has disclosed no financial relationships relevant to this
article. This article does not contain a discussion of an unapproved/investigative use of a
commercial product/device.
Accepted for Publication Date: November 1, 2024
https://doi.org/10.1542/neo.26-2-016
Copyright © 2025 American Academy of Pediatrics

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e123

 affecting humans. About 30% to 60% of adults have positive
antibodies to parvovirus.2 Similarly, about 35% to 53% of
pregnant patients have evidence of immunity from previous
infection, given serologic evidence of IgG to the virus.3 The
incidence of B19 infection is highest in schoolteachers (16%)
and daycare workers (9%).4 Notably, the Centers for Disease
Control and Prevention (CDC) issued a statement in August
2024 stating there is an increase in the cases of B19 infection
in the United States as well as 14 other European countries.5
Thus, this should increase clinical suspicion for patients with
common parvovirus symptoms.
Parvovirus infection can present as erythema infectio-
sum, or fifth disease, classically characterized with a
FIGURE 1. Fetal abdomen with ascites (arrow) as a component of “slapped cheek” rash on the face and lacy rash along the
fetal hydrops.
trunk. Although adults can manifest with a rash, the classic
appearance on the face or the trunk is rare. These derma-
tologic findings are usually accompanied by systemic
symptoms, most commonly arthralgias in the adult
population. The recommended treatment is routine sup-
portive care, given the virus is self-limiting, especially in
immunocompetent individuals.6 However, in pregnancy,
there are unique considerations for the fetus exposed to
parvovirus B19.

APPROACHING THE B19-POSITIVE PREGNANT

PATIENT
If there is a clinical suspicion of parvovirus B19 in a pregnant
patient, assessing serologic IgG and IgM antibodies is rec-
FIGURE 2. Middle cerebral artery Dopplers with elevated value
concerning for fetal anemia in the setting of parvovirus infection. The ommended.6 Patients with seropositive IgM antibodies indi-
fetal anemia is subsequently confirmed via a percutaneous umbilical cate active parvovirus infection. Counseling should be
blood sampling.
tailored depending on the gestational age at the time of par-
vovirus diagnosis.6
MATERNAL OUTCOME Pregnant patients presenting with active infection before
The patient was counseled extensively regarding mode of 20 weeks’ gestation should be counseled that the PUBS pro-
delivery, including induction of labor vs dilation and evac- cedure is not typically feasible given limited visualization and
uation. She underwent dilation and evacuation procedure the smaller size of fetal structures. Typically, after 20 weeks’
under ultrasonogram guidance. She recovered with no physi- gestation, patients may have weekly ultrasonograms to
cal concerns. She was discharged the same day with physi- monitor for ultrasonographic evidence of hydrops fetalis
cian and social services follow-up. (ie, edema, ascites, cardiomegaly, and polyhydramnios).
Additionally, MCA peak systolic velocity Doppler is measured
FETAL AUTOPSY to assess anemia, with the anemia characterized as a peak sys-
tolic blood velocity more than 1.5 multiples of the median.
A fetal autopsy was offered to the patient at the time of coun-
The usual duration of time for testing is about 10 to 11 weeks
seling for the dilation and evacuation. The patient declined
after the infection. It is less likely for the fetus to develop fetal
an autopsy after the procedure.
hydrops if the infection has not occurred 8 weeks after infec-
tion in the pregnant person.6 Susceptible pregnant patients
HUMAN PARVOVIRUS B19 (no history of exposure, schoolteachers, and daycare workers)
Parvoviridae are a class of small, nonenveloped DNA should be recommended to engage in proper hand hygiene
viruses.1 Human parvovirus B19 is the predominant strain and to avoid sharing food or drinks.6

e124 NeoReviews
HYDROPS FETALIS resuscitation includes paracentesis, thoracentesis, or infu-
Hydrops fetalis is a known but fortunately infrequent result sion of blood products, depending on the gestational age
of parvovirus B19 infection in pregnancy. Hydrops fetalis is and severity of clinical manifestations of the parvovirus infec-
ultrasonographic evidence of fluid accumulation around the tion in the infant. Additionally, mental health support should
soft tissues and serous cavities of the fetus.7 There is a wide be considered for the parents. Fetal hydrops can be psycho-
variety of possible causes. These include immune-mediated logically altering events, and mental health should be priori-
(eg, isoimmunization) and nonimmune-mediated causes, tized postpartum.
such as congenital infections, abnormalities in hemoglobin
function, or anatomic malformations such as congenital SUMMARY
heart or lung defects. Parvovirus B19 infection is cytotoxic A fetus can succumb to complications stemming from
to red blood cells, which results in profound fetal anemia. parvovirus-induced hemolytic anemia at a previable gesta-
The likelihood of fetal loss is directly correlated with the tional age. Although most parvovirus infections do not cause
severity of the anemia in the fetus. anemia and hydrops, a minority of parvovirus infections in
Fortunately, most cases of parvovirus infection in preg- pregnancy will result in adverse outcome for the fetus despite
nancy resolve spontaneously without fetal infection or fetal appropriate surveillance and treatment.
sequelae. Studies suggest the rate of hydrops fetalis associ-
ated with parvovirus B19 infection before and after 20 weeks
of gestation is 11% and less than 1%, respectively.8 One study
American Board of Pediatrics
from Sweden demonstrated that the risk of third trimester
stillbirth from B19 infection was very low, citing 93 deaths Neonatal-Perinatal Content
out of 33 759 deliveries.9 Additionally, infection in the first Specification
trimester will increase the risk of adverse outcomes. • Development of immune defenses in the fetus and
neonate.
• Assessment of fetal well-being.
MANAGEMENT OF ANEMIA AND HYDROPS
FETALIS
A fetus with evidence of mild-to-moderate anemia is usually References
self-limited and typically resolves spontaneously without
1. Heegaard ED, Brown KE. Human parvovirus B19. Clin Microbiol
long-term sequalae. Because the anemia caused by parvovi-
Rev. 2002;15(3):485–505. PubMed doi: 10.1128/CMR.15.3.485-505.
rus is transient, there is low utility in determining the fetal 2002
hemoglobin levels, unless there is ultrasonographic evidence 2. Woolf AD, Campion GV, Chishick A, et al. Clinical manifestations
of hydrops. Two of the primary modalities for monitoring of human parvovirus B19 in adults. Arch Intern Med. 1989;149(5):
fetal anemia include the MCA peak systolic blood velocity 1153–1156. PubMed doi: 10.1001/archinte.1989.00390050111022

and ductus venosus velocity; the MCA is usually preferred 3. Rodis JF, Quinn DL, Gary GW Jr, et al. Management and
outcomes of pregnancies complicated by human B19 parvovirus
given its accessibility for measurement via ultrasonogram. infection: a prospective study. Am J Obstet Gynecol. 1990;
Patients with elevated MCA Doppler ultrasonograms are 163(4 Pt 1):1168–1171. PubMed doi: 10.1016/0002-9378(90)
recommended to have a PUBS procedure, in addition to an 90681-V

intrauterine fetal blood transfusion. The evidence demon- 4. Cartter ML, Farley TA, Rosengren S, et al. Occupational risk
factors for infection with parvovirus B19 among pregnant women.
strates that intrauterine transfusion improved the survival J Infect Dis. 1991;163(2):282–285. PubMed doi: 10.1093/infdis/163.
rate of fetal parvovirus infection to 82% with transfusion 2.282
vs 55% without intrauterine transfusion.10 Although intra- 5. Centers for Disease Control. Increase in human parvovirus B19
venous immunoglobulin has been used to treat patients activity in the United States. Published August 13, 2024. Accessed
October 31, 2024. https://emergency.cdc.gov/han/2024/han00514.
infected with parvovirus B19, there is no recommendation
asp
for its use in the management of infected pregnant patients
6. Practice bulletin no. 151: cytomegalovirus, parvovirus B19, varicella
outside of a research protocol. zoster, and toxoplasmosis in pregnancy. Obstet Gynecol. 2015;
Given the high risk of neonatal compromise in the setting 125(6):1510–1525. PubMed doi: 10.1097/01.AOG.0000466430.
19823.53
of hydrops, it is critical to have coordinated efforts between
7. Norton ME, Chauhan SP, Dashe JS; Society for Maternal-Fetal
the obstetrics team and the neonatologists arrange for a coor-
Medicine (SMFM). Society for maternal-fetal medicine (SMFM)
dinated delivery planning with prepared respiratory support clinical guideline #7: nonimmune hydrops fetalis. Am J Obstet
and mechanical ventilation. Additional preparation for Gynecol. 2015;212(2):127–139. PubMed doi: 10.1016/j.ajog.2014.12.018

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e125

 8. Enders M, Weidner A, Zoellner I, Searle K, Enders G. Fetal association with third-trimester intrauterine fetal death. BJOG.
morbidity and mortality after acute human parvovirus B19 2000;107(4):476–480. PubMed doi: 10.1111/j.1471-0528.2000.
infection in pregnancy: prospective evaluation of 1018 cases. Prenat tb13265.x
Diagn. 2004;24(7):513–518. PubMed doi: 10.1002/pd.940 10. von Kaisenberg CS, Jonat W. Fetal parvovirus B19 infection.
9. Skjöldebrand-Sparre L, Tolfvenstam T, Papadogiannakis N, Ultrasound Obstet Gynecol. 2001;18(3):280–288. PubMed doi:
Wahren B, Broliden K, Nyman M. Parvovirus B19 infection: 10.1046/j.1469-0705.2001.00471.x

e126 NeoReviews
 VISUAL DIAGNOSIS

A Late Preterm Neonate With

a Small Chest
Abhilasha Gupta, MD, Prashanth Ranya Raghavendra, DM, Sruthi Nair, DrNB, Anitha Haribalakrishna, MD, FRACP

CASE
A late preterm neonate with a small chest.

PRENATAL AND BIRTH HISTORIES

• Born to a 30-year-old gravida 2, para 1 woman.

• A 20-week scan was normal except for the possibility of bilateral short femurs;
additional fetal ultrasonogram scans showed similar findings with no fetal growth
restriction.
• The parents were nonconsanguineous.
• A previous sibling is aged 5 years and healthy.
• Prenatal maternal laboratory tests returned normal results. No other abnormal-
ities were detected by ultrasonography. The umbilical cord Doppler scan result
was normal, and there was no polyhydramnios.
• The estimated gestational age was 36 weeks’ gestation.
• This was a spontaneous preterm labor with no additional risk factors for sepsis.
• Born in a lower-segment Cesarean delivery because of previous lower-segment
Cesarean secondary to cephalopelvic disproportion.
• The neonate cried immediately after birth with good tone.
• The Apgar scores were 9 and 9 at 1 and 5 minutes, respectively.
• Respiratory distress was noted soon after birth.

PROGRESSION (SOON AFTER BIRTH)

Vital Signs ABBREVIATION

SD skeletal dysplasia
• Heart rate: 150 beats per minute

Address correspondence to: Sruthi Nair, DrNB, Department of Neonatology, Seth G.S. Medical Department of Neonatology, Seth G.S.
College and King Edward Memorial Hospital, Acharya Donde Marg, Parel, Mumbai 400012, India. Medical College and King Edward Memorial
[email protected], +91-94-2961 3621 Hospital, Mumbai, India
AUTHOR DISCLOSURE: Drs Gupta, Ranya Raghavendra, Nair, and Haribalakrishna have disclosed
no financial relationships relevant to this article. This article does not contain a discussion of an
unapproved/investigative use of a commercial product/device.
Accepted for Publication Date: April 21, 2024
https://doi.org/10.1542/neo.26-2-014
Copyright © 2025 American Academy of Pediatrics

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e127

 • Respiratory rate: 72 breaths per minute • Hip examination: no developmental dysplasia of the hip
• Blood pressure: 62/42 (mean 50) mm Hg and no limb-length discrepancy
• Oxygen saturation: 88% (in room air) • Skin: no icterus, birthmarks, or other rashes
• Temperature: 98.6°F (36.5°C)

PROGRESSION
Physical Examination The neonate was admitted to the neonatal intensive care unit.
• Birthweight: 2100 g (10th centile as per the modified At age 5 minutes, he was placed on continuous positive air-
Fenton’s chart) way pressure with fraction of inspired oxygen of 0.25 and
• Length: 46 cm (30th centile as per the modified Fenton’s peak end expiratory pressure of 5 cm H2O. A venous blood
chart) gas test was normal with a pH of 7.35, partial pressure of car-
• Head circumference: 32 cm (30th centile as per the modi- bon dioxide of 39 mm Hg, partial pressure of oxygen of
fied Fenton’s chart) 60 mm Hg, and bicarbonate level of 23.4 mEq/L. A chest
• Head: normocephalic with normal, open, and flat radiograph was obtained (Figure 2). He was started on gavage
fontanelles feedings. Detailed anthropometry and body measurements
• Face: depressed nasal bridge with no coarse facial features showed that he had a small chest with normal limb length
• Oral cavity: pink mucosae, intact palate, normal sucking, with findings summarized in Table 1. A skeletal survey
and rooting reflex was obtained (Figures 3A and B) and genetics was consulted.
• Thorax: bell-shaped, small thorax with pectus carinatum
(Figure 1A) DIFFERENTIAL DIAGNOSIS
• Lungs: moderate respiratory distress with intercostal and • Asphyxiating thoracic dysplasia (dystrophy)
subcostal retractions; bilateral air entry normal • Thoracolaryngopelvic dysplasia (Barnes syndrome)
• Cardiovascular: normal S1 and S2, regular rate and • Schneckenbecken dysplasia
rhythm, and no murmurs or gallops • Fibrochondroplasia
• Abdomen: protuberant, soft, and nontender; normal bowel • Jansen metaphyseal dysplasia
sounds; and no hepatosplenomegaly (Figure 1A)
• Genitourinary: normal male genitalia and patent anus The skeletal survey (Table 2) demonstrates the following
• Skeletal: spine appears normal findings: elevated clavicles, hypomineralized bones with cup-
• Limb examination: no shortening of limbs. No excess skin ping of the distal ends of the radii, a bell-shaped thorax, a
folds, no evidence of fracture, no congenital talipes equino- small and narrow pelvis, bowing of the femurs, and thoracic
varus, and no contractures scoliosis. Because of the potential of having a skeletal

FIGURE 1. Clinical features of thoracicpelvic dysostosis in the index neonate. (A) Bell-shaped thorax and protuberant abdomen (black arrows).
(B) Neonate at the time of discharge at age 16 days with small thorax (black arrow).

e128 NeoReviews
 that the transverse diameter of the inlet, the mediolateral
diameter of the midplane, and mediolateral diameter of
the outlet were less than 1 unit (ie, 10 cm, normal 15 cm), sug-
gestive of a small pelvis and, given the mother’s height of
141 cm, contributing to cephalopelvic disproportion. The
skeletal surveys in the father and sibling were normal.

PRESUMED DIAGNOSIS
Thoracopelvic dysostosis (variant of Barnes Syndrome)

CASE PROGRESSION
The infant’s respiratory distress was thought to be most likely
caused by mild surfactant deficiency. He is weaned off res-
piratory support at age 3 days and then started to feed orally.
The genetics team met with the family and explained the
FIGURE 2. Radiograph at the time of admission to the neonatal need for genetic confirmation; the family deferred genetic
intensive care unit showing mild surfactant deficiency and no testing initially because of financial constraints. He was dis-
pulmonary hypoplasia.
charged home at age 16 days (Figure 1B) at 38 weeks 2 days
postmenstrual age with a weight of 2180 g exclusively breast-
dysplasia (SD) associated with airway abnormalities, a laryn- feeding. He has follow-up with his pediatrician and genetics.
goscopy is done that shows no evidence of laryngeal stenosis.
The infant’s liver function tests, blood urea nitrogen and cre- WHAT THE EXPERTS SAY
atinine levels, ultrasonogram scans of the head and
SD refers to a group of disorders with abnormalities in the
abdomen, and echocardiography were obtained to rule out
structure and growth of bone and cartilage with an overall
systemic associations; these were all found to be normal.
prevalence of 2.3 to 7.6 per 10 000 births.1 The major contrib-
Serum calcium, phosphorous, and alkaline phosphorus lev-
uting factor to mortality in cases of SD is the degree of tho-
els were normal. In consultation with radiology and genetics,
racic underdevelopment and pulmonary hypoplasia. The
a clinical diagnosis of thoracopelvic dysostosis was made.
extensive involvement of the vertebrae and associated rib
A detailed evaluation of the parents was done, which
anomalies result in thoracic case deformity and improper
showed a small pelvis in the mother with a normal thorax.
ventilation.
The radiograph of the mother’s pelvis (Figure 3C) showed
Thoracolaryngopelvic dysplasia, also known as Barnes
syndrome, is an SD whereby affected infants have a small
TABLE 1. Detailed Anthropometry and Body thorax with short ribs and a small pelvis with laryngeal steno-
Measurements sis.2 Barnes syndrome has an autosomal dominant pattern of
Interpretation inheritance with 9 cases (3 female adults and 6 infants)
Infant’s of Infant’s
reported to date globally and an estimated prevalence of less
Measurement Value Measurement
than 1/1 000 000.2
Chest circumference, cm 25 Less than −2 SDs
Upper arm length, cm Right: 9 Mean to +2 SDs The hallmark feature of Barnes syndrome is a small, rigid
Left: 9 bell-shaped chest with short ribs and a small pelvis with
Forearm length, cm Right: 7.5 Mean to +2 SDs a normal height and limb length. Among the 3 women
Left: 7.5
Hand length, cm Right: 5 Mean to +2 SDs reported,3–5 all underwent cesarean section for cephalo-
Left: 5 pelvic disproportion, similar to the mother of our patient.
Upper thigh length, cm Right: 10 Mean to −2 SDs
However, in contrast to the reported cases, our patient did
Left: 10
Leg length, cm Right: 9.5 Mean to −2 SDs not have laryngeal stenosis and did not require prolonged
Left: 9.5 ventilation or tracheostomy, suggesting that this infant prob-
Foot length, cm Right: 7 Mean to −2 SDs
Left: 7 ably has a variant of Barnes syndrome (ie, thoracopelvic dys-
Upper and lower 1.72:1 Normal ostosis without laryngeal stenosis). Among the previously
segment ratio reported 6 infant cases, all required a tracheostomy in early
Abbreviation: SD, standard deviation. infancy.3–5 In addition, 1 died in the neonatal period and the

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e129

 FIGURE 3. (A) Skeletal survey of the index neonate at age 4 days demonstrating elevated clavicles (black arrow), bell-shaped thorax with short
horizontal ribs (black asterisk), cupping of the distal end of the left radius (white asterisk), and scoliosis (black arrowhead). (B) Additional
radiograph of index neonate at age 4 days showing small and narrow pelvis (black asterisk) and hypomineralized femurs with bowing at the
medial ends (black arrow). (C) Radiograph of the index neonate’s mother showing a small and narrow pelvis (1, pelvic inlet; 2, midplane; and
3, pelvic outlet).

other in early adolescence after multiple chest expansion sur- asphyxiating thoracic dysplasia have bowed extremities with
geries and numerous hospitalizations for recurrent chest a trident pelvis, polydactyly, short limbs, and associated renal
infections.3–5 Long-term data of the remaining 4 infants and cardiac malformations in addition to short ribs.6 The
are not available. absence of rhizomelic shortening of long bones, distinct
The patient in this case required noninvasive support for a facial features, and splaying of the end of ribs and spurs
short period and remained hemodynamically stable. Because arising from the iliac bones makes fibrchondroplasia and
this infant did not have major involvement of the chest and Schneckenbecken dysplasia less likely.7 Jansen metaphyseal
pelvis, relative sparing of the long bones, absence of respira- dysplasia is also of low probability because affected patients
tory infections after discharge, and normal growth, this have predominant involvement of the long bones, which was
infant is likely to have a variant of Barnes syndrome that is not evident in this patient.7
probably associated with a better quality of life and prognosis
than patients with the originally described syndrome. This
patient still requires genetic testing to confirm the diagnosis TAKE-HOME LESSONS
and increase our understanding of the molecular basis of the • A variant of thoracolaryngopelvic dysplasia (Barnes syn-
variation in presentation. drome) should be suspected in neonates with a bell-shaped
The other potential diagnoses considered in this case thorax and maternal-infant dyad having small pelvis and
were ruled out clinically and radiographically. Infants with no laryngeal stenosis.
• SDs without pulmonary hypoplasia and other systemic
manifestations are less lethal.
TABLE 2. Skeletal Survey of the Neonate (Figure 3) • A detailed clinical examination and skeletal survey of a
Bone Location Interpretation neonate with an SD as well as their parents can aid in
Skull Normal the clinical-radiological diagnosis.
Clavicle Elevated location
Ribs and thorax (Figure 2) Bell-shaped thorax with short
horizontal ribs; adequate
pulmonary expansion
Humerus, radius, and ulna Normal appearance with
hypomineralized bones; cupping
of distal end of left radius
American Board of Pediatrics
Pelvis Small and narrow pelvis Neonatal-Perinatal Content
Femur and tibia Normal with hypomineralized
bones with bowing of medial end Specification
Phalanges of hand and feet Normal with hypomineralized
bones • Recognize the diagnostic implications of single vs
Spine Thoracic scoliosis multiple anomalies.

e130 NeoReviews
Acknowledgments 3. Bankier A, Danks DM. Thoracic-pelvic dysostosis: a ‘new’
The authors thank Dr Sangeeta Ravat, Dean, Seth GS autosomal dominant form. J Med Genet. 1983;20(4):276–279.
Medical College and KEM Hospital, Mumbai, India, for PubMed doi: 10.1136/jmg.20.4.276
granting permission for publication. 4. Burn J, Hall C, Marsden D, Matthew DJ. Autosomal dominant
thoracolaryngopelvic dysplasia: Barnes syndrome. J Med Genet.
1986;23(4):345–349. PubMed doi: 10.1136/jmg.23.4.345
5. Wood E, Kearns D. Laryngotracheal stenosis in
References thoracolaryngopelvic dysplasia: Barnes syndrome. Otolaryngol Head
1. Barbosa-Buck CO, Orioli IM, da Graça Dutra M, Lopez-Camelo J, Neck Surg. 1995;113(6):807–809. PubMed doi: 10.1016/S0194-
Castilla EE, Cavalcanti DP. Clinical epidemiology of skeletal 59989570027-7
dysplasias in South America. Am J Med Genet A. 2012;158A(5): 6. Campbell RM Jr. Asphyxiating thoracic dystrophy. In: National
1038–1045. PubMed doi: 10.1002/ajmg.a.35246 Organization for Rare Disorders. NORD Guide to Rare Disorders.
2. Patel SH, Banzali FM Jr, Post RJ, et al. Parturient with Lippincott Williams & Wilkins; 2003:155–156.
Barnes syndrome (thoracolaryngopelvic dysplasia) undergoing 7. İpek MS, Akgul Ozmen C. Skeletal dysplasias that cause thoracic
cesarean delivery of a neonate with Barnes syndrome: a case insufficiency in neonates: illustrative case reports. Medicine
report. A A Pract. 2018;11(6):151–154. PubMed doi: 10.1213/XAA. (Baltimore). 2016;95(14):e3298. PubMed doi: 10.1097/MD.
0000000000000765 0000000000003298

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e131

 OUTCOMES OF NICU GRADUATES

OUTCOMES OF
NICU GRADUATES

Preterm Infants With Bronchopulmonary

Dysplasia and Pulmonary Hypertension
Kathryn Hasselfeld, MD,1,2 Erik Hysinger, MD,2,3 Melissa House, MD4

CASE PRESENTATION
We present the case of a male infant born preterm with a postnatal course compli-
cated by grade 3 bronchopulmonary dysplasia (BPD) and pulmonary hypertension
(PH) who was followed in our multidisciplinary neonatal intensive care unit (NICU)
follow-up clinic.
The infant was born at 251/7 weeks’ gestation to a 28-year-old gravida 1 para 0
woman via vaginal delivery secondary to preterm labor and concern for chorioam-
nionitis. Pregnancy was complicated by subchorionic bleeding noted on 20-week
ultrasonogram. The pregnant woman had received an incomplete course of betame-
thasone prior to delivery. Delivery was significant for meconium-stained amniotic
fluid. The infant was initially vigorous with good tone but quickly developed
poor respiratory effort and hypoxemia requiring intubation in the delivery room.
The infant’s Apgar scores were 7 and 8 at 1 and 5 minutes of age, respectively.
The infant’s birth weight was 760 g, which was appropriate for gestational age.
He was admitted to a level III NICU for further management.
Upon admission, he received a dose of surfactant and was extubated to continu-
ous positive airway pressure the following day. In the first week of age, he received a
course of ibuprofen to facilitate patent ductus arteriosus (PDA) closure that was
diagnosed on echocardiography. He was reintubated and placed on conventional
ventilation at 6 days of age following multiple apnea and bradycardia events.
Three days later, he was found to have a total parenteral nutrition–related pericardial
effusion with cardiac tamponade that resolved after pericardiocentesis and removal
of the peripherally inserted central line. At 12 days of age, he had worsening respi-
ratory failure, and he was treated with 14 days of antibiotics for culture-positive
Escherichia coli bacteremia and pneumonia. At 31 days of age, systemic

1
Perinatal Institute, Division of Neonatology AUTHOR DISCLOSURE: Dr Hysinger works under a grant from the National Institutes of Health
and Pulmonary Biology, Cincinnati (NIH). Drs Hasselfeld and House have disclosed no financial relationships relevant to this article.
Children’s Hospital Medical Center, This article does not contain a discussion of an unapproved/investigative use of a commercial
Cincinnati, Ohio; 2Department of Pediatrics, product/device.
University of Cincinnati College of Medicine,
Accepted for Publication Date: May 29, 2024
Cincinnati, Ohio; 3Division of Pulmonary
Medicine, Cincinnati Children’s Hospital https://doi.org/10.1542/neo.26-2-015
Medical Center, Cincinnati, Ohio; and Copyright © 2025 American Academy of Pediatrics
4
Division of Neonatology, Department of
Pediatrics, Children’s Healthcare of Atlanta,
Emory School of Medicine, Atlanta, Georgia

e132 NeoReviews
dexamethasone via the Dexamethasone: A Randomized Trial his overall clinical appearance and ability to wean on oxygen
protocol1 was initiated to facilitate weaning of respiratory support, he was not initiated on pulmonary vasodilator
support, but it was discontinued early due to worsening res- therapy, and echocardiograms remained stable. At time of
piratory failure requiring escalation to high-frequency oscil- discharge, he was on 0.25 LPM supplemental oxygen via
latory ventilation. Infectious workup at this time was notable NC and being treated with budesonide and chlorothiazide.
for sputum culture positive for E. coli and Stenotrophomonas, His overall NICU course was also significant for feeding
and after completion of antibiotic therapy, he transitioned to intolerance requiring continuous postpyloric feedings. He
conventional ventilation. An additional course of systemic was slowly transitioned to nasogastric (NG) feeds, and by
dexamethasone was initiated at 54 days of age. He weaned the time of discharge, he was tolerating a combination of
on respiratory support throughout his course but ultimately
was unable to be extubated. During this time, diuretics were
initiated. At 356/7 weeks’ postmenstrual age (PMA), he had a
failed extubation attempt. At 36 weeks’ PMA, he was on inva-
sive mechanical ventilation and met Jensen criteria for grade
3 BPD. He remained on the conventional ventilator until
arrival at our facility.
He transferred to our facility at 39 weeks’ PMA for poten-
tial PDA device closure and further management of chronic
lung disease. Plain chest radiograph was obtained on admis-
sion (Figure 1). The PDA was found to have spontaneously
closed. He was initiated on an additional course of systemic
dexamethasone on DOL 99 and extubated from conventional
ventilation to continuous positive airway pressure. At 44
weeks’ PMA, a follow-up echocardiogram was performed
due to his continued tachypnea and need for respiratory sup-
port. He was found to have a new diagnosis of right ventricu-
lar hypertension based on interventricular septum position
during systole and tricuspid regurgitation pressure gradient
of 41 mm Hg (normal <32 mm Hg) (Figure 2). Over the
course of 3 months, he slowly weaned to 0.25 L per minute
(LPM) supplemental oxygen via nasal cannula (NC). Given

FIGURE 1. Plain chest radiograph on level IV neonatal intensive care FIGURE 2. (A) Echocardiographic evidence of normal interventricular
unit admission with findings consistent with bronchopulmonary (IV) septal curvature. (B) Echocardiographic evidence of IV septal
dysplasia. Endotracheal tube tip in mid thoracic trachea. Postpyloric flattening in systole. (C) Tricuspid regurgitation demonstrated on
feeding tube in place. Evidence of bilateral chronic lung disease with echocardiogram with measured pressure gradient (PG) of 41 mm Hg.
coarse opacities evident, right greater than left. LV, left ventricle; RV, right ventricle; Vel, velocity.

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e133

 oral feeding and NG gavage feedings. The family received off supplemental oxygen during the day and remained on
education on NG insertion prior to discharge. Multiple 0.125 LPM at night.
head ultrasonograms were negative for intraventricular Echocardiography 4 months after discharge showed con-
hemorrhage, and his retinas matured appropriately without tinued mild right ventricular hypertension; therefore, cardi-
intervention. He passed his hearing screen bilaterally prior ology recommended he not be weaned further and remain on
to discharge. his nocturnal supplemental oxygen. A nocturnal home oxi-
At the time of discharge, the infant was 6 months old in metry study was then performed in room air at 7 months’
chronologic age, or 51 weeks’ PMA. Prior to discharge, the corrected age, which showed no oxyhemoglobin desaturation
team discussed with the family that he required close outpa- below 90% and an oxyhemoglobin desaturation event index
tient monitoring and management of numerous health con- of 2.4 (Figure 3). The reference values for this index are not
cerns. It was anticipated that he would slowly be able to wean officially established in former preterm infants and are under
off all oxygen support and diuretics. Cardiology would con- investigation in infants aged less than 1 year, but evidence
tinue to follow his PH closely. His family was counseled that shows it would typically be less than 5 to 10 at this age in
he may require a gastrostomy tube in the outpatient setting if healthy infants. A repeat echocardiogram at 8 months’ cor-
his oral feeding did not progress. Scheduled discharge fol- rected age showed resolution of right ventricular hyperten-
low-up included a multidisciplinary BPD clinic, cardiology, sion, and he was subsequently weaned off supplemental
occupational therapy for developmental and oral feeding sup- oxygen support. Chlorothiazide was discontinued at 5 months’
port, and a referral to early intervention. corrected age, and budesonide was discontinued at 8 months’
corrected age. He did not require albuterol after discharge. An
echocardiogram was completed off supplemental oxygen,
FOLLOW-UP COURSE which continued to show no evidence of right ventricular
The child is now 5 years old, and he was followed in the BPD hypertension. He never required pulmonary vasodilators,
multidisciplinary clinic until the age of 3 years. The clinic and he had no respiratory-related readmissions.
team included neonatology, pulmonology, occupational From a feeding perspective, he progressed to full oral feed-
therapy, physical therapy, and speech therapy. He also was ings and his NG tube was removed within 1 week of discharge.
followed separately by cardiology for PH management. He continued to advance in his oral motor skills appropriately
Due to his severe BPD, the decision to wean his respira- and did not require feeding therapy. He demonstrated ade-
tory support as an outpatient was made in collaboration quate growth postdischarge, and at his last NICU follow-up
between BPD and cardiology clinic providers. Three weeks clinic appointment, his weight was in the 85th percentile,
after discharge, he was weaned from 0.25 LPM NC to and length was in the 88th percentile. Due to NICU stay
0.125 LPM NC. Approximately 1 month later, he weaned greater than 5 days, audiology follow-up was obtained.

FIGURE 3. Overnight oximetry study in room air. This demonstrates that the patient is spending <2% of the night saturating <95%, with no
evidence of desaturations <92%.

e134 NeoReviews
On a routine otoacoustic emissions test at 14 months’ cor- outcomes compared with premature infants without a diag-
rected age, there was concern for abnormal cochlear function nosis of BPD, including increased emergency department
of his right ear, but an auditory brainstem response evaluation visits, hospital readmissions, health care utilization, and
was performed and was normal bilaterally. requirement of respiratory support after initial hospital dis-
At 43 weeks’ PMA, he had poor repertoire writhing move- charge.3,4 Rates of discharge to home on supplemental oxy-
ments on a general movements assessment, but at 51 weeks’ gen vary from 28% to 50% of premature infants with BPD.5,6
PMA, he had an assessment that demonstrated normal age- For patients with BPD who are discharged on supplemental
specific fidgety movements. He was followed by outpatient oxygen, reported duration of home oxygen needs is as short
occupational therapy twice a month from the time of dis- as 2 to 3 months to more than 12 months of age.7–9 Those
charge until approximately 9 months’ corrected age and by discharged on supplemental oxygen have even further
early intervention physical therapy from 5 to 12 months’ cor- increases in rate of respiratory rehospitalization, total num-
rected age. He was discharged from both disciplines due to ber of hospitalizations, asthma or BPD medication use, and
appropriate developmental progression. Per family report, home nursing care in the first 2 years of age.10 Infants born
there were no concerns about developmental delay at fol- <1250 g with severe BPD requiring supplemental oxygen at
low-up visits. At 22 months’ corrected age, concern was the time of discharge are more likely to require respiratory
raised for expressive language delay at a routine developmen- medications than both survivors with less severe BPD and
tal follow-up appointment with neonatology. He underwent survivors without BPD at 3-year follow-up.11
Bayley-III Developmental Assessment at 25 months’ cor- Infants with BPD are also at increased risk of sleep-disor-
rected age. This revealed he was delayed in all 3 categories: dered breathing, including obstructive sleep apnea, central
cognitive (composite score 60, 0.4 percentile), language sleep apnea, hypoventilation, and nonapneic hypoxemia,12
(composite score 68, 2nd percentile), and motor (composite and may require polysomnography as an outpatient prior
score 79, 8th percentile). He was referred to outpatient to being weaned off supplemental oxygen. It has been
speech therapy and received therapy biweekly until he started reported that infants with BPD who require home supple-
preschool, at which time his services were transitioned to mental oxygen have more abnormalities on polysomnogra-
school-based therapy. He is currently in kindergarten and phy, particularly increased central events, compared with
continues to have evidence of global developmental delay. infants with BPD who are discharged in room air.13 The risk
He is receiving speech therapy and occupational therapy of airway obstruction and/or obstructive sleep apnea due to
and has an individualized education plan. He enjoys school prematurity may even persist until adulthood.14 The pres-
and is continuing to make developmental progress. ence of sleep-disordered breathing may increase the duration
Overall, he has been in great health since discharge of time that an infant is required to remain on supplemental
from the NICU. He had 1 emergency department visit at oxygen after discharge. The patient described in this case
12 months’ corrected age for right acute otitis media and left required an adenoidectomy after discharge due to adenoid
lower lobe pneumonia, which resolved with amoxicillin. hypertrophy with associated snoring, but there have not been
He had snoring, chronic nasal congestion, and recurrent published reports documenting increased rates of tonsillec-
right otitis media and so ultimately underwent bilateral tomies or adenoidectomies in former preterm infants, and
adenoidectomy and right myringotomy at 15 months’ cor- predischarge magnetic resonance imaging performed in pre-
rected age with resolution of symptoms. He continues to fol- term and full-term newborns did not demonstrate differ-
low up with pulmonology annually and currently does not ences in adenoidal or tonsillar volumes at near-term and
require any medications. He had 1 final echocardiogram at term PMAs.15
2 years of age that continued to show no evidence of PH; Beyond infancy, children with BPD have higher rates of
therefore, he was discharged from the cardiology clinic. wheezing and asthma compared with preterm survivors
without BPD and are more likely to use bronchodilators up
to the age of 2 years, with more persistent wheezing between
EXPERT DISCUSSION 2 and 5 years.3,4 Rates of rehospitalization, wheezing/
Respiratory Outcomes asthma, and medication use in former premature infants
BPD is the most common pulmonary morbidity related to decrease stepwise in the first 5 years of age and beyond,3,16
prematurity.2 BPD arises from abnormal postnatal develop- but symptoms may continue and remain higher in children
ment of the lung and is defined by alveolar simplification, fib- with BPD than those without. Children with BPD are
rosis, inflammation, and abnormal vascular development. 4.5 times more likely to have wheezing and chronic cough
Infants with BPD are at increased risk of poorer pulmonary than matched preterm controls without BPD at 9.5 years

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e135

 of age.17 Compared with 0 control patients, a quarter of these BPD at 36 weeks’ PMA as well as prior to discharge. The eti-
children are also receiving asthma medications at this age. ology of BPD-related PH is likely multifactorial, but it is
On the contrary, an additional study found that prematurity hypothesized to be related to hypoxia/hyperoxia-induced vas-
alone is associated with increased risk of hospitalization and cular remodeling, persistent hypercapnia, vascular growth
respiratory complaints between ages 5 and 11 years, but hav- arrest, and pulmonary overcirculation related to intra- or
ing a diagnosis of BPD was not significantly associated with extracardiac shunts that promote pulmonary vasoconstric-
risk.16 Not only do these children potentially remain sympto- tion.31 In addition, in the BPD lung, intermittent hypoxemia
matic, but those with BPD have persisting structural abnor- adversely affects alveolar development and vascular remodel-
malities in their lungs on computed tomography (CT). ing and growth.32 Infants with BPD born at younger gesta-
Abnormalities on CT were detected in 81% of school-aged tional ages and lower birth weights are at highest risk of
children, with most abnormalities in the children who had PH.33 Risk of PH increases significantly with the severity
the most severe BPD, which may imply continued long-term of BPD from 6%, 12%, and 39% for those with mild, mod-
pulmonary symptoms.18 erate, and severe BPD, respectively.34 Infants with BPD-
Children with BPD have consistently been shown to related PH can be managed medically with supplemental oxy-
have lung function impairment throughout childhood gen and/or pulmonary vasodilators. The American Thoracic
and adolescence that is primarily characterized by obstruc- Society clinical practice guideline for home oxygen therapy
tive respiratory disease, although some children have a for affected children strongly recommends home oxygen
mixed obstructive and restrictive pattern.19–21 Furthermore, therapy be prescribed in children with PH. This is due to
former preterm infants with and without BPD have impaired the potential benefit of lessening the undesirable conse-
diffusion capacity and reduced exercise tolerance even into quences of chronic hypoxemia because it directly interrupts
adulthood.22,23 Perhaps more concerning, former preterm the vicious cycle of PH-causing hypoxemia, which in turn
infants with BPD have early-onset decline in lung function worsens the PH.35 PH can also be managed with pulmonary
by the teenage years24; the combination of decreased lung vasodilators. Up to 11% of patients with severe BPD require a
function and early-onset decline in lung function sets these pulmonary vasodilator at discharge,36 and single therapy with
vulnerable children up for the development of early-onset sildenafil is the most commonly used vasodilator.37
chronic obstructive pulmonary disease.25 Despite the signifi- Infants with BPD-associated PH are at even higher risk of
cant ongoing respiratory challenges for these patients suboptimal outcomes. Infants with BPD-related PH are at
throughout their life span, there are no specific therapies risk of increased mortality overall, with a reported mortality
for impaired lung function in BPD, although 1 clinical trial rate of up to 48% within 2 years of PH diagnosis.38 A meta-
showed improvement in expiratory flow rate with a combina- analysis of preterm infants with BPD-related PH reports a
tion of inhaled steroids and long-acting beta agonists.26 long-term follow-up mortality rate of 40%, with an overall
Several long-term studies have demonstrated that infants almost 5 times increased relative risk of death compared with
with BPD have abnormal pulmonary function into adulthood those with BPD and no PH.34 Of the infants who die with
as well as increased risk of pulmonary vascular diseases.27 BPD-related PH, 24% die after discharge from their initial
Duration of mechanical ventilation in the neonatal period hospitalization.39 BPD with PH is also associated with addi-
is the strongest predictor of mean pulmonary artery pressure tional respiratory and feeding support requirements at dis-
in adults. Adults who were born premature are also at charge. BPD with PH is associated with higher rates of
increased risk of developing hypertension, glucose intoler- tracheostomy, supplemental oxygen use, and tube feedings
ance, and congestive heart failure.28,29 Due to these findings, upon initial hospital discharge compared with BPD without
it is imperative that patients with a diagnosis of BPD have PH.30 PH is also associated with increased frequency of
lifelong follow-up with a pulmonologist. readmission in the first year of age30 as well as higher oxygen
flows at discharge and longer supplemental oxygen needs.7 It
Cardiovascular Outcomes is important for all neonatologists to be aware of these risks to
Along with adverse pulmonary outcomes, infants with BPD improve counseling of families and to ensure adequate fol-
may have comorbid cardiovascular disease. In a study low-up with PH specialists after discharge.
reported from the Children’s Hospital Neonatal Consortium, Fortunately, for infants with BPD-related PH who survive
22% of patients with severe BPD had concomitant PH.30 The beyond 6 months, the PH typically resolves. Reported PH
diagnosis of PH is typically made via transthoracic echocar- resolution rates are 47%, 79%, and 94% at 1, 2, and 2.5 years’
diography during the neonatal intensive care hospitalization, corrected age, respectively.40 An additional study examining
and screening should occur in any infant with established the postdischarge disease trajectory in 44 survivors with

e136 NeoReviews
BPD-related PH found that at 3 years’ corrected age, 66% had language scores, are seen in infants with BPD, even after
resolution of their PH.39 Of the one-third that still had PH, adjusting for major risk factors, including intraventricular
half were still on both oxygen and pulmonary vasodilators, hemorrhage or cystic periventricular leukomalacia.45,46
and the remaining were either on oxygen or pulmonary vaso- This may be related to disease severity and brain injury asso-
dilators alone.39 This population included patients dis- ciated with frequent hypoxemic episodes or associated with
charged on mechanical ventilation, and, therefore, the postnatal therapies such as systemic corticosteroids. In
outcomes may describe a more severe population. A separate infants that are less than 28 weeks’ gestational age at birth,
population had a much shorter duration of vasodilators, with the risk of CP is 6-fold higher for quadriplegic CP and 4-fold
58% of patients weaning off vasodilators by less than a year of higher for diplegic CP at 2 years of age in infants who were
age.37 The patient described in this case followed the typical intubated at 36 weeks’ PMA compared with those without
trajectory with slight prolongation of supplemental oxygen BPD.47 Infants born <1000 g with a diagnosis of BPD are over
needs related to his PH but resolution of his PH by 2 years 2 times more likely to have any diagnosis of CP, blindness,
of age. deafness, or cognitive delay at age 18 months.48 There are also
It is important to mention that there has been growing evi- several reports of persistence of cognitive deficits from early
dence implicating cardiovascular abnormalities in early childhood to school age in this population. This includes per-
adulthood in former preterm infants with BPD. Former pre- sistently lower scores on the Mental Developmental Index of
term infants have higher mean pulmonary arterial pressures the Bayley Scales at the age of 3 years49 and deficits in general
with almost half meeting criteria for borderline or overt PH intelligence, reading, mathematics, motor performance,
in the third decade of life.27 There are also noted increases in memory, and attention at 8 years of age with higher utilization
pulmonary vascular resistance and elastance at rest and dur- of special education services compared with both term
ing exercise in former preterm adults, and they are less able and preterm peers.50 Not only do children with BPD have
to augment cardiac index for exercise.27 As younger and lower scores, but the proportion of children who are signifi-
smaller infants are surviving to discharge and into early cantly delayed are increased in the group with BPD.50
adulthood, monitoring long-term cardiovascular outcomes Interestingly, in this same cohort, of the children with BPD,
will be of the utmost importance, including improving those who had a history of steroid exposure had lower IQ
awareness of our adult providers of all implications of being scores, perceptual organization, motor scores, and higher par-
born preterm. ticipation in special education. In addition to motor and cog-
nitive delays, language development is reported to be delayed
Neurodevelopmental Outcomes in children with BPD, including increased risk of significant
Lastly, infants with BPD are at risk for poorer feeding out- language delay (<2 SDs below the mean) at age 18 to 22
comes and neurodevelopmental impairments. They are at months46; lower receptive, expressive, and total communica-
increased risk of feeding difficulties and experience a delay tion competence scores at 3 years of age51; and lower scores in
in achieving oral feeding goals for age. Infants with BPD have both expressive and receptive language at 8 years of age52 com-
irregular breathing during oral feeding compared with term pared with peers without BPD as well as term controls. There
infants; therefore, there is a higher risk of swallow dsyfunc- have also been reports of difficulties in perceptual motor tasks
tion.41 Compared with preterm infants without a diagnosis of in patients who required a longer duration of supplemental
BPD, infants with BPD have higher rates of apneic swallows oxygen in 7- and 16-year-old former very-low-birthweight chil-
after 35 weeks’ PMA and have less coordination of swallow- dren.53,54 Although risks are overall increased in BPD, there
ing and breathing during feeding, implying they do not fol- have been multiple studies that have demonstrated similar
low expected maturational patterns with oral feeding.42 But, neurodevelopmental outcomes between infants with BPD
unlike other diagnoses, infants with BPD with dysphagia or discharged on supplemental oxygen or breathing room air,
aspiration will typically have a functional swallow by 2 to 4 including cognitive, CP, and neurosensory impairment.10,55,56
months’ corrected age.43,44 If there are concerns regarding Along with more severe respiratory outcomes, premature
feeding safety and ability to progress, it is imperative for infants with a diagnosis of PH have significantly lower cog-
the patient to have follow-up with feeding therapy. The nitive (85 vs 95, P = .004), language (81 vs 89, P = .040), and
patient described in this case required discharge with an motor (88 vs 94, P = .010) scores of the Bayley-III at 18 to 24
NG tube but progressed quickly and met feeding goals by months’ corrected age when compared with other preterm
about 3 months’ corrected age. infants.57 In total, 45% of infants with PH met criteria for
Increased rates of cerebral palsy (CP) and neurodevelop- cognitive delay.57 In addition, weight z scores and head cir-
mental impairments, including lower cognitive and cumference z scores were significantly lower in those with

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e137

 PH.57 In a subgroup analysis of just infants with BPD, the 3. Skromme K, Leversen KT, Eide GE, Markestad T, Halvorsen T.
cognitive score was significantly lower, and weight z score Respiratory illness contributed significantly to morbidity in
children born extremely premature or with extremely low
after discharge was poorer in the BPD + PH group compared birthweights in 1999-2000. Acta Paediatr. 2015;104(11):1189–1198.
with BPD without PH.57 The patient described in this case PubMed doi: 10.1111/apa.13165
had significant cognitive, language, and motor delays at 4. Praprotnik M, Stucin Gantar I, Lučovnik M, Avčin T, Krivec U.
2 years’ corrected age, as would have been expected due to Respiratory morbidity, lung function and fitness assessment after
bronchopulmonary dysplasia. J Perinatol. 2015;35(12):1037–1042.
his clinical history.
PubMed doi: 10.1038/jp.2015.124
5. Lagatta JM, Clark RH, Brousseau DC, Hoffmann RG, Spitzer AR.
CONCLUSION Varying patterns of home oxygen use in infants at 23-43 weeks’
gestation discharged from United States neonatal intensive care
In summary, preterm infants with BPD are at increased risk units. J Pediatr. 2013;163(4):976–982.e2. PubMed doi: 10.1016/j.
of suboptimal respiratory and neurodevelopmental out- jpeds.2013.04.067

comes, and PH is a risk factor of worsened outcomes in this 6. Lagatta J, Murthy K, Zaniletti I, et al. Home oxygen use and 1-year
readmission among infants born preterm with bronchopulmonary
population. The evidence suggests the importance of coun-
dysplasia discharged from children’s hospital neonatal intensive
seling families of these risks to support decision-making care units. J Pediatr. 2020;220:40–48.e5. PubMed doi: 10.1016/j.
and to ensure close medical and developmental follow-up jpeds.2020.01.018
ideally with programmatic multidisciplinary follow-up to 7. Yeh J, McGrath-Morrow SA, Collaco JM. Oxygen weaning after
hospital discharge in children with bronchopulmonary dysplasia.
ultimately optimize the outcome of preterm infants with
Pediatr Pulmonol. 2016;51(11):1206–1211. PubMed doi: 10.1002/
BPD and PH. These patients often require follow-up with ppul.23442
pulmonology, neonatology, feeding teams, cardiology, and 8. House M, Klein S, Parham D, Hysinger EB, Brady JM. Frequent
developmental specialists along with multiple therapy disci- hypoxemia found in infants with bronchopulmonary dysplasia
plines and benefit from lifelong follow-up with pulmonology. after weaning home oxygen. Pediatr Pulmonol. 2022;57(11):
2638–2645. PubMed doi: 10.1002/ppul.26076
It is imperative that neonatologists are aware of these out-
9. Rhein L, White H, Simoneau T, et al. Transmitted home oximetry
come risks in order to appropriately support and counsel and duration of home oxygen in premature infants. Pediatrics.
families throughout their neonatal intensive care hospitali- 2020;146(2):e20200079. PubMed doi: 10.1542/peds.2020-0079
zation and beyond. 10. DeMauro SB, Jensen EA, Bann CM, et al. Home oxygen and
2-year outcomes of preterm infants with bronchopulmonary
dysplasia. Pediatrics. 2019;143(5):e20182956. PubMed doi: 10.1542/
peds.2018-2956
American Board of Pediatrics 11. Lodha A, Ediger K, Rabi Y, et al. Does chronic oxygen dependency
in preterm infants with bronchopulmonary dysplasia at NICU
Neonatal-Perinatal Content discharge predict respiratory outcomes at 3 years of age? J
Specification Perinatol. 2015;35(7):530–536. PubMed doi: 10.1038/jp.2015.7

• Know the management of BPD/chronic lung disease 12. Flores-Fenlon N, Wright N, Lew C, et al. Retrospective analysis of
inpatient polysomnogram characteristics and discharge outcomes
• Know the prognosis, long-term complications, and per-
in infants with bronchopulmonary dysplasia requiring home
manent sequelae of BPD oxygen therapy. Pediatr Pulmonol. 2021;56(1):88–96. PubMed doi:
• Know the risks of neurodevelopmental impairments in 10.1002/ppul.25129
full-term infants with medical risk factors, such as PH, 13. Ortiz LE, McGrath-Morrow SA, Sterni LM, Collaco JM. Sleep
congenital heart disease, and chronic lung disease disordered breathing in bronchopulmonary dysplasia. Pediatr
Pulmonol. 2017;52(12):1583–1591. PubMed doi: 10.1002/ppul.23769
14. Paavonen EJ, Strang-Karlsson S, Räikkönen K, et al. Very low birth
weight increases risk for sleep-disordered breathing in young adult-
References hood: the Helsinki Study of Very Low Birth Weight Adults. Pediatrics.
2007;120(4):778–784. PubMed doi: 10.1542/peds.2007-0540
1. Doyle LW, Davis PG, Morley CJ, McPhee A, Carlin JB; DART
Study Investigators. Low-dose dexamethasone facilitates extubation 15. Smitthimedhin A, Whitehead MT, Bigdeli M, Nino G, Perez G,
among chronically ventilator-dependent infants: a multicenter, Otero HJ. MRI determination of volumes for the upper airway and
international, randomized, controlled trial. Pediatrics. 2006;117(1): pharyngeal lymphoid tissue in preterm and term infants. Clin
75–83. PubMed doi: 10.1542/peds.2004-2843 Imaging. 2018;50:51–56. PubMed doi: 10.1016/j.clinimag.2017.12.010

2. Stoll BJ, Hansen NI, Bell EF, et al; Eunice Kennedy Shriver 16. Skromme K, Vollsæter M, Øymar K, Markestad T, Halvorsen T.
National Institute of Child Health and Human Development Respiratory morbidity through the first decade of life in a national
Neonatal Research Network. Neonatal outcomes of extremely cohort of children born extremely preterm. BMC Pediatr. 2018;
preterm infants from the NICHD Neonatal Research Network. 18(1):102. PubMed doi: 10.1186/s12887-018-1045-7
Pediatrics. 2010;126(3):443–456. PubMed doi: 10.1542/peds. 17. Vom Hove M, Prenzel F, Uhlig HH, Robel-Tillig E. Pulmonary
2009-2959 outcome in former preterm, very low birth weight children with

e138 NeoReviews
 bronchopulmonary dysplasia: a case-control follow-up at school 31. Lignelli E, Palumbo F, Myti D, Morty RE. Recent advances in our
age. J Pediatr. 2014;164(1):40–45.e4. PubMed doi: 10.1016/j.jpeds. understanding of the mechanisms of lung alveolarization and
2013.07.045 bronchopulmonary dysplasia. Am J Physiol Lung Cell Mol Physiol.
18. Ronkainen E, Perhomaa M, Mattila L, Hallman M, Dunder T. 2019;317(6):L832–L887. PubMed doi: 10.1152/ajplung.00369.
Structural pulmonary abnormalities still evident in schoolchildren 2019
with new bronchopulmonary dysplasia. Neonatology. 2018; 32. Mankouski A, Kantores C, Wong MJ, et al. Intermittent hypoxia
113(2):122–130. PubMed doi: 10.1159/000481356 during recovery from neonatal hyperoxic lung injury causes long-
19. Doyle LW, Andersson S, Bush A, et al; Adults born Preterm term impairment of alveolar development: a new rat model of
International Collaboration. Expiratory airflow in late adolescence BPD. Am J Physiol Lung Cell Mol Physiol. 2017;312(2):L208–L216.
and early adulthood in individuals born very preterm or with very PubMed doi: 10.1152/ajplung.00463.2016
low birthweight compared with controls born at term or with 33. Nagiub M, Kanaan U, Simon D, Guglani L. Risk factors for
normal birthweight: a meta-analysis of individual participant data. development of pulmonary hypertension in infants with
Lancet Respir Med. 2019;7(8):677–686. PubMed doi: 10.1016/ bronchopulmonary dysplasia: systematic review and meta-analysis.
S2213-2600(18)30530-7 Paediatr Respir Rev. 2017;23:27–32. PubMed
20. Fawke J, Lum S, Kirkby J, et al. Lung function and respiratory 34. Arjaans S, Zwart EAH, Ploegstra MJ, et al. Identification of gaps
symptoms at 11 years in children born extremely preterm: the in the current knowledge on pulmonary hypertension in extremely
EPICure study. Am J Respir Crit Care Med. 2010;182(2):237–245. preterm infants: a systematic review and meta-analysis. Paediatr
PubMed doi: 10.1164/rccm.200912-1806OC Perinat Epidemiol. 2018;32(3):258–267. PubMed doi: 10.1111/ppe.
21. Shepherd EG, Clouse BJ, Hasenstab KA, et al. Infant pulmonary 12444
function testing and phenotypes in severe bronchopulmonary 35. Hayes D Jr, Wilson KC, Krivchenia K, et al. Home oxygen therapy
dysplasia. Pediatrics. 2018;141(5):e20173350. PubMed doi: 10.1542/ for children. An official American Thoracic Society Clinical
peds.2017-3350 Practice Guideline. Am J Respir Crit Care Med. 2019;199(3):e5–e23.
22. Satrell E, Clemm H, Røksund OD, et al. Development of lung PubMed doi: 10.1164/rccm.201812-2276ST
diffusion to adulthood following extremely preterm birth. Eur 36. Kielt MJ, Logan JW, Backes CH, Reber KM, Nelin LD, Shepherd
Respir J. 2022;59(5):2004103. PubMed doi: 10.1183/13993003. EG. In-hospital outcomes of late referrals for established
04103-2020 bronchopulmonary dysplasia. J Perinatol. 2021;41(8):1972–1982.
23. Clemm HH, Vollsæter M, Røksund OD, Eide GE, Markestad T, PubMed doi: 10.1038/s41372-021-01041-6
Halvorsen T. Exercise capacity after extremely preterm birth. 37. Jeremiasen I, Tran-Lundmark K, Dolk M, Naumburg E. Outpatient
Development from adolescence to adulthood. Ann Am Thorac Soc. prescription of pulmonary vasodilator therapy to preterm children
2014;11(4):537–545. PubMed doi: 10.1513/AnnalsATS.201309-311OC with bronchopulmonary dysplasia. Acta Paediatr. 2023;112(3):
24. Simpson SJ, Turkovic L, Wilson AC, et al. Lung function 409–416. PubMed doi: 10.1111/apa.16615
trajectories throughout childhood in survivors of very preterm 38. Khemani E, McElhinney DB, Rhein L, et al. Pulmonary artery
birth: a longitudinal cohort study. Lancet Child Adolesc Health. hypertension in formerly premature infants with
2018;2(5):350–359. PubMed doi: 10.1016/S2352-4642(18)30064-6 bronchopulmonary dysplasia: clinical features and outcomes in the
25. Polverino F, Hysinger EB, Gupta N, et al. Lung MRI as a potential surfactant era. Pediatrics. 2007;120(6):1260–1269. PubMed doi: 10.
complementary diagnostic tool for early COPD. Am J Med. 1542/peds.2007-0971
2020;133(6):757–760. PubMed doi: 10.1016/j.amjmed.2019.12.009 39. Altit G, Bhombal S, Hopper RK, Tacy TA, Feinstein J. Death or
26. Goulden N, Cousins M, Hart K, et al. Inhaled corticosteroids alone resolution: the “natural history” of pulmonary hypertension in
and in combination with long-acting β2 receptor agonists to treat bronchopulmonary dysplasia. J Perinatol. 2019;39(3):415–425.
reduced lung function in preterm-born children: a randomized PubMed doi: 10.1038/s41372-018-0303-8
clinical trial. JAMA Pediatr. 2022;176(2):133–141. PubMed doi: 10. 40. Arjaans S, Haarman MG, Roofthooft MTR, et al. Fate of
1001/jamapediatrics.2021.5111 pulmonary hypertension associated with bronchopulmonary
27. Goss KN, Beshish AG, Barton GP, et al. Early pulmonary vascular dysplasia beyond 36 weeks postmenstrual age. Arch Dis Child Fetal
disease in young adults born preterm. Am J Respir Crit Care Med. Neonatal Ed. 2021;106(1):45–50. PubMed doi: 10.1136/archdischild-
2018;198(12):1549–1558. PubMed doi: 10.1164/rccm.201710- 2019-318531
2016OC 41. Craig CM, Lee DN, Freer YN, Laing IA. Modulations in breathing
28. Flahault A, Paquette K, Fernandes RO, et al; HAPI collaborating patterns during intermittent feeding in term infants and preterm
group*. Increased Incidence but lack of association between infants with bronchopulmonary dysplasia. Dev Med Child Neurol.
cardiovascular risk factors in adults born preterm. Hypertension. 1999;41(9):616–624. PubMed doi: 10.1111/j.1469-8749.1999.
2020;75(3):796–805. PubMed doi: 10.1161/HYPERTENSIONAHA. tb00665.x
119.14335 42. Gewolb IH, Vice FL. Abnormalities in the coordination of
29. Crump C, Groves A, Sundquist J, Sundquist K. Association of respiration and swallow in preterm infants with
preterm birth with long-term risk of heart failure into adulthood. bronchopulmonary dysplasia. Dev Med Child Neurol. 2006;
JAMA Pediatr. 2021;175(7):689–697. PubMed doi: 10.1001/ 48(7):595–599. PubMed doi: 10.1017/S0012162206001241
jamapediatrics.2021.0131 43. Davis NL, Liu A, Rhein L. Feeding immaturity in preterm
30. Lagatta JM, Hysinger EB, Zaniletti I, et al; Children’s Hospital neonates: risk factors for oropharyngeal aspiration and timing of
Neonatal Consortium Severe BPD Focus Group. The impact of maturation. J Pediatr Gastroenterol Nutr. 2013;57(6):735–740.
pulmonary hypertension in preterm infants with severe PubMed doi: 10.1097/MPG.0b013e3182a9392d
bronchopulmonary dysplasia through 1 year. J Pediatr. 44. White BR, Ermarth A, Thomas D, Arguinchona O, Presson AP,
2018;203:218–224.e3. PubMed doi: 10.1016/j.jpeds.2018.07.035 Ling CY. Creation of a standard model for tube feeding at neonatal

Vol. 26 No. 2 F E B R U A R Y 2 0 2 5 e139

 intensive care unit discharge. JPEN J Parenter Enteral Nutr. 51. Singer LT, Siegel AC, Lewis B, Hawkins S, Yamashita T, Baley J.
2020;44(3):491–499. PubMed doi: 10.1002/jpen.1718 Preschool language outcomes of children with history of
45. Hintz SR, Kendrick DE, Vohr BR, Poole WK, Higgins RD; bronchopulmonary dysplasia and very low birth weight. J Dev
National Institute of Child Health and Human Development Behav Pediatr. 2001;22(1):19–26. PubMed doi: 10.1097/00004703-
Neonatal Research Network. Changes in neurodevelopmental 200102000-00003
outcomes at 18 to 22 months’ corrected age among infants of less 52. Lewis BA, Singer LT, Fulton S, et al. Speech and language
than 25 weeks’ gestational age born in 1993-1999. Pediatrics. outcomes of children with bronchopulmonary dysplasia.
2005;115(6):1645–1651. PubMed doi: 10.1542/peds.2004-2215 J Commun Disord. 2002;35(5):393–406. PubMed doi: 10.1016/
46. Natarajan G, Pappas A, Shankaran S, et al. Outcomes of extremely S0021-9924(02)00085-0
low birth weight infants with bronchopulmonary dysplasia: impact 53. Taylor HG, Klein N, Schatschneider C, Hack M. Predictors of
of the physiologic definition. Early Hum Dev. 2012;88(7):509–515. early school age outcomes in very low birth weight children.
PubMed doi: 10.1016/j.earlhumdev.2011.12.013 J Dev Behav Pediatr. 1998;19(4):235–243. PubMed doi: 10.1097/
47. Van Marter LJ, Kuban KC, Allred E, et al; ELGAN Study 00004703-199808000-00001
Investigators. Does bronchopulmonary dysplasia contribute to the 54. Taylor HG, Minich N, Bangert B, Filipek PA, Hack M. Long-term
occurrence of cerebral palsy among infants born before 28 weeks neuropsychological outcomes of very low birth weight: associations
of gestation? Arch Dis Child Fetal Neonatal Ed. 2011;96(1): with early risks for periventricular brain insults. J Int Neuropsychol
F20–F29. PubMed doi: 10.1136/adc.2010.183012 Soc. 2004;10(7):987–1004. PubMed doi: 10.1017/S135561770
48. Schmidt B, Asztalos EV, Roberts RS, Robertson CM, Sauve RS, 4107078
Whitfield MF; Trial of Indomethacin Prophylaxis in Preterms 55. Lodha A, Sauvé R, Bhandari V, et al. Need for supplemental
(TIPP) Investigators. Impact of bronchopulmonary dysplasia, brain oxygen at discharge in infants with bronchopulmonary dysplasia is
injury, and severe retinopathy on the outcome of extremely low- not associated with worse neurodevelopmental outcomes at 3 years
birth-weight infants at 18 months: results from the trial of corrected age. PLoS One. 2014;9(3):e90843. PubMed doi: 10.1371/
indomethacin prophylaxis in preterms. JAMA. 2003;289(9): journal.pone.0090843
1124–1129. PubMed doi: 10.1001/jama.289.9.1124 56. Trittmann JK, Nelin LD, Klebanoff MA. Bronchopulmonary
49. Singer L, Yamashita T, Lilien L, Collin M, Baley J. A longitudinal dysplasia and neurodevelopmental outcome in extremely preterm
study of developmental outcome of infants with broncho- neonates. Eur J Pediatr. 2013;172(9):1173–1180. PubMed doi: 10.
pulmonary dysplasia and very low birth weight. Pediatrics. 1007/s00431-013-2016-5
1997;100(6):987–993. PubMed doi: 10.1542/peds.100.6.987 57. Choi EK, Shin SH, Kim EK, Kim HS. Developmental outcomes of
50. Short EJ, Klein NK, Lewis BA, et al. Cognitive and academic preterm infants with bronchopulmonary dysplasia-associated
consequences of bronchopulmonary dysplasia and very low birth pulmonary hypertension at 18-24 months of corrected age.
weight: 8-year-old outcomes. Pediatrics. 2003;112(5):e359. PubMed BMC Pediatr. 2019;19(1):26. PubMed doi: 10.1186/s12887-019-
doi: 10.1542/peds.112.5.e359 1400-3

ANSWER KEY FOR FEBRUARY 2025 NEOREVIEWS

Decoding Hearts: Genetic Insights and Clinical Strategies in Congenital Heart Disease:
1. C; 2. C; 3. E; 4. B; 5. E
Effects of Assisted Reproductive Technology on Genetics, Obstetrics, and Neonatal Outcomes:
1. A; 2. C; 3. D; 4. E; 5. B

e140 NeoReviews