2012 Surfaktan Protein D Dan ACE Pada Lung Disease Preterm

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J Perinatol. 2012 May ; 32(5): 349355. doi:10.1038/jp.2011.104.
Genetic Associations of Surfactant Protein D and Angiotensin-

Converting Enzyme with Lung Disease in Preterm Neonates
Kelli K. Ryckman, PhD1, John M. Dagle, MD, PhD1, Keegan Kelsey, BS1,2, Allison M
Momany1, and Jeffrey C. Murray, MD1,*
1Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA,
52242
2Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA, 14853
Abstract
ObjectiveTo replicate genetic associations with respiratory distress syndrome (RDS) and
bronchopulmonary dysplasia (BPD) in genes related to surfactant deficiency, inflammation and
infection and the renin-angiotensin system.

Study DesignWe examined eight candidate genes for associations with RDS and BPD in 433
preterm (PTB - <37 weeks) infants (251 with RDS and 134 with BPD). Both case-control and
family-based analyses were performed in preterm (<37 weeks) and very preterm (VPTB - <32
weeks) infants.
ResultsWe replicated a previous finding that rs1923537, a marker downstream of surfactant
protein D (SFTPD) is associated with RDS in VPTB infants in that the T allele was over-
transmitted from parents to offspring with RDS (p=8.4103). We also observed the A allele of
rs4351 in the angiotensin-converting enzyme (ACE) gene was over-transmitted from parents to
VPTB offspring with BPD (p=9.8103).
ConclusionThese results give further insight into the genetic risk factors for complex neonatal
respiratory diseases and provide more evidence of the importance of SFTPD and ACE in the
etiology of RDS and BPD, respectively.
Keywords
bronchopulmonary dysplasia; respiratory distress syndrome; single nucleotide polymorphism
Introduction
Respiratory disease is the largest contributor to morbidity and mortality in infants born
preterm and low-birth weight (LBW).1,2 The two most common types of respiratory
disorders observed in preterm infants are respiratory distress syndrome (RDS) and
bronchopulmonary dysplasia (BPD). RDS is caused by surfactant deficiency and a lack of
lung development and is extremely frequent in very preterm birth (VPTB - <32 weeks
gestation) infants.1,3 RDS can develop into BPD, which is characterized by chronic lung
damage and inflammation; however, the etiology is complex and studies have shown that
chronic lung disease may also develop in infants with little or no initial pulmonary
disease.4,5 BPD occurs in approximately 2030% of very low birth weight (VLBW - <1,500
*
Corresponding Author: Dr. Jeffrey C. Murray Department of Pediatrics University of Iowa 500 Newton Road, 2182ML Iowa City,
Iowa 52242 Telephone: 319-384-4464 Fax: 319-335-6970 jeff-murray@uiowa.edu.
Conflicts of Interest: There are no conflicts of interest to disclose.
Ryckman et al. Page 2
grams) infants.4,6,7 Originally, these respiratory illnesses were attributed to preterm birth
(PTB), LBW and in the case of BPD to the effects of ventilation and supplemental oxygen
on underdeveloped lungs. However, other environmental influences have been identified to
play a role in the complexity of these diseases. For example, chorioamnionitis, defined by
intrauterine inflammation, is associated with a decreased risk of RDS and an increased risk
of BPD.8,9 Identifying other underlying risk factors is extremely important for
understanding the pathogenesis of these complex diseases to improve treatment and
prevention strategies.
In addition to environmental influences, genetic factors play a role in the pathogenesis of

both RDS and BPD.2,10 Twin studies show shared genetic and environmental risk factors
explain 65% of the risk for developing BPD after controlling for gender, gestational age and
birth weight.11 The heritability of RDS, based on several twin studies, is estimated between
2082%.1215 Specific genetic associations have been identified with both BPD and RDS.
Due to decreased concentrations of surfactant in the lungs of infants with RDS and BPD, the
majority of genetic association studies have focused on surfactant protein genes.
Associations in surfactant protein genes A (SFTPA2), B (SFTPB), C (SFTPC) and D
(SFTPD) with both RDS and BPD have been identified.2,14,1624 Additionally, several
studies have discovered associations between BPD and the mannose-binding lectin gene
(MBL2), which is involved in the complement system and inflammatory process.25,26 A few
studies have identified associations between BPD and other inflammatory genes including
tumor necrosis factor (TNF) and interferon gamma (IFNG).27,28 The insertion/deletion
polymorphism in the angiotensin-converting enzyme (ACE) gene was associated with BPD;
however, this association failed to replicate.29,30 Many of these associations with BPD and
RDS have not been tested in multiple independent populations or have not consistently
replicated across studies.4,30,31
To determine if genetic associations previously identified replicate, we examined eight

candidate genes for association with BPD and RDS susceptibility: SFTPA2, SFTPB,
SFTPC, SFTPD, MBL2, TNF, IFNG and ACE. Several single nucleotide polymorphisms
(SNPs) from each gene were tested for association using both family-based and case-control
analyses. A total of 433 PTB infants/families (251 with RDS and 134 with BPD) were
evaluated.
Materials and Methods

Study Population
Infants born PTB and admitted to the Neonatal Intensive Care Unit at the University of Iowa
Children's Hospital between 2000 and 2009 were enrolled. This was an observational study,
in that enrollment generally occurred 24 weeks after birth and in some cases this would be
after the development of a particular condition such as BPD. Blood or buccal swabs were
collected from infants and both parents if available. These individuals were recruited to
examine PTB and neonatal complications of prematurity.32,33 Approval was obtained from
the Institutional Review Board (200506792) for sample collection and access clinical
information. RDS was defined radiologically in combination with the requirement of oxygen
for 2 hours or more. BPD was diagnosed by radiologic findings as well as an infant that
required supplemental oxygen at 36 weeks gestational age. Treatment strategy varied over
the 10 year time span of this study. In general, surfactant was not administered as
prophylaxis but instead treatment occurred within the first hour after birth using an early
rescue approach. A total of 433 singleton PTB Caucasian infants without congenital
anomalies were included in the analysis of RDS and BPD.

DNA Processing and Genotyping

Aliquots of sample DNA (2 ng) were transferred to a 384-well plate. Thirty-four SNP
markers from eight candidate genes that were previously genotyped for associations with
prematurity and complications of prematurity were examined. These genes and SNPs were:
SFTPA2 (rs1965708), SFTPB (rs2040349, rs1130866, rs934774, rs1030862 and
rs10204426), SFTPC (rs8192306, rs2070687 and rs7592), SFTPD (rs2256703, rs2256588,
rs1923537, rs2243639, rs721917 and rs958865), MBL2 (rs2136892, rs10762864,
rs10740509, rs1838065, rs5030737, rs7096206, rs930506, rs11003136, rs11003231 and
rs2462479), IFNG (rs3181034 and rs2069718), TNF (rs1799964 and rs1800629) and ACE
(rs4293, rs4341, rs4351, rs4267385 and rs8066114). In general, tagSNPs were selected to
provide the most adequate coverage of each gene including markers both upstream and
downstream of the given region. Emphasis was often given to SNPs in coding regions and
promoter elements. Genotyping was performed using the Applied Biosystems (Foster City,
CA, USA) TaqMan chemistry under standard conditions. Allele determination was
performed using the Applied Biosystems 7900 HT Sequence Detection System with SDS
2.3 software.
Statistical Analysis
Birth weight, gestational age, Apgar scores at 1 and 5 minutes, gender, days on ventilation,
days on oxygen supplementation, antenatal treatment with corticosteroids, treatment with
surfactant, mode of delivery and maternal chorioamnionitis were compared between infants
with and without BPD and between infants with and without RDS. Ranksum tests were used
for comparisons of quantitative traits and Fisher's exact tests were used for categorical traits.
Analyses were performed with STATA version 10.1 (Stata Corp, College Station, Texas).
Markers were tested for deviations from Hardy-Weinberg Equilibrium (HWE) in RDS and
BPD cases and controls separately. All markers were in HWE in RDS and BPD cases and
controls using a threshold of p>0.001. Deviations greater than p=0.001 but less than p=0.05
are noted in Supplemental Table 1. Fisher's exact tests were performed to compare allele and
genotype frequencies for each SNP between cases and controls (i.e., infants with BPD
compared to infants without BPD and infants with RDS compared to infants without RDS).
This analysis was performed in PTB (<37 weeks) and VPTB (<32 weeks) infants.
Significant (p<0.01) associations were analyzed using logistic regression adjusting for
covariates that differed between cases and controls and are known confounders with BPD or
RDS. Associations with RDS were adjusted for gestational age and mode of delivery and
associations with BPD were adjusted for gestational age, chorioamnionitis and mode of
delivery. Haplotype association testing for 2, 3 and 4 sliding window haplotype blocks were
performed in PTB and VPTB infants. Analyses were performed using PLINK
(http://pngu.mgh.harvard.edu/purcell/plink/).34 Family-based association tests (FBAT) were

performed on BPD or RDS case parent-infant trios including any genotyped siblings in PTB
and VPTB groups to determine if the transmission of parental alleles to affected offspring is
associated with either BPD or RDS.35,36 Analyses were also performed including twins and
in general similar trends were observed (data not shown) but due to problems with
additional confounding only analyses excluding twins are presented. Family based haplotype
association tests (HBAT) were performed in PTB and VPTB families.37
Linear regression was performed to test for additive genetic association of infant genotype
with days on a ventilator or days on supplemental oxygen adjusting for gestational age. Days
on ventilator and days on oxygen were transformed using the Box Cox transformation due to
the non-normal distribution. Analyses were performed with STATA version 10.1 (Stata
Corp, College Station, Texas). Quantitative disequilibrium tests (QTDT), adjusting for
gestational age, were also performed on the parent-infant trios including any genotyped

siblings to determine if the transmission of parental alleles to the offspring were associated
with days on a ventilator or days on oxygen. QTDT is based on the same principles as the
transmission disequilibrium test (TDT), building upon the methods developed for linkage-
disequilibrium mapping and using variance components to construct tests that utilize
information from all available offspring.38 Permutation tests were used to correct for the
non-linear distribution of days on oxygen and a ventilator. Correcting for thirty four
markers, a Bonferroni threshold of p<0.001 was used to determine significant associations.
None of the associations between a single marker and RDS or BPD met this significance
threshold. However, as this study is a replication analysis of previous work, p-values <0.01
were still considered to be of interest and are also discussed in the results.
Results
Birth weight, gestational age, Apgar score at 1 minute and Apgar score at 5 minutes were
significantly lower (p<0.05) in infants with RDS or BPD than controls (Table 1). There were
more infants whose mothers received antenatal corticosteroids, more treatment with
surfactant, more caesarean deliveries and more time spent on supplemental oxygen or a
ventilator in infants with RDS or BPD compared to controls. Additionally, there was
significantly more maternal chorioamnionitis in infants with BPD than controls; however
there was no difference comparing infants with RDS to controls. As expected, the vast
majority of BPD cases were less than 32 weeks gestation, therefore, for BPD only the results
in VPTB infants are presented. For RDS the results were similar for PTB and VPTB infants;
therefore, only the results for VPTB infants is presented and all other results can be found in
the supplemental material. No single locus associations met the Bonferroni significance
threshold (p<0.001); however, we present findings of interest with RDS and BPD at a
significance of p<0.01.
Genetic Associations with RDS

The most significant association with RDS was rs2256588 downstream of SFTPD, where
the AA genotype was more frequent in VPTB cases compared to controls (p=5.9103)
(Table 2, Supplemental Table 2); however, this did not remain significant when adjusting for
gestational age and mode of delivery (p=0.21). The T allele at rs1923537 downstream of
SFTD was over-transmitted in VPTB offspring with RDS (p=8.4103). Additionally, the T
allele was marginally more prevalent in RDS cases compared to controls (p=0.14) and the
TT genotype was associated (p=0.02) with more days on oxygen compared to the CC
genotype (62 versus 55 days on oxygen, respectively). There were several haplotype effects
including these signals in the family-based but not case-control analyses (Figure 1 and
Supplemental Table 3). The most significant haplotype effect included rs1923537 and
rs2243639, where the T-C haplotype was significantly over-transmitted to VPTB offspring
with RDS (p=4.7104) (Supplemental Table 4).
Genetic Associations with BPD

The most significant association with BPD was rs8066114, downstream of the ACE gene,
where the G allele was more frequent in VPTB cases compared to controls (p=5.0103)
(Table 2). Additionally the GG genotype was more frequent in BPD cases compared to
controls (p=0.02) and this effect remained significant after adjusting for gestational age,
chorioamnionitis and mode of delivery (p= 0.03). There were no significant associations
with this SNP in the family-based analysis (p=0.47). The A allele of rs4351 in ACE was
significantly over-transmitted to VPTB offspring with BPD (p=9.8103). This effect was
not significant in the case-control analysis (p=0.83). There were several significant
haplotype associations, all of which included either rs8066114 or rs4351 in both the case-
control and family-based analyses (Figure 2 and Supplemental Table 3). Most notably was

the T-C haplotype at rs4267385 and rs8066114 which was significantly more frequent in the
BPD cases (p=3.8104) compared to controls and marginally over-transmitted in the
family-based analysis (p=0.06) (Supplemental Table 4).
Other significant associations with BPD include rs721917 in SFTPD, where the C allele was
more frequent in VPTB cases compared to controls (p=0.03) (Table 2 and Supplemental
Table 2). There was also marginal over-transmission of the C allele to offspring affected
with BPD (p=0.07). The T allele of rs1923537 downstream of SFTPD was over-transmitted
to VPTB infants with BPD (p=0.03). There were several significant haplotype associations
in the family based analyses only (Figure 1 and Supplemental Table 3). Most notably was
the T-C haplotype at rs1923537 and rs2243639 (p=1.8103) (Supplemental Table 4).
Discussion
Very PTB (<32 weeks gestation), very LBW (<1,500 grams) infants are at a particularly
high risk for development of RDS and BPD.1,3,4,6,7 The etiology and precise mechanisms of
RDS and BPD development and progression in PTB infants remains largely undiscovered.
In addition to environmental factors, genetic factors are implicated in increasing the risk of
RDS and BPD and while these two diseases are related, the underlying genetic mechanisms
and causes for each disease may be quite distinct and complex. Genetic studies have largely
focused on surfactant protein genes and many studies have suggested genetic associations
with RDS or BPD but few have been replicated or tested in independent populations.
The C allele of a polymorphism downstream of SFTPD (rs1923537) was associated with a

lower incidence of RDS in a German population of VPTB infants.22 We replicated this
association as the C allele was under-transmitted in the family-based analysis of VPTB
infants with RDS and was marginally (p=0.1) protective in the case-control analysis..
Similar to the previous study we also observed fewer days on oxygen in infants with the CC
genotype. SFTPD encodes a hydrophilic protein that is involved in surfactant homeostasis
and pulmonary innate immunity.39 The heritability of serum surfactant protein D levels is
0.91 according to a twin study, indicating that mutations in this gene could lower
concentrations of surfactant protein D which is associated with more severe respiratory
disease.40 Our results are a direct replication of a previous association using two analytical
methods (i.e., family-based and case-control).
Additionally, the C allele (Thr11) of a missense variant (Thr11Met, position 31 from the
transcriptional start site, rs721917) in SFTPD was marginally associated with BPD in both
the case-control and family-based analyses. The C allele was previously associated with
lower serum SP-D levels and tuberculosis.4143 Interestingly, the opposite allele (Met11)
was previously associated with respiratory syncytial virus bronchiolitis in infants.44 Higher
levels of SP-D were observed in acute respiratory distress syndrome in adults, while lower
levels are associated with the risk of infection and surfactant deficiency is the underlying
cause of RDS in preterm infants.45,46 It is unclear why the results for this effect are
conflicting; however, may be due to type I error as our sample sizes were small and our
results are only marginally significant. However, due to the predicted deleterious effects on
protein structure and associations with respiratory syncytial virus bronchiolitis, tuberculosis
and now BPD further investigation of the associations with this SNP and respiratory
phenotypes is warranted.
Another gene implicated in increasing the risk for BPD is ACE. One study found that an
insertion/deletion polymorphism in intron 16 (rs1799752) was associated with BPD in
VLBW (<1250 grams) infants; however, this effect has not been replicated.29,47 While we
did not genotype this SNP in our population, we observed several single locus and haplotype

associations with BPD in the ACE gene. The insertion/deletion polymorphism is 100 base
pairs away from rs4341 which was involved in eight haplotypic associations with BPD
(Figure 2); therefore we likely captured the effect previously identified with the insertion/
deletion polymorphism in our haplotype analysis. There is increasing evidence that the
renin-angiotensin system plays a role in lung disease and injury. One possible explanation
for the role of ACE in BPD is that mutations in ACE may influence circulating
concentrations of ACE and its product angiotensin II (AII) and higher levels of these
enzymes may enhance lung inflammation and disease.29 While this is not a direct
replication, there is indication that the ACE gene is involved in BPD but not RDS and that
haplotypes, more so than single variants, play a strong role in this effect.
Additionally, we identified weaker associations in genes that have been previously

associated with RDS or BPD, specifically, SFTPB, MBL2, and TNF (Supplemental Figure
1). However, these effects did not directly replicate previous associations. Also, we did not
replicate associations in SFTPC or IFNG. This is possibly due to our relatively small sample
size and lack of power to detect these effects, which may explain why we often saw
differing results between family-based and case-control methods. Additionally, our sample
was a homogenous collection from Iowa that spanned a 10 year period and may be subject
to selection bias as diagnosis, treatment and admission procedures changed during this time
span. In general, subjects were enrolled in our study between 24 weeks after birth.
Therefore, infants with RDS that died before enrollment were not captured in our cohort.
The strength of our study was the ability to test multiple SNPs from genes previously shown
to associate with RDS or BPD using both family-based and case-control analyses. Few
studies have utilized both study designs to detect associations with neonatal complications.
We verified that the associations observed with the family data were not surrogates for
associations with PTB itself as there was no association with PTB for any of the
significantly-associated markers when the full sample (RDS and BPD cases and controls;
n=433) was analyzed. We directly replicated a previous association between SFTPD and
RDS and pseudo-replicated associations in SFTPD and ACE with BPD. These results give
further insight into the genetic risk factors for complex neonatal respiratory diseases and
provide more evidence of the importance of SFTPD and ACE in the etiology of RDS and
BPD.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
We would like to express our thanks to all the participating families in our study. We would also like to express our
gratitude to the coordinating medical and research staff at the University of Iowa Children's Hospital in Iowa City,
IA; including a special thanks to research coordinators Susan Berends and Laura Knosp. Additionally, we would
like to thank the research technician involved in genotyping and sample management including Tamara Busch and
students Rim Halaby and Jad al Danaf. This work was supported by the of Dimes (grants 1-FY05-126 and 6-
FY08-260) and the NIH (grants R01 HD-52953 and R01 HD-57192). Dr. Ryckman's postdoctoral fellowship was
supported by a NIH/NRSA T-32 training grant (5T32 HL 007638-24).
This work was supported by the March of Dimes (grants 1-FY05-126 and 6-FY08-260) and the NIH (grants R01
HD-52953 and R01 HD-57192). Dr. Ryckman's postdoctoral fellowship was supported by a NIH/NRSA T-32
training grant (5T32 HL 007638-24).
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Figure 1.
Single locus and haplotype associations between SFTPD and RDS or BPD in VPTB infants.
Each gene is represented by a solid line and SNPs within exons are represented by a box.
Dotted lines represent SNPs outside the gene or in the promoter region. The 3 end of the
gene is represented by an arrow. R2 values are given in each box and shading indicates the
strength of LD determined by the 95% confidence bounds of D. White shading indicates
strong evidence for recombination, light grey indicates lack of information to determine the
strength of LD and dark grey indicates strong LD.

Figure 2.
Single locus and haplotype associations between ACE and RDS or BPD in VPTB infants.
Each gene is represented by a solid line and SNPs within exons are represented by a box.
Dotted lines represent SNPs outside the gene or in the promoter region. The 3 end of the
gene is represented by an arrow. R2 are values given in each box and shading indicates the
strength of LD determined by the 95% confidence bounds of D. White shading indicates
strong evidence for recombination, light grey indicates lack of information to determine the
strength of LD and dark grey indicates strong LD.

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 1
Demographic and Clinical Characteristics.
Trait (total n=433) No BPD (n=255) BPD (n=134) p-value No RDS (n=154) RDS (n=251) p-value
Birth weight - grams (n=433) 1962 (728) 947 (398) 11041 2038 (694) 1423 (776) 21016
Ryckman et al.
Gestational Age - weeks (n=433) 32 (3) 27 (2) 51046 33 (3) 29 (4) 71022
Gestational Age <32 weeks (n=230) 92 (36%) 130 (97%) 21036 40 (26%) 178 (71%) 61019
Apgar Score 1 min (n=427) 6 (2) 5 (2) 51011 7 (2) 5 (2) 1109
Apgar Score 5 min (n=428) 8 (1) 7 (2) 41011 8 (1) 7 (2) 2109
Infant Gender - Male (n=433) 134 (53%) 80 (60%) 0.20 76 (49%) 150 (60%) 0.05
Mechanical Ventilation - days (n=398) 3 (7) 37 (28) 11045 3 (7) 22 (27) 21027
Oxygen Supplementation - days (n=402) 13 (16) 89 (43) 61054 12 (17) 55 (50) 31026
Antenatal Corticosteroids (n=402) 4 (2%) 67 (51%) 31032 5 (4%) 67 (29%) 11010
Treatment with Surfactant (n=425) 69 (27%) 119 (89%) 91033 4 (3%) 196 (79%) 51058
Mode of Delivery (n=433)
Vaginal 126 (49%) 50 (37%) 0.03 89 (58%) 101 (40%) 7104
Caesarean 129 (51%) 84 (63%) 65 (42%) 150 (60%)
Maternal Chorioamnionitis (n=366) 20 (9%) 21 (19%) 0.01 12 (9%) 28 (14%) 0.23
Means and standard deviation in parentheses or counts and percent in parentheses are presented.
P-values compare BPD cases to controls or RDS cases to controls.

Page 12
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 2
Significant Single Locus Associations with BPD or RDS in very preterm infants.
Allele and Genotype Frequencies p-value

Gene Locus (A/B) Status N A AA AB BB Allelic Genotypic over-transmitted allele FBAT p-value
Ryckman et al.
SFTPD rs2256588 RDS 127 0.61 0.42 0.39 0.19 1.0 5.9103 A 0.15
(A/G) Controls 28 0.61 0.25 0.71 0.04
rs1923537 BPD 93 0.65 0.41 0.48 0.11 0.48 0.72 T 0.03
(T/C) Controls 69 0.61 0.36 0.49 0.14
RDS 124 0.65 0.44 0.44 0.13 0.14 0.08 T 8.4103
Controls 31 0.55 0.23 0.65 0.13
rs721917 BPD 51 0.44 0.20 0.49 0.31 0.03 0.07 C 0.07
(T/C) Controls 46 0.60 0.33 0.54 0.13
ACE rs8066114 BPD 91 0.58 0.32 0.52 0.16 5.0103 0.02 C 0.47
(C/G) Controls 61 0.74 0.54 0.39 0.07
rs4351 BPD 106 0.56 0.31 0.49 0.20 0.83 0.46 A 9.8103
(A/G) Controls 73 0.54 0.25 0.59 0.16
N= number of observations

Page 13

2012 Surfaktan Protein D Dan ACE Pada Lung Disease Preterm

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J Perinatol. 2012 May ; 32(5): 349355. doi:10.1038/jp.2011.104.

Genetic Associations of Surfactant Protein D and Angiotensin-

infection and the renin-angiotensin system.

In addition to environmental influences, genetic factors play a role in the pathogenesis of

To determine if genetic associations previously identified replicate, we examined eight

Materials and Methods

J Perinatol. Author manuscript; available in PMC 2013 May 01.

DNA Processing and Genotyping

(http://pngu.mgh.harvard.edu/purcell/plink/).34 Family-based association tests (FBAT) were

J Perinatol. Author manuscript; available in PMC 2013 May 01.

Genetic Associations with RDS

with RDS (p=4.7104) (Supplemental Table 4).

Genetic Associations with BPD

J Perinatol. Author manuscript; available in PMC 2013 May 01.

The C allele of a polymorphism downstream of SFTPD (rs1923537) was associated with a

J Perinatol. Author manuscript; available in PMC 2013 May 01.

Additionally, we identified weaker associations in genes that have been previously

J Perinatol. Author manuscript; available in PMC 2013 May 01.

birth weight. Obstetrics and Gynecology. 2003; 102:488492. [PubMed: 12962929]

bronchopulmonary dysplasia. Frontiers in Bioscience : A Journal and Virtual Library. 2006;

J Perinatol. Author manuscript; available in PMC 2013 May 01.

infant. Acta Paediatrica (Oslo, Norway : 1992). 2009; 98:112117.

J Perinatol. Author manuscript; available in PMC 2013 May 01.

infection. Pediatric Research. 2002; 51:696699. [PubMed: 12032263]

J Perinatol. Author manuscript; available in PMC 2013 May 01.

J Perinatol. Author manuscript; available in PMC 2013 May 01.

J Perinatol. Author manuscript; available in PMC 2013 May 01.

J Perinatol. Author manuscript; available in PMC 2013 May 01.

Allele and Genotype Frequencies p-value

J Perinatol. Author manuscript; available in PMC 2013 May 01.

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