Objective-Little is known about the developmental trajectory of cortisol levels in preterm infants after hospital discharge.Study design-In a cohort of 225 infants (gestational age at birth <33 weeks) basal salivary cortisol levels were compared in infants born at extremely low gestational age (ELGA, 23-28 weeks), very low gestational age (VLGA, 29-32 weeks) and full-term (37-42 weeks), at 3, 6, 8 and 18 months corrected age (CA). Infants with major neurosensory and/or motor impairment were excluded.Results-At 3 months CA, salivary cortisol levels were lower in both preterm groups compared to the full-term infants (p = .003). Conversely, at 8 and 18 months CA, the ELGA infants had significantly higher basal cortisol levels than the VLGA and full-term infants (p = .016; p = .006 respectively).Conclusions-In ELGA infants, the shift from low basal cortisol levels at 3 months to significantly high levels at 8 and 18 months CA suggests long-term 're-setting' of endocrine stress systems. Multiple factors may contribute to these higher cortisol levels in the ELGA infants, including physiological immaturity at birth, cumulative stress related to multiple procedures and mechanical ventilation during lengthy hospitalization. Prolonged elevation of the cortisol "set-point" may have negative implications for neurodevelopment and later health. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.No author has any potential conflict of interest with this manuscript. Early environmental stress can permanently reorganize hormonal, physiological and behavioral systems, and increase vulnerability to illness and disorders later in life, a process referred to as "early programming." 1-6 For example, in rats, early adverse experiences such as prenatal stress, maternal separation or early deprivation result in increased stress hormone responses throughout the preweaning period and into adulthood. 2,3,6 Increased exposure to endogenous corticosteroids has adverse effects on cognitive abilities 7 and increases emotionality and anxiety-like behaviors in aversive situations. 8,9 NIH Public AccessIn general, sicker and smaller infants often show relatively low cortisol levels while in the neonatal intensive care unit (NICU). 10 We have recently shown a developmental shift whereby greater cumulative neonatal stress (higher number of skin-breaking procedures from birth to term) predicted lower cortisol levels in the NICU, 11 but elevated cortisol levels at 8 months corrected age (CA). 12 Little is known about the developmental trajectories of cortisol secretion in preterm infants after hospital dis...

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Objective Pain response may be altered in infants born very preterm owing to repeated exposure to procedures in the neonatal intensive care unit. Findings have been inconsistent in studies of behavioral and cardiac responses to brief pain in preterm versus full-term infants following neonatal intensive care unit discharge. To our knowledge, cortisol reactivity to pain has not been compared in preterm and full-term infants. We examined pain reactivity to immunization in preterm and full-term infants. Method Cortisol, facial behavior, and heart rate reactivity before, during, and after immunization were examined in infants born preterm at extremely low gestational age (ELGA 24 to 28 wk), very low gestational age (VLGA 29 to 32 wk), and full-term, at corrected age 4 months. Results In all groups, cortisol, behavior, and heart rate increased during immunizations. Cortisol concentrations were lower in preterm ELGA and VLGA boys, compared with full-term boys. In contrast, facial and heart rate responses to immunization did not differ between preterm and full-term infants. Discussion Although earlier reports found differences in pain processing in preterm infants earlier and later in development, the present findings indicate that pain responses, indexed by behavior and heart-rate, do not seem to differ in preterm compared with full-term infants at 4 months corrected age. Importantly, however, stress regulation seems altered in preterm male infants. As cortisol impacts development and functioning of the brain, altered stress regulation has important implications beyond pain systems.

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Outborn infants were less mature and more ill than inborn infants at NICU admission. However, even after adjustment for perinatal risks and admission illness severity, inborn infants had better outcomes than outborn infants. Our results support in-utero transfer of high-risk pregnancies to a tertiary level facility.

Omphalitis remains a clinical issue. Cessation of bacteriocidal care of the umbilical stump must be accompanied by vigilant attention to the signs and symptoms of omphalitis.

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Objectives To test whether children with recurrent abdominal pain (RAP) exhibit subliminal (nonconscious) and supraliminal (conscious) attentional biases to pain-related words, and to determine correlates of these biases. Previous research indicates that individuals attend to disorder-relevant threat words, and in this study, attentional biases to disorder-relevant threat (pain), alternative threat (social threat), and neutral words were compared. Methods Participants were 59 children with RAP who completed a computer-based attentional bias task. Participants and their parents also completed questionnaires measuring pain, somatic complaints, anxiety/ depression, and body vigilance. Results Children with RAP showed attentional biases toward subliminal pain-related words and attentional biases away from supraliminal painrelated words. Participants' attentional biases to social threat-related words were marginally significant and also reflected subliminal attention and supraliminal avoidance. Attentional biases were related to parent and child reports of pain, body vigilance, and anxiety/ depression. Conclusions Children with RAP show nonconscious attention to and conscious avoidance of threat-related words. Their attentional biases relate to individual differences in symptom severity. Implications for models of pediatric pain and future studies are discussed.