Editorial: Perspectives in Care of Extremely Premature Infants

Qiuping Li^1,2*Rong JU³Fu-Sheng Chou⁴

• ¹Bayi Children's Hospital, Beijing, China
• ²The Seventh Medical Center of PLA General Hospital, Beijing, China
• ³Chengdu Women and Children's Central Hospital, Chengdu, China
• ⁴Loma Linda University Medical Center, Loma Linda, United States

A core focus of the Research Topic lies in iden fying effec ve interven ons to mi gate acute neonatal complica ons, a cri cal determinant of short-term survival and long-term health. Yao et al.'s original research provides compelling evidence that early low-dose hydrocor sone administra on not only reduces the risk of Grade II+ bronchopulmonary dysplasia (BPD) but also shortens the dura on of noninvasive ven la on in infants born before 26 weeks of gesta on [1]. This finding is par cularly significant because it offers an ac onable strategy to improve respiratory outcomes, knowing that BPD is one of the leading causes for chronic respiratory morbidity in EPIs. To complement this task, Park et al. developed a C5.0 decision tree model to predict massive pulmonary hemorrhage (MPH) and MPHassociated mortality in extremely low birth weight infants (ELBWIs) with gesta onal age ≤25+2 weeks and 5-minute Apgar score ≤7 emerging as key discriminators [2]. The model's high predic ve accuracy (AUC >88%) enables early iden fica on of high-risk infants, thus facilita ng mely interven ons to reduce mortality.A retrospec ve study by Suh et al. addressed another cri cal issue in neonatal nutri on: hypertriglyceridemia (HTG) in preterm infants under 32 weeks of gesta on [3]. They iden fied lower birth weight, patent ductus arteriosus treatment, and higher intravenous lipid emulsion intake as significant risk factors for HTG, demonstra ng that reducing lipid doses accelerated triglyceride normaliza on and lowered the risk of severe re nopathy of prematurity. Meanwhile, a prospec ve study by Alanazi et al. clarified the correla on between Oxygena on Index (OI) and Oxygen Satura on Index (OSI) in EPIs, showing that measurements within the first 24 hours predicted early mortality, and daily mean values from days 4-7 forecast BPD at 36 weeks postmenstrual age [4]. Together, these studies advance precision medicine in neonatal care, equipping clinicians with tools to tailor interven ons and monitor responses. Survival and morbidity outcomes for EPIs vary widely across healthcare se ngs, highligh ng the need for context-specific data to guide care policies. Rodriguez-Sibaja et al.'s original research fills a cri cal gap by evalua ng EPIs born between 22.0-27.6 weeks in a middle-income se ng by using mul ple denominators to provide a comprehensive survival assessment [5]. Their findings underscore the challenges of resource-limited environments and offer valuable benchmarks for regions with similar socioeconomic profiles. Similarly, Kalyanam et al. inves gated 1627 ELBWIs across three U.S. NICUs and found that the center-specific varia ons in survival and severe intraventricular hemorrhage were a ributable to differences in care prac ces such as resuscita on decisions [6]. This emphasizes the importance of evidence-based prac ce-sharing to standardize and improve care quality.A network analysis conducted by Peterson et al. on periviable infants born between 22 +0 and 23 +6 weeks gesta on offers novel insights into the ming of mortality. The study reveals that 65% of infants born at 22 weeks and 52% of those born at 23 weeks who died did so within the first seven days of life. Furthermore, 89% of the 22-week infants who died succumbed by day 14 [7]. This supports a "trial of therapy" approach, balancing the poten al for survival against the risk of iatrogenic harm. Collec vely, these prognos c studies highlight the need to contextualize outcomes within healthcare resources, care prac ces, and gesta onal age, informing both clinical decision-making and health policy. The impact of extreme preterm birth extends far beyond the neonatal period, necessita ng long-term monitoring and proac ve management. A narra ve review by Ge e et al. comprehensively delineates the long-term complica ons of preterm birth, spanning neurodevelopmental, respiratory, cardiovascular, renal, gastrointes nal, and endocrine systems [8]. By synthesizing the current literature, the review equips healthcare providers with a holis c understanding of lifelong risks, emphasizing the value of long-term follow-up programs. To complement this, Zhao et al. conducted a real-world observa onal study in 79,514 Chinese preterm infants and established growth curves for 0-36 months corrected age, revealing that very preterm infants consistently lagged behind term standards in weight and length even at 36 months [9]. Their study addresses the lack of specialized growth benchmarks for preterm infants, providing a cri cal tool for assessing postnatal development.Care Delivery: Enhancing Family-Centered and Trauma-Informed Prac ce Op mal care for EPIs requires a mul disciplinary approach that integrates clinical exper se with family needs and psychological support. Peterson et al.'s rapid review and thema c analysis of periviable counselling prac ces iden fied three core principles known as Transparency, Collabora on and Empowerment that align with trauma-informed care [10]. Their findings highlight the importance of honest and individualized communica on with parents, including discussions of comfort care, to build trust and support informed decision-making. A companion study by Peterson et al. compared interna onal guidelines for periviable infants across 10 high healthcare-spending countries, no ng varia ons in viability defini ons (22+0-25+6 weeks) and delivery room management, while emphasizing the need for structured shared decision-making tools [11]. Another study by Peterson et al. explored parent and perinatal professional priori es in pre-birth periviable conversa ons through thema c analysis of semi-structured interviews, which further enriches the understanding of effec ve communica on strategies [12].A clinical observa onal study by Zhan et al. iden fied 1-minute Apgar score and gesta onal age as contextual factors influencing pain responses, which adds a cri cal dimension to neonatal care [13].Infants with lower Apgar scores and younger gesta onal age o en exhibit less pronounced pain responses, challenging the reliability of observa on-based pain assessment alone. Their study advocates for integra ng physiological markers into pain evalua on to improve care quality. Together, these ar cles advance family-centered and trauma-informed care, highligh ng the pivotal roles of communica on, psychological support, and holis c assessment in op mizing outcomes. Two case reports in the Research Topic address rare but clinically significant complica ons, offering prac cal insights for frontline clinicians. Hooper et al. described a delayed recurrence of staphylococcal scalded skin syndrome (SSSS) in an ELBWI, which was ini ally misdiagnosed as a yeast infec on, emphasizing the need for mul disciplinary teams to manage complex infec ons in immunocompromised preterm infants [14]. A case report by Calandrino et al. reported an elevated methemoglobin level in a preterm infant treated with glyceryl trinitrate (GTN) patches for limb ischemia, underscoring the importance of monitoring and dosage cau on in GTN therapy, especially in infants with immature skin and enzyme systems [15]. These cases provide valuable lessons for diagnosis and management of rare complica ons, filling gaps in clinical knowledge. The 15 ar cles cited in this Research Topic broaden our horizons about the care of EPIs, spanning therapeu c innova on, prognos c contextualiza on, long-term health, family-centered prac ce, and specialized case management. By integra ng insights from diverse se ngs-from middle-income countries to high-resource NICUs-and across the care con nuum, the collec on offers a roadmap for improving outcomes. Key priori es emerging from these studies include precision interven ons tailored to individual risk profiles, evidence-based prac ce standardiza on, long-term follow-up programs, trauma-informed family counselling, and vigilance for rare complica ons. As neonatal care con nues to evolve, this Research Topic underscores the importance of collabora ve, mul disciplinary research to address the unique challenges of EPIs, ul mately striving for equitable and high-quality care that op mizes both survival and quality of life.