Neonates who survive fetal growth restriction and extreme prematurity face measurable cardiopulmonary sequelae that persist into adolescence and adulthood, yet birth history is often overlooked in routine pediatric and adult care. Experts warn that systematic documentation of early life risk factors is essential to guide long-term surveillance and prevention strategies.

Specialists in Italy gathered to examine the future of neonatal care, informed by The Lancet Child & Adolescent Health Commission on the Future of Neonatology. Set against declining birth rates, discussions focused on the Italian context and its specific challenges, concerns raised by the Italian Society of Neonatology (SIN).

“Today, more than ever, advances in medicine allow the survival of extremely premature neonates and those with very low birth weight,” said Massimo Agosti, MD , neonatologist, president of the SIN, Italy. “At the same time, rising maternal age translates into more neonates born with complex health conditions. As neonatologists, we must set new goals: not only to save lives but to manage the long-term consequences of early health insults through collaboration with pediatricians and physicians caring for adults.”

Cardiac Remodeling

Fetal growth restriction (FGR) is diagnosed when estimated fetal weight on ultrasound falls below the 10th percentile for gestational age. Placental insufficiency is the most common cause, leading to chronic hypoxia that limits attainment of genetic growth potential.

“This condition activates adaptive hemodynamic mechanisms aimed at preserving the heart and brain,” said Tullio Ghi, MD, PhD, professor of obstetrics and gynecology, Università Cattolica del Sacro Cuore, and director, Unità Operativa Complessa di Ostetricia e Patologia Ostetrica, Policlinico Agostino Gemelli, Rome, Italy.

“In response to increased workload, the cardiac walls initially undergo functional changes, followed by structural remodeling detectable on prenatal ultrasound. Assessment of myocardial deformation shows higher velocity during the cardiac cycle in fetuses who are small for gestational age compared with those with normal growth.”

Over time, the structure of the heart changes, becomes more globular and less elongated. By 6 months of age, infants born with low birth weight demonstrate differences left ventricle per unit of time and the thickness of the intraventricular septum compared with those of infants born at a normal weight.

Cardiac differences persist during childhood infants born with low birth weight have a thicker carotid artery wall. In adolescence, these individuals show less resistance to fatigue during physical activity, and the increased cardiovascular risk persists in adulthood.

Pediatricians and primary care physicians should therefore incorporate birth in their patients’ medical history. “Individuals who have experienced FGR during pregnancy should be encouraged early to adopt a balanced diet and healthy lifestyle,” Ghi said. “After sustaining their first injury during the prenatal period, limiting exposure to additional risk factors is crucial to reduce cardiovascular risk across the lifespan.”

Pulmonary Sequelae

Low birth weight and extreme immaturity also affect long term lung health.

“Forty five percent of children born before 28 weeks of gestation and weighing less than 1500 g develop bronchopulmonary dysplasia (BPD), characterized by arrested alveolar development,” said Eugenio Baraldi , MD, professor of pediatrics, University of Padua, Padova, Italy.

“Today, we can identify babies at risk for severe BPD as early as the tenth day of life by assessing their lung function using ultrasound.”

The short-term consequences of BPD are well established, notably prolonged oxygen dependence and frequent hospitalizations, whereas its long-term effects are less well recognized.

A longitudinal study conducted at the Università di Padova from 1991 to 2024 showed that children with moderate-to-severe BPD do not achieve full normalization of pulmonary function as they grow. As adults, they face higher risk for emphysema, fibrosis, and chronic obstructive pulmonary disease.

While effective treatments to prevent BPD in newborns remain under investigation, with some now in advanced trials, pediatricians and general practitioners must remain aware of its long-term consequences to assess patients’ risk for lung disease.

This story was translated from Univadis Italy, part of the Medscape Professional Network.