The outcome of extreme prematurity

Nobody likes premies: the relative value of patients' lives

OBJECTIVE

The objective of this study was to examine whether patient selection or triage requires placing a relative value on human lives and whether the values placed on these lives are consistent with current ethical theories.

STUDY DESIGN

An anonymous questionnaire was administered to groups of physicians and students in Montreal. It presented eight currently incompetent patients with potential neurological sequelae requiring emergency care. Predicted outcomes were explicitly described. Four patients had a predicted 50% survival and a 50% chance of impairment; they were a preterm and a term neonate, a 2-month-old and a 50-year-old. Two already disabled patients, a 7-year-old and an 80-year-old, had 50% predicted survival. A 14-year-old and a 35-year-old had 5% survival, but differing impairment. Respondents were asked if they would resuscitate and in what order they would resuscitate if all needed intervention simultaneously.

RESULT

Eighty-five percent response rate, n=524. The proportion stating they would always resuscitate was smallest for the 80-year-old (18% P<0.001 compared to other patients), then the preterm (35%, P<0.001), then the term and the 50-year-old (53 and 58%, P<0.01). The 2-month-old and the 7-year-old would be resuscitated most frequently (74 and 77%, P<0.01), followed by the patients with 5% survival (64 and 68%, P<0.001). The median order of triage was first the 2-month-old, followed by the 7-year-old, the 14-year-old, the term newborn, the 50-year-old, the 35-year-old, the premature newborn and the 80-year-old.

CONCLUSION

Order of resuscitation was not closely related to the predicted survival, impairment or potential life years gained. Age appeared to have a strong influence, with children's lives being valued more than the adults'. This tendency was reversed for the newborn infants who were undervalued compared with older children, and most particularly for the premature. The value placed on the life of newborns, in particular the premature, is less than that expected by any objective medical data and was not consistent with any ethical theory that we tested.

Transcriptional regulation of the processes of human labour and delivery

Preterm birth is the most important complication contributing to poor pregnancy and neonatal outcome. A critical issue that must be resolved is how spontaneous onset labour is initiated both at term and preterm. Over the past decade, we and others have provided evidence in support of the hypothesis that labour onset is regulated by specific nuclear regulatory factor (NR) pathways, involving an interplay between transcription factors (TFs) and nuclear hormone receptors, that control the expression of many of the effector pathways requisite for labour and delivery. There is now compelling evidence implicating NRs, including the nuclear factor-kappaB (NF-kappaB) family of nuclear TFs, the nuclear hormone receptor superfamily of peroxisome proliferator activated receptors (PPARs), and the steroid receptors for progesterone (PRA, PRB and PRC), as candidate upstream regulators of labour-associated processes. Based on these studies and recent data obtained in our laboratory, we provide a new model of how the multiple pathways involved in spontaneous onset labour and delivery are coordinated at a nuclear level. We propose that spontaneous onset labour and delivery are consequent upon withdrawal of the repressive effect of nuclear receptors (PPAR and PR) on pro-labour TF pathways (NF-kappaB). The withdrawal of NR-mediated repression is affected by competition between TFs and NRs for a limited pool of nuclear cofactors. We also propose that coordination of these different pathways is achieved by competition for common cofactors that control the activity of NRs in human gestational tissues.

Morphological aspects of dental hard tissues in primary teeth from preterm infants

BACKGROUND

Preterm children with very low birth weight suffer from several neonatal and post-natal complications that may affect the mineralization of the teeth. Clinical studies have shown enamel aberrations in both dentitions.

AIMS

The aims of this study were to describe enamel histo-morphology in primary teeth, and investigate the relationship between medical history and morphological appearance.

DESIGN

Dental enamels in 44 exfoliated primary teeth, from 14 children with a gestational age below 29 weeks and with a very low birth weight, were investigated, using polarized light microscopy (POLMI) and under a scanning electron microscope (SEM).

RESULTS

The neonatal line was found in 1/3 of the sections located coronally of the crown. In the post-natal enamel, 31 teeth showed a degree of porosity higher than 5% with a varying extension. More than half of the teeth showed one or more increment lines. The SEM analysis confirmed the POLMI findings with irregular prisms covered with a structure-less film.

CONCLUSIONS

Enamel from primary teeth of preterm children was found to have a high frequency of mineralization disturbances found in POLMI and SEM. The morphological features of the enamel from preterm children do not reflect the disturbances on general growth and development occurred during the neonatal period.

Dental behavioural management problems and dental caries prevalence in 3- to 6-year-old Swedish children born preterm

BACKGROUND

Today, most children born preterm survive without major impairments. But high frequencies of cognitive and behavioural difficulties arise. Studies on dental behavioural management problems (DBMP) in these children are lacking. In addition, studies on caries prevalence are few and inconclusive.

AIM

This study aims to compare the frequency of behavioural problems and poor compliance with dental treatment in preschool children born preterm with those born full-term. The prevalence of caries was also studied.

METHODS

The study group included 187 children born between 23 and 32 weeks of gestation. The control group constituted full-term children matched by age, sex, immigrant background, and dental operator. DBMP, number of dental visits, missed appointments, and caries between ages 3 and 6 were noted.

RESULTS

At age 3, but not at age 6, the prevalence of DBMP at clinical examinations was significantly higher in preterm children compared with the control group. Of the children who received dental treatments during preschool years, preterm children displayed significantly more DBMP. No significant difference in dental visits or in caries prevalence was found. Preterm children, however, missed significantly more dental appointments.

CONCLUSION

Children born preterm display a higher prevalence of DBMP at dental examinations and treatments during preschool years.

The association of growth impairment with neurodevelopmental outcome at eight years of age in very preterm children

BACKGROUND

The relative contributions of poor growth before and after birth in very preterm infants to subsequent outcomes at school-age are not certain.

AIMS

To determine the associations between weight and head circumference, at birth and postnatally, with cognitive, academic and motor outcomes at age 8 years for very preterm children free of neurosensory impairment.

STUDY DESIGN

This was a regional cohort study from the state of Victoria, Australia.

SUBJECTS

179 very preterm infants (<28 weeks' gestational age) born in 1991 and 1992 who were free of neurosensory impairment.

OUTCOME MEASURES

At 8 years of age children had cognitive, academic and motor assessments. Weight and head circumference data were collected at birth, at the time of discharge (weight only), at 2 years of age and at 8 years of age, and growth restriction was calculated using Z-scores (standard deviation scores) relative to the expected mean for age.

RESULTS

Very preterm children were significantly lighter and had smaller head circumferences than the reference group at all ages. Weight at any age was mostly unrelated to any outcomes. While head circumference at birth was not related to school-aged outcomes, smaller head circumferences at ages 2 and 8 years were associated with poorer performance in most outcome measures. Catch-up growth in weight in early childhood was not associated with 8-year outcomes.

CONCLUSIONS

Intrauterine growth restriction was not substantially associated with neurodevelopmental status at age 8. Weight after birth had little influence, but head circumference became more important in early childhood.

The best-interest standard is not applied for neonatal resuscitation decisions

OBJECTIVE

Legal and ethical standards require resuscitation when it is considered to be in the patient's best interest. We hypothesized that newborn infants might be dealt with according to different standards, compared with older patients.

METHODS

An anonymous questionnaire describing 8 currently incompetent patients with potential neurologic sequelae who required resuscitation was administered to groups of physicians and students. Survival and morbidity rates were explicitly described; a very preterm infant, a full term infant and a 2-month-old infant had identical outcomes. Two patients, a 7-month-old infant and an 80-year-old patient, were previously significantly impaired. Respondents were asked whether resuscitation was in the patient's best interest and whether they would comply with the families' wishes if resuscitation was refused.

RESULTS

There was an 85% response rate (n = 524). The largest proportions of respondents stated that it was in the best interests of the 2-month-old infant and the 7-year-old child to be resuscitated (97% and 94%, respectively), followed by the 50-year-old patient and the term infant (87%), the 2 patients with 5% chance of survival (76% and 80%), the premature infant (69%), and finally the 80-year-old patient (32%). Approximately one fifth of the respondents who thought that it was in a patient's best interests to be resuscitated would nevertheless accept the family's refusal of resuscitation for all scenarios except the 80-year-old patient (72% acceptance) and the preterm infant (54% acceptance).

CONCLUSIONS

Whether resuscitation is considered in a patient's best interests is not closely related to survival rates or disability. Newborn infants and particularly preterm infants are systematically devalued, in comparison with older patients whose outcomes are the same or worse. Accepting a family's refusal of resuscitation, even among respondents who thought that resuscitation was in the patient's best interest, was much more common for the newborns.

Limits of viability: definition of the gray zone

INTRODUCTION

As survival and long-term morbidity of very preterm infants have improved over the past decade, the limits of infant viability, the level of maturity below which survival and/or acceptable neurodevelopmental outcome are extremely unlikely, have also decreased.

STUDY DESIGN

In an effort to define the current limits of infant viability, the data in the literature on survival and long-term neurodevelopmental outcome in very preterm neonates have been reviewed.

RESULT

The gestational age and birth weight below which infants are too immature to survive, and thus provision of intensive care is unreasonable, appears to be at <23 weeks and <500 g, respectively. Infants born at > or =25 weeks' gestation and with a birth weight of > or =600 g are mature enough to warrant initiation of intensive care, as the majority of these patients survive, and at least 50% do so without severe long-term disabilities. Finally, for infants born between 23(0/7) and 24(6/7) weeks' gestation and with a birth weight of 500 to 599 g, survival and outcome are extremely uncertain. For these infants born in the so-called 'gray zone' of infant viability, the line between patient autonomy and medical futility is blurred, and medical decision-making becomes even more complex and needs to embrace careful consideration of several factors. These factors include appraisal of prenatal data and the information obtained during consultations with the parents before delivery; evaluation of the patient's gestational age, birth weight and clinical condition upon delivery; ongoing reassessment of the patient's response to resuscitation and intensive care and continued involvement of the parents in the decision-making process after delivery.

CONCLUSION

Based on these findings an algorithm is offered for consideration for neonatologists managing infants born in the 'gray zone' of infant viability. However, caution must be exercised when one considers incorporating this guideline into clinical practice because the algorithm is based on the analysis of the findings in the literature and the authors' experience rather than direct evidence.

Caregivers attitudes for very premature infants: what if they knew?

BACKGROUND

Decisions about resuscitation of extremely premature babies are controversial. Such decisions may reflect poor understanding of outcomes.

OBJECTIVE

To compare caregivers' attitudes towards the resuscitation of a premature infant if they are only told the infant's gestational age or if they are only given prognostic information for infants at that gestational age.

DESIGN/METHODS

Residents and nurses involved in perinatal care were asked whether they would resuscitate a depressed AGA 24-week gestation infant at birth. In another question they were asked whether they would resuscitate a depressed preterm infant with a 50% chance of survival, knowing that of those who survived, 50% would have a development 'within normal limits', 20-25% a serious handicap and 40% with behavioural and/or learning disability.

RESULTS

Two hundred and seventy-nine caregivers responded (91% response rate). In the scenario that only presented gestational age, 21% of respondents would resuscitate. In the scenario that only presented prognostic statistics, 51% of respondents would resuscitate (p<0.05).

CONCLUSIONS

Providers of perinatal health care respond to vignettes differently depending upon the format in which information is provided. The relative unwillingness to resuscitate a baby of 24-week gestation is surprising since outcomes for such babies are the same or better than those we described in the scenario that provided only outcome data without specifying gestational age. Two explanations are possible: (1) respondents have irrational negative associations with low gestational ages or (2) respondents are unaware of actual outcomes.

Cognitive and educational deficits in children born extremely preterm

A large body of research indicates that children born very preterm are at increased risk for neurobehavioral impairments; however, research examining outcome for extremely preterm (EP) children is limited. This chapter will review the literature focusing on early development delay, general intellectual functioning, specific cognitive skills, basic educational skills, and behavioral and emotional functioning in children born <26 weeks' gestation or with a birth weight <750 g. Findings are generally consistent and indicate that a large proportion of EP children and their families will face major challenges, including significant development delay, cognitive impairments, learning disabilities, and behavioral and emotional problems. However, a considerable proportion of these high-risk children will escape major impairments, and this variability in outcome is thought to be related to genetic (gender), perinatal (brain injury, bronchopulmonary dysplasia), and social-environmental (social risk, parenting) factors.

Etiologies of hearing impairment among infants and toddlers: 1986-1987 versus 2001

OBJECTIVE

This study compares etiological factors for hearing loss, relevant neuro-sensory impairments and demographics between two groups of children referred for early hearing habilitation in Israel. Group I was referred in the years 1986-1987 (n=73) and group II was referred during 2001 (n=73).

METHODS

Family history, pregnancy, risk factors, developmental milestones, medical history, auditory brainstem response, tympanometry, otoacoustic emissions and behavioral audiometric results were retrospectively retrieved in 2003 from medical records at the MICHA Society for Deaf Children in Israel.

RESULTS

New referrals per year have doubled themselves over the 15 years that elapsed between 1986-1987 and 2001. No changes in gender and age at time of admission were found. The prevalence of mild-to-moderate hearing loss was higher in Group II while severe and profound hearing loss was more prevalent in Group I. Assisted reproductive technologies were involved only in Group II. There were more twin births and post-natal hypoxia in Group II. Rh incompatibility was reported only in Group I. Severe hearing loss was associated with younger age at admission. No significant associations were found between age at admission and etiology with the exception of the fact that children with genetic background were admitted at an earlier age. Since no significant association between genetic background and severity of hearing loss was found, it is conclude that the association between severity of hearing loss and age at admission did not account for changes in etiology in our sample.

CONCLUSIONS

Classic risk factors for hearing loss among infants and toddlers have not changed much over time, and the few changes that have been noticed are probably due to expanded medical knowledge and improved technologies.

Neonatal immune responses to coagulase-negative staphylococci

PURPOSE OF REVIEW

Coagulase-negative staphylococci have emerged as the most common nosocomial pathogen in neonatal intensive care units worldwide. Our understanding of the interactions between coagulase-negative staphylococci and the immune system is incomplete, especially in the newborn. This review summarizes current knowledge on the human immune response to coagulase-negative staphylococci, with particular emphasis on the neonatal innate immune system.

RECENT FINDINGS

There are very limited data on innate immune responses to coagulase-negative staphylococci in neonates. Levels of serum proteins, including transplacental anti-coagulase-negative staphylococci immunoglobulin and complement, correlate with gestational age, and this relative deficiency in preterm infants contributes to their suboptimal opsonization and impaired bacterial killing of coagulase-negative staphylococci. In adults, coagulase-negative staphylococci elicit significant cytokine responses in vitro, which are probably partly mediated by Toll-like receptors, including Toll-like receptor type 2, but these pathways have not been characterized in the high-risk neonatal population.

SUMMARY

The susceptibility of human preterm neonates to coagulase-negative staphylococci relates partly to the immaturity of the neonatal immune response. Strategies to reduce the burden of coagulase-negative staphylococci infections require a thorough understanding of host-pathogen interactions, particularly the engagement of coagulase-negative staphylococci by the neonatal innate immune system.

Preterm infants as young adults: a Swedish national cohort study

OBJECTIVE

Increasing numbers of infants born preterm survive into adulthood. In this study, we analyzed the effect of having been born preterm on disability and vocational success in young adults.

METHODS

A Swedish national cohort of 522,310 infants born in 1973-1979 were followed up for disabilities and income in national registers in 2002 at the age of 23 to 29. Hypotheses were tested in multivariate analysis with logistic regression models on the log scale for dichotomized outcomes and linear regression for continuous variables.

RESULTS

There was a stepwise increase in disability in young adulthood with increasing degree of preterm birth. A total of 13.2% of children born at 24 to 28 weeks' gestation and 5.6% born at 29 to 32 weeks' gestation received economic assistance from society because of handicap or persistent illness, which is equivalent to nearly 4 [corrected] times the risk of those born at term after adjustment for socioeconomic and perinatal confounders. Moderate (33-36 weeks' gestation) and marginal (37-38 weeks' gestation) preterm birth also carried significantly increased risks for disability and were responsible for 74% of the total disability associated with preterm birth. Preterm birth was associated with a lower chance of completing a university education and a lower net salary in a stepwise manner. The total economic gain for Swedish society, in terms of taxes and decreased costs for benefits, if all long-term effects of preterm birth could have been prevented in the birth cohorts in this study, would have amounted to 65 million euros in 2002 alone.

CONCLUSIONS

The majority of adults who were born very preterm lived an independent and self-supportive life. Moderately preterm birth carries a considerable risk for long-term impairment. There are strong economic incentives for secondary prevention of disability associated with preterm birth.

Preterm birth-associated cost of early intervention services: an analysis by gestational age

OBJECTIVES

Characterizing the cost of preterm birth is important in assessing the impact of increasing prematurity rates and evaluating the cost-effectiveness of therapies to prevent preterm delivery. To assess early intervention costs that are associated with preterm births, we estimated the program cost of early intervention services for children who were born in Massachusetts, by gestational age at birth.

METHODS

Using the Pregnancy to Early Life Longitudinal Data Set, birth certificates for infants who were born in Massachusetts between July 1999 and June 2000 were linked to early intervention claims through 2003. We determined total program costs, in 2003 dollars, of early intervention and mean cost per surviving infant by gestational age. Costs by plurality, eligibility criteria, provider discipline, and annual costs for children's first 3 years also were examined.

RESULTS

Overall, 14,033 of 76,901 surviving infants received early intervention services. Program costs totaled almost $66 million, with mean cost per surviving infant of $857. Mean cost per infant was highest for children who were 24 to 31 weeks' gestational age ($5393) and higher for infants who were 32 to 36 weeks' gestational age ($1578) compared with those who were born at term ($725). Cost per surviving infant generally decreased with increasing gestational age. Among children in early intervention, mean cost per child was higher for preterm infants than for term infants. At each gestational age, mean cost per surviving infant was higher for multiples than for singletons, and annual early intervention costs were higher for toddlers than for infants.

CONCLUSIONS

Compared with their term counterparts, preterm infants incurred higher early intervention costs. This information along with data on birth trends will inform budget forecasting for early intervention programs. Costs that are associated with early childhood developmental services must be included when considering the long-term costs of prematurity.

Environmental evaluation of a child with developmental disability

Children's health can be affected adversely by the environment in which they live. It is well recognized that some environmental chemicals are harmful to the brain, but the role these chemicals play in the development of specific disabilities such as attention deficit hyperactivity disorder and autism is not certain. Parents of children who have developmental disabilities often ask the primary care physician whether certain environmental toxicants might be the cause of the illness. A detailed environmental history and physical examination may help clarify whether there is a plausible relationship between an environmental toxicant and a child's disability.

A Long-term, epidemiological survey of outcome and adjustment of children with developmental disabilities

The medical, educational, and psychosocial outcomes of 3224 subjects (age range, 7-33 years; mean age, 20.06 years; SD, 5.74) diagnosed and treated in the Institute for Child Development in Tel Aviv between the years 1975 and 1994 were assessed by a telephone interview. Results indicate that only 9% of the subjects are seriously disabled, and 8% are mentally retarded. Over the years, subjects were referred to the Child Development Center at an increasingly younger age, probably reflecting greater professional and parental awareness of the importance of early intervention. The nature of interventions changed, so that physiotherapy, occupational therapy, and psychological guidance were more often provided. While more children were referred to special education at kindergarten, the percentage of those graduating from regular schools has increased. Most completed 12 years of schooling and successfully acquired full or partial matriculation certificates. As adults, most function independently; fulfill civic obligations, such as their army service; are fully employed; and express satisfaction with their life. These results suggest that children with developmental disabilities who receive early intervention are likely to be functionally independent and to be satisfied with their lives, although they continue to need medical services and require some government support. Further studies are essential to examine the correlation of specific risk factors and early interventions with outcome.

Are newborns morally different from older children?

Policies and position statements regarding decision-making for extremely premature babies exist in many countries and are often directive, focusing on parental choice and expected outcomes. These recommendations often state survival and handicap as reasons for optional intervention. The fact that such outcome statistics would not justify such approaches in other populations suggests that some other powerful factors are at work. The value of neonatal intensive care has been scrutinized far more than intensive care for older patients and suggests that neonatal care is held to a higher standard of justification. The relative value placed on the life of newborns, in particular the preterm, is less than expected by any objective medical data or any prevailing moral frameworks about the value of individual lives. Why do we feel less obligated to treat the premature baby? Do we put newborns in a special and lesser moral category? We explore this question from a legal and ethical perspective and offer several hypotheses pertaining to personhood, reproductive choices, "precious children," and probable evolutionary and anthropological factors.

Electrical potential difference across the nasal epithelium is reduced in premature infants with chronic lung disease but is not associated with lower airway inflammation

Airway liquid content and insufficient absorptive airway ion transport at birth are potentially important factors in the development and severity of neonatal respiratory disease. The role of deficient absorptive airway ion transport in the development of chronic lung disease of prematurity is unknown. Additionally, lung inflammatory mediators modulate airway ion transport. Their effect on preterm lung ion transport and absorptive capacity is not established. We performed serial nasal potential difference studies and broncho-alveolar lavage in preterm infants born less than 30 wk postmenstrual age over the first four postnatal weeks. Our study aims were to: 1) compare nasal potential difference between preterm infants developing chronic lung disease and babies of similar gestation who do not; and 2) examine for an association between airway inflammation and ion transport parameters. We found that potential difference across the nasal epithelium increased with gestation, remained low and unchanged in infants developing chronic lung disease over the first four postnatal weeks, was significantly lower at four weeks in chronic lung disease infants, and was not associated with lower airway inflammation at any time point. We conclude that infants with chronic lung disease postnatally have a persistently reduced absorptive airway ion transport capacity.

Birth weight and the risk of testicular cancer: A meta-analysis

The high incidence of testicular cancer in young males indicates a potential role of events during early life. Birth weight has been identified as a factor possibly associated with the risk of cancers later in life. To investigate the association between birth weight and testicular cancer, we conducted a Systematic Review and Meta-Analysis of published studies investigating the association between birth weight and testicular cancer. Data were combined using a fixed-effects model. Thirteen epidemiologic studies, published between 1983 and 2004, were included in the analysis, encompassing 5,663 patients with testicular cancer. Men weighing less than 2,500 grams at birth had a higher risk for developing testicular cancer later in life than those with normal birth weight (2,500-4,000 g) (OR = 1.18; 95% confidence interval (CI) 1.01-1.38). A similar trend was found for men with a birth weight above 4,000 g, (OR = 1.12; 95% CI 1.02-1.22). When seminoma and nonseminoma testicular cancer cases were considered separately, low birth weight was a risk factor specifically for seminomas (OR = 1.44; 95% CI 1.11-1.88). A U-shaped association was observed between birth weight and the risk for testicular cancer. The underlying biological mechanisms for this phenomenon remain to be elucidated.

Growth in 10- to 12-year-old children born at 23 to 25 weeks' gestation in the 1990s: a Swedish national prospective follow-up study

BACKGROUND

Knowledge of long-term growth of extremely preterm infants in relation to gestational age is incomplete, and there are concerns regarding their poor growth in early childhood. As part of a longitudinal study of a national cohort of infants born at <26 weeks' gestation (extremely immature), growth development from birth to the age of 11 years was examined, and correlates of growth attainment were analyzed.

METHODS

Two hundred forty-seven extremely immature children were born alive from April 1990 through March 1992 in the whole of Sweden, and 89 (36%) survived. Growth and neurosensory outcomes of all extremely immature survivors were evaluated at 36 months of age. Eighty-six (97%) extremely immature children were identified and assessed at 11 years of age. In this growth study, 83 extremely immature infants (mean [SD]: birth weight, 772 g [110 g]; gestational age, 24.6 weeks [0.6 weeks]) without severe motor disability were followed up prospectively from birth to 11 years old and compared with a matched group of 83 children born at term. z scores for weight, height, head circumference, and BMI were computed for all children. We also examined gender-specific longitudinal growth measures. Predictors of 11-year growth were studied by multivariate analyses.

RESULTS

Extremely immature children were significantly smaller in all 3 growth parameters than the controls at 11 years. Extremely immature children showed a sharp decline in weight and height z scores up to 3 months' corrected age, followed by catch-up growth in both weight and height up to 11 years. In contrast to weight and height, extremely immature children did not exhibit catch-up growth in head circumference after the first 6 months of life. The mean BMI z scores increased significantly from 1 to 11 years in both groups. The mean BMI change between 1 and 11 years of age was significantly larger in extremely immature than in control participants. Extremely immature girls showed a faster weight increase than extremely immature boys, whereas catch-up growth in height and head circumference was similar in these groups. Multiple-regression analyses revealed that preterm birth and parental height were significant predictors of 11-year height, and group status (prematurity) correlated strongly with head circumference.

CONCLUSIONS

Children born at the limit of viability attain poor growth in early childhood, followed by catch-up growth to age 11 years, but remain smaller than their term-born peers. Strategies that improve early growth might improve the outcome.

Chronic conditions, functional limitations, and special health care needs in 10- to 12-year-old children born at 23 to 25 weeks' gestation in the 1990s: a Swedish national prospective follow-up study

BACKGROUND

Children born extremely immature (gestational age < 26 weeks' gestation) increasingly reach school age. Information on their overall functioning and special health care needs is necessary to plan for their medical and educational services. This study was undertaken to examine neurosensory, medical, and developmental conditions together with functional limitations and special health care needs of extremely immature children compared with control subjects born at term.

METHODS

We studied 11-year-old children born before 26 completed weeks of gestation in all of Sweden from 1990 through 1992. All had been evaluated at 36 months' corrected age. Identification of children with chronic conditions lasting > or = 12 months was based on a questionnaire administered to parents. Neurosensory impairments were identified by reviewing health records. Information regarding other specific medical diagnoses and developmental disabilities was obtained by standard parent and teacher questionnaires.

RESULTS

Of 89 eligible children, 86 (97%) were studied at a mean age of 11 years. An equal number of children born at term served as controls. Logistic-regression analyses adjusting for social risk factors and gender showed that significantly more extremely immature children than controls had chronic conditions, including functional limitations (64% vs 11%, respectively), compensatory dependency needs (59% vs 25%), and services above those routinely required by children (67% vs 22%). Specific diagnoses or disabilities with higher rates in extremely immature children than in controls included neurosensory impairment (15% vs 2%), asthma (20% vs 6%), poor motor skills of > 2 SDs above the mean (26% vs 3%), poor visual perception of > 2 SDs above the mean (21% vs 4%), poor learning skills of > 2 SDs above the mean (27% vs 3%), poor adaptive functioning with T scores of < 40 (42% vs 9%), and poor academic performance with T score < 40 (49% vs 7%).

CONCLUSIONS

Children born extremely immature have significantly greater health problems and special health care needs at 11 years of age. However, few children have severe impairments that curtail major activities of daily living.

Challenges in design and transition to a private room model in the neonatal intensive care unit

As the need for neonatal intensive care units (NICU) continues to increase, a growing body of evidence on the developmentally appropriate healing environment for neonates suggests that changes are needed in NICU design. The private room NICU model is emerging as an alternative to large multi-bed wards; however, some have suggested that such a radical design change may be difficult to implement. This article presents the experience of one unit in the design and transition from a traditional setting to the private room model. Using change theory, this model was developed with staff input throughout the entire design and implementation process, resulting in a successful transition, as suggested by preliminary data on patient outcomes, family experiences, and nursing staff satisfaction.

Parental authority, patient's best interest and refusal of resuscitation at borderline gestational age

Potential conflict exists when parents refuse a medical intervention for their child that the physician feels obligated to provide. For the anticipated delivery of a preterm newborn, this conflict might exist if the parents refuse resuscitation. At borderline viability, most neonatologists are likely to respect the parents' wishes. However, there will be some gestational age threshold above which the physician will feel compelled to resuscitate despite parental refusal, and will be ethically justified in doing so. The location of that threshold should be determined by the application of sound ethical reasoning, rather than relying on habit or arbitrary standards. That reasoning should include an honest assessment of the benefits and burdens to the child, short-term and long-term, of attempted resuscitation, made in light of relevant mortality and morbidity data. However, a rational analysis will also require consideration of whether the patient's best interest standard should be strictly applied, or whether the interests of others, such as family members, should also be taken into account.

Quantitative ultrasound assessment of the rat cervix

OBJECTIVE

The purpose of this research was to detect cervical ripening with a new quantitative ultrasound technique.

METHODS

Cervices of 13 nonpregnant and 65 timed pregnant (days 15, 17, 19, 20, and 21 of pregnancy) Sprague Dawley rats were scanned ex vivo with a 70-MHz ultrasound transducer. Ultrasound scatterer property estimates (scatterer diameter [SD], acoustic concentration [AC], and scatterer strength factor [SSF]) from the cervices were quantified and then compared to hydroxyproline and water content. Insertion loss (attenuation) was measured in 3 rats in each of the 6 groups. Discriminant analysis was used to predict gestational age group (cervical ripening) from the ultrasound variables SD, SSF, and AC.

RESULTS

Differences were observed between the groups (SD, AC, and SSF; P < .0001). Quantitative ultrasound measures changed as the cervix ripened: (1) SD increased from days 15 to 21; (2) AC decreased from days 15 to 21; and (3) SSF was the greatest in the nonpregnant group and the least in the day 21 group. Cervix hydroxyproline content increased as pregnancy progressed (P < .003) and correlated with group, SD, AC, and SSF (P < .001). Discriminant analysis of ultrasound variables predicted 56.4% of gestational group assignment (P < .001) and increased to 77% within 2 days of the predicted analysis. Cervix insertion loss was greatest for the nonpregnant group and least for the day 21 group.

CONCLUSIONS

Quantitative ultrasound predicted cervical ripening in the rat cervix, but before use in humans, quantitative ultrasound will need to predict gestational age in the later days of gestation with more precision.

Morbidity and mortality of infants born at the threshold of viability: ten years' experience in a single neonatal intensive care unit, 1991-2000

BACKGROUND

The purpose of the present paper was to evaluate the mortality and morbidity of infants born at 22-24 weeks gestation.

METHODS

A total of 78 infants born at 22-24 weeks gestation, who were admitted between January 1991 through December 2000, were retrospectively studied.

RESULTS

Seventy-one of 78 infants were enrolled in the present study. One year survival rates at 22, 23 and 24 weeks were 40.0% (2/5), 61.1% (11/18), and 50.0% (24/48), respectively. Failure of response to surfactant and air leak were associated with death in infants born at 23 weeks gestation. Low Apgar score, intraventricular hemorrhage (> or =III), and sepsis were correlated with death in infants born at 24 weeks gestation. The handicap rates of survivors born at 22, 23, and 24 weeks gestation were 100, 36.4, and 26.1%, respectively.

CONCLUSIONS

The present study indicates that infants born at 22 weeks gestation, in whom pulmonary structure is established, that is, a viable lung that can exchange gas with exogenous surfactant, have a chance to survive, but neurological outcome is still poor. Every possible effort should be made to extend gestation beyond 22 weeks.

Artificial reproduction technologies (RTs) - all the way to the artificial womb?

In this paper, I argue that the development of an artificial womb is already well on its way. By putting together pieces of information arising from new scientific advances in different areas, (neo-natal care, gynecology, embryology, the human genome project and computer science), I delineate a distinctive picture, which clearly suggests that the artificial womb may become a reality sooner than we may think. Currently, there is a huge gap between the first stages of gestation (using in vitro fertilization) and the 22nd week (inside the womb). At the present time this gap seems an insurmountable barrier for fully developing a fetus outside a natural womb - a notion better known as ectogenesis. The history of science however, suggests that impenetrable barriers are such only temporarily. It is just a matter of time (and due research) until someone - intentionally or by chance - accesses the right answer and finds a way to overcome existing obstacles. Despite misgivings that the case of the artificial womb presents too many barriers, it would be naive to suppose things would happen any differently. I observe in this paper, that it is time to acknowledge the consequences of new developments in different areas of scientific research which are leading to the advent of an artificial womb; and I modestly suggest that we might initiate a discussion on this topic now, while we have still enough time to decide what we may want and why.

Physicians' refusal to resuscitate at borderline gestational age

Most neonatologists believe there is a minimal gestational age, below which it is appropriate to refuse to provide resuscitation or intensive care. Determination of this threshold should involve knowledge of the outcome data, but also an understanding of the potential for misuse of these data. In particular, there is a risk of deception, of the parents and of ourselves, due to the uncertainty of the true gestational age, and the "self-fulfilling prophecy" that may occur when a center refuses to try below a certain gestational age because they have had no survivors below that age. Finally, any refusal to treat requires ethical justification. Concepts such as futility and patient's best interest should play a role in the determination of the gestational age threshold, applied in light of the data's inherent weaknesses.

The legal landscape at the threshold of viability for extremely premature infants: a nursing perspective, part II

This is the second of a 2-part article exploring the legal landscape overlying the difficult decisions that can confront a family with an extremely premature infant at the threshold of viability. In Part I, recent legal regulations and litigation were analyzed to show that the baby doe regulations are largely inert and that recent litigation arises out of state laws and regulations. Part II takes up the analysis to show that the common thread through all these conflicts, and the subsequent litigation, is a failure to obtain parental consent for the course of treatment at issue. The author argues that the central focus of all parties seeking to minimize legal risks in these situations must be on creating a transparent decision-making process that includes the parents from the onset. Nurses play a pivotal role in that process and are supported broadly by the professional guidelines of the American Nurses Association, the Association of Women's Health Obstetric and Neonatal Nurses, the National Association of Neonatal Nurses, the American Academy of Pediatrics, and the Principles of Family-Centered Neonatal Care.

Caregiver--child interaction in infants and toddlers born extremely premature

Infants born extremely premature are increasing in incidence and survival rates. This longitudinal study examined caregiver-child interaction in a new generation of extremely premature infants. Caregiver-child interaction and child developmental status were assessed in 41 primary caregivers and their infants at three periods (9-13 and 21-25 months adjusted age and 33-36 months chronological age). Caregiver interaction was stable over the three ages and significantly lower than cross-sectional comparison samples randomized from the Nursing Child Assessment Satellite Training computer database. Caregiver interaction was related to later child interaction but not developmental status. Implications for intervention and developmental surveillance are discussed.

Effectiveness of an intervention to improve parent-professional collaboration in neonatal intensive care

OBJECTIVE

This study tested the effect of an intervention to strengthen parent-professional collaboration by increasing the accuracy of parents' understanding of medically relevant information and providing parent-professional meetings to plan infants' care.

METHODS

A tri-ethnic sample of mothers of 154 very-low-birth-weight infants participated, with parents of 77 infants in a control group and parents of 77 infants in an intervention group. Comprehension of infant medical condition and satisfaction with collaboration in treatment decisions in the 2 groups were measured 3 times during the first 28 days after admission using 9 collaboration scales. Intervention effects were analyzed with ANOVA and ANCOVA.

RESULTS AND CONCLUSIONS

Statistically significant change was found in 6 of 9 scales used to measure collaboration and accuracy of parents' understanding. The intervention group had fewer unrealistic concerns (P = .018), and less uncertainty about infant medical conditions (P = .003); less decision conflict (P < or = .001), more satisfaction with the process by which medical decisions were made (P = .012) and with the amount of decision input they had (P = .058), and reported more shared decision making with professionals (P = .010). There were no statistically significant differences between the groups in satisfaction with infants' care, satisfaction with relationships with physicians and nurses, and satisfaction with the decisions made for their infants' treatment. Infant birth weight and gestational age and maternal demographic characteristics were found to influence collaboration results. The intervention was especially effective in improving understanding and collaboration in low-income, young, minority mothers.

Morbilidad a los dos años de edad en niños con un peso al nacimiento menor de 1.500 g

OBJECTIVES

To determine morbidity at 2 years' corrected age in a cohort of neonates with a birth weight of less than 1,500 g born in 1999-2000 in a tertiary hospital in the Autonomous Community of Madrid.

PATIENTS AND METHODS

An observational longitudinal follow-up study was performed in a cohort of 213 infants with a birth weight of < 1,500 g. Of these, 188 (87%) completed the 2-year follow-up. Various types of neurosensorial disability were studied, paying special attention to the main impairments: vision, hearing and motor impairment, and low development quotient.

RESULTS

Among the patients initially included in the study, 87% completed the follow-up; 17.1% had one or more major sequela. We found one case (0.4%) of bilateral neurosensorial deafness and one case of bilateral blindness. At the age of 2 years, 5.8 % (11/188) had cerebral palsy, 14.9% had a development quotient below 85 and 18% had not reached the 3rd percentile for weight. Factors of poor neurological prognosis were subnormal head size at the age of 2 years and white matter disease (including persistent intraparenchymal periventricular echodensity and ventriculomegaly or irregular shape) as ultrasound findings.

CONCLUSIONS

Less than a fifth of the very low birth weight infants presented severe sequelae at 2 years of follow-up. Factors of poor neurological prognosis were subnormal head size at 2 years and the presence of white matter disease on ultrasonography. The findings on growth and development were worrying, since 18 % of the patients had not reached the 3rd percentile for weight at 2 years' corrected age.

Ensuring accurate knowledge of prematurity outcomes for prenatal counseling

OBJECTIVES

To determine the accuracy of knowledge of different health care providers regarding survival and long-term morbidity rates for very premature infants and to examine whether a focused educational intervention improves the accuracy of this knowledge and influences health care decisions.

METHODS

Using hypothetical case scenarios with infants at < or =28 weeks of gestation, we surveyed a variety of caregivers involved in perinatal communication and decision-making processes at a tertiary center that provides intensive care for neonates. We asked physicians from the pediatrics and obstetrics services and nurses and nurse practitioners from the NICU and obstetrics ward for their best estimates of survival and major long-term disability rates and for their opinions regarding the appropriateness of resuscitation and life support at each week of gestation of <29 weeks. After the survey, we educated all providers about current data on survival and long-term disability rates for preterm infants and gave them pocket-sized cards summarizing this information for reference during prenatal counseling. One month after the educational intervention and complete dissemination of the cards, a questionnaire with questions identical to those in the first survey was mailed to the same individuals.

RESULTS

Fifty-one health care providers were involved in the baseline survey. The response rates for the postintervention survey were 100% for physicians (20 of 20 subjects) and nurses (20 of 20 subjects) and 91% (10 of 11 subjects) for the nurse practitioners. In the baseline survey, statistically significant underestimates of survival rates were seen for physicians and nurses at 23 to 28 weeks of gestation and for nurse practitioners at 23 to 27 weeks of gestation. Statistically significant overestimates of disability rates were seen for physicians and nurse practitioners at < or =26 weeks of gestation and for nurses at < or =28 weeks of gestation. After the intervention, respondents demonstrated significant improvements in the accuracy of survival and disability estimates at many, but not all, gestational ages. Although underestimation of survival rates and overestimation of disability rates decreased after the intervention, it persisted to some degree. After the intervention, a larger proportion of physicians (53% vs 21%) and a smaller proportion of nurses (10% vs 37%) were likely to recommend resuscitation for infants born at 23 weeks of gestation.

CONCLUSIONS

Physicians, nurses, and nurse practitioners underestimated survival rates and overestimated long-term disability rates for very premature infants. After education, their estimates of survival and long-term disability rates for these infants improved significantly. More accurate estimates of survival and disability rates affected physicians' and nurses' theoretical decision-making regarding the appropriateness of resuscitation at 23 weeks of gestation.

Changes in mortality and morbidities among infants born at less than 25 weeks during the post-surfactant era

OBJECTIVES

To compare mortality and death or major morbidity (DOMM) among infants <25 weeks estimated gestational age (EGA) born during two post-surfactant era time periods.

STUDY DESIGN AND PATIENTS

Comparative cohort study of very low birthweight (501-1500 g) infants <25 weeks EGA in the NICHD Neonatal Research Network born during two post-surfactant era time periods (group I, 1991-1994, n=1408; group II, 1995-1998, n=1348). Perinatal and neonatal factors were compared, and group related mortality and DOMM risk were evaluated.

RESULTS

Mortality was higher for group I (63.1% v 56.7%; p=0.0006). Antenatal steroids (ANS) and antenatal antibiotics (AABX), surfactant (p<0.0001), and bronchopulmonary dysplasia (p=0.0008) were more prevalent in group II. In a regression model that controlled for basic and delivery factors only, mortality risk was greater for group I than for group II (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2 to 1.7); the addition of AABX and surfactant, or ANS (OR 0.97, 95% CI 0.79 to 1.2) to the model appeared to account for this difference. There was no difference in DOMM (86.8% v 88.4%; p=0.2), but risk was lower for group I in regression models that included ANS (OR 0.70, 95% CI 0.52 to 0.94).

CONCLUSION

Survival to discharge was more likely during the more recent period because of group differences in ANS, AABX, and surfactant. However, this treatment shift may reflect an overall more aggressive management approach. More consistent application of treatment has led to improving survival of <25 week EGA infants during the post-surfactant era, but possibly at the cost of greater risk of major in-hospital morbidities.

Combination therapy

OBJECTIVE

Inhibiting preterm labour at extremely early gestations.

DESIGN

Observational study. Case reports.

SETTING

Perinatal Centre Lund University Hospital, South Sweden.

POPULATION

Twenty-five women (13 cases with intact membranes and 12 cases with ruptured) with threatened preterm labour and advanced cervical status before 26 completed weeks of gestation.

METHODS

A combination of different drugs was used. Atosiban, an oxytocin antagonist, was the first line drug and was given as an infusion for several days as required. Supportive therapy was also given to most women with subcutaneous injections of the beta-receptor agonist terbutaline (0.25 mg up to six times a day); sulindac, a prostaglandin synthetase inhibitor (200 mg one to two times a day up to a week); and broad-spectrum antibiotics (metronidazole and cefuroxime intravenously for three days and thereafter oral therapy).

MAIN OUTCOME MEASURES

Prolongation of pregnancy more than 48 hours or 7 days. Neonatal survival.

RESULTS

Prolongation of pregnancy for more than 48 hours to enable administration of corticosteroid therapy was obtained in all but three cases. Eight women were delivered after more than a week from admission. Three neonates died at birth due to obstetric complication or sepsis. The other neonates had normal pH in cord or venous blood at birth. No severe side effects were recorded and in no case did the treatment have to be discontinued due to side effects.

CONCLUSION

The policy described here is not evidence based, relating only to clinical observations, and as such is of very limited value. However, it seems that with this combined approach to management, some days can be gained by achieving full effect of corticosteroid treatment and prolongation of the pregnancy, hopefully reducing time in the neonatal intensive care in these critical cases. No severe side effects were reported.

International patterns and trends in testis cancer incidence

Although the incidence of testis cancer has risen markedly in many Western populations over the past half-century, it is not clear whether rates in other populations also have increased. To clarify this issue, we examined testis cancer incidence rates over the 25-year time period of 1973-1997 for selected populations around the world. Age-standardized incidence rates for 21 registries in the Americas, Asia, Europe and Oceania over successive 5-year time periods were obtained from volumes 4-8 of Cancer Incidence in Five Continents. Testis cancer rates rose between 1973 and 1997 in most populations worldwide, although the increases were strongest and most consistent among populations of European ancestry. Rates appear to be leveling off in some populations. The increases in testis cancer remain unexplained, although changes in the prevalence of important risk factors for this disease may be responsible.

Neonatal intensive care at borderline viability--is it worth it?

BACKGROUND

Very preterm infants at the borderline of viability, especially those <25 weeks of gestational age, have survived in increasing numbers in recent years, but concerns persist about their long-term outcome and their consumption of scarce hospital resources.

AIMS

To determine incremental changes in long-term outcome and consumption of resources by very preterm infants in the 1990s.

DESIGN

Cohort study.

PATIENTS

Consecutive livebirths with gestational ages 23-27 weeks born in the state of Victoria in two discrete eras, 1991-1992 (n=401) and 1997 (n=208), and randomly selected contemporaneous normal birthweight (NBW, birthweight >2499 g) controls (1991-1992 n=265, 1997 n=198).

MAIN OUTCOME MEASURES

Survival, and neurosensory impairments, disabilities and utilities, and consumption of hospital resources to 2 years of age.

RESULTS

Compared with 1991-1992, in 1997 more infants were offered intensive care and the survival rate was higher at each week of gestation, and overall (absolute increase in survival 16%; 95% confidence interval, 8%, 24%). The largest increases in the survival and quality-adjusted survival rates were in infants at 23 weeks (31% and 20%, respectively). The incremental resource costs of improving survival and quality-adjusted survival were similar in infants of 23-24 weeks compared with those of 25-27 weeks (e.g., 112 vs. 105 days of assisted ventilation per additional survivor, or 167 vs. 180 days of assisted ventilation per additional quality-adjusted survivor, respectively).

CONCLUSIONS

Increased intensive care in the late 1990s for infants at the borderline of viability was associated with improved outcomes, at incremental costs that were not excessive compared with slightly more mature infants.

Handicap neuro-sensoriel grave de l’enfant grand prématuré

OBJECTIVE

Advances in perinatal care have resulted in a sharply increasing survival rate among very preterm infants. However, there is some concern about the later neurodevelopmental outcome of those infants who survive. In this paper, we review the prevalence estimates of motor (cerebral palsy), sensorineural and cognitive impairments and their recent time-trends in very preterm infants.

METHOD

A review of studies describing neurodevelopmental outcome of very preterm infants in Europe, Australia and America North.

RESULTS

The gestational age-specific prevalences of cerebral palsy (CP) were 72-86 for extremely preterm children (<28 weeks), 32-60 for very preterm (28-31 weeks) and 5-6 for moderate preterm (32-36 weeks), and 1.3-1.5 for term children per 1000. The live birth prevalence for CP remained unchanged in extremely and very preterm infants since 1990. The prevalence estimates of moderate and severe cognitive impairments are 15 to 25% in very preterm children. Less than 4% of very preterm infants develop severe hearing or visual loss.

CONCLUSION

This review indicates that very preterm infants have high risk of disability. Most studies have been conducted between 1985 and 1995. Thus, these results should be interpreted with caution before generalisation to recent cohorts.

Predicting outcome in ex-premature infants supported with extracorporeal membrane oxygenation for acute hypoxic respiratory failure

OBJECTIVE

To identify predictors of outcome in ex-premature infants supported with extracorporeal membrane oxygenation (ECMO) for acute hypoxic respiratory failure.

METHODS

Retrospective review of ex-premature infants with acquired acute hypoxic respiratory failure requiring ECMO support in the United Kingdom from 1992 to 2001. Review of follow up questionnaires completed by general practitioners and local paediatricians.

RESULTS

Sixty four ex-premature infants (5-10 each year) received ECMO support, despite increased use of advanced conventional treatments over the decade. The most common infective agent was respiratory syncytial virus (85% of cases). Median birth gestation was 29 weeks and median corrected age at the time of ECMO support was 42 weeks. Median ECMO support duration was relatively long, at 229 hours. Survival to hospital discharge and to 6 months was 80%, remaining similar throughout the period of review. At follow up, 60% had long term neurodisability and 79% had chronic pulmonary problems. Of pre-ECMO factors, baseline oxygen dependence, younger age, and inpatient status were associated with non-survival (p < or = 0.05). Of ECMO related factors, patient complications were independently associated with adverse neurodevelopmental outcome and death (p < 0.01).

CONCLUSIONS

Survival rates for ex-premature infants after ECMO support are favourable, but patients suffer a high burden of morbidity during intensive care and over the long term. At the time of ECMO referral, baseline oxygen dependence is the most important predictor of death, but no combination of the factors considered was associated with a mortality that would preclude ECMO support.

Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal management strategies

OBJECTIVE

There is a need for evidence-based knowledge regarding perinatal management in extreme prematurity. The benefit of a proactive attitude versus a more selective one is controversial. The objective of the present study was to analyze perinatal practices and infant outcome in extreme prematurity in relation to different management policies in the North (proactive) and South of Sweden.

METHODS

A population-based, retrospective, cohort study design was used. Data in the Swedish Medical Birth Register (MBR) from 1985 to 1999 were analyzed according to region of birth and gestational age (22 weeks + 0 days to 27 weeks + 6 days). A total of 3 602 live-born infants were included (North = 1040, South = 2562). Survival was defined as being alive at 1 year. Morbidity in survivors, based on discharge diagnoses of major morbidity during the first year of life, was described by linking the MBR to the Hospital Discharge Register.

RESULTS

In infants with a gestational age of 22 to 25 weeks, the proactive policy was significantly associated with 1) increased incidence of live births, 2) higher degree of centralized management, 3) higher frequency of caesarean section, 4) fewer infants with low Apgar score (<4) at 1 and 5 minutes, 5) fewer infants dead within 24 hours, and 6) increased number of infants alive at 1 year. There were no indications of increased morbidity in survivors of the proactive management during the first year of life, and the proportion of survivors without denoted morbidity was larger.

CONCLUSION

In infants with a gestational age of 22 to 25 weeks, a proactive perinatal strategy increases the number of live births and improves the infant's postnatal condition and survival without evidence of increasing morbidity in survivors up to 1 year of age.

Fetal infants: the fate of 4172 infants with birth weights of 401 to 500 grams--the Vermont Oxford Network experience (1996-2000)

OBJECTIVE

Improvement in the survival of extremely low birth weight infants requires that we evaluate the limits of our care and assess the impact of treatment on a population of infants who previously rarely survived.

METHODS

A review was conducted of demographic and clinical data of infants who had birth weight 401 to 500 g and were entered in the Vermont Oxford Network Database between 1996 and 2000.

RESULTS

A total of 4172 infants who weighed 401-500 g (mean gestational age: 23.3 +/- 2.1 weeks) were born at 346 participating centers. Overall, 17% survived until discharge. A total of 2186 (52%) died in the delivery room (DR), and 1986 (48%) were admitted to a neonatal intensive care unit (NICU). Compared with infants who died in the DR, infants who survived the DR and were admitted to the NICU were more likely to be female (58% vs 49%), to be small for gestational age (56% vs 11%), to have received prenatal steroids (61% vs 12%), and to have been delivered by cesarean section (55% vs 5%). Thirty-six percent of NICU admissions survived to discharge. Mean gestational age of the 690 NICU survivors was 25.3 +/- 2.0 weeks. These survivors experienced significant morbidity in the NICU.

CONCLUSIONS

An appreciable number of these marginally viable fetal infants survive. They experienced a high rate of serious morbidities while in the NICU. There is very little information about long-term outcomes, as the medical and developmental status of few of these infants has been followed carefully. Parents should be made aware of the high incidence of serious problems, and concerted efforts should be made to follow the status of these infants.

Preterm delivery, level of care, and infant death in sweden: a population-based study

OBJECTIVE

To elucidate the role of level of care in combination with other perinatal risk factors for infant death in very preterm deliveries.

DESIGN

Population-based cohort study.

SETTING

Sweden, 1992-1998.

SUBJECTS

Singleton infants (2285) born at 24 to 31 completed weeks of gestation to primiparous women.

MAIN OUTCOME MEASURE

Infant mortality.

RESULTS

The rate of infant mortality increased from 5% among infants born at 31 weeks' gestation to 56% among infants born at 24 weeks' gestation. Compared with infants born at university hospitals, the unadjusted odds ratio (OR) of infant death was 0.70 (95% confidence interval [CI]: 0.54-0.90) among infants delivered at general hospitals. However, after adjustment, the OR of infant death shifted to 1.33 (95% CI: 0.88-2.02) for preterm births at general hospitals. This shift was primarily due to different gestational age distributions in regional and general hospitals. Among infants born at 24 to 27 weeks' gestation, infant mortality rates were 23% (87 deaths) in university hospitals and 32% (73 deaths) in general hospitals, giving an adjusted OR of 2.00 for general versus university hospitals (95% CI: 1.15-3.49). The risk of death at 24 to 27 weeks' gestation in general hospitals was increased specifically in pregnancies with placental complications.

CONCLUSION

Taking obstetric complications into account, there is an excess mortality risk among extremely preterm infants born at general hospitals.

Nutrition et dysplasie bronchopulmonaire

Bronchopulmonary dysplasia remains a frequent complication of extreme prematurity. In preterm neonates catch-up and pulmonary alveolar growth occur during the first two years of life. However 10 to 25% of preterm infants with bronchopulmonary dysplasia are under-nourished after two years of age, and 30 to 60% of them also suffer from persistent airway obstruction, hyperinflation and bronchial hyperreactivity. Recommendations on nutritional requirements in this population are not yet clearly defined, but an adequate nutritional status in prenatal and early postnatal period can have long-term consequences on brain and lung development. There are a few randomised trial of nutrition for preterm infants with bronchopulmonary dysplasia after discharge. Caloric and protein requirements in this population are probably higher than in full-term infants. Moreover there are potential benefits in using specific nutrients: supplementation with long chain polyunsaturated fatty acids could decrease lung inflammation injuries, glutamine is the main source of energy of pneumocyte, vitamin A is essential for lung development, inositol is necessary for surfactant synthesis, vitamin E and selenium have anti-oxidant effects. Controlled nutritional trial are needed with a long term follow-up in late childhood in order to test their effects on growth and pulmonary status.

Management decisions in extremely premature infants

Survival rates in excess of 25% at 23 weeks' gestation and in excess of 50% at 24 weeks' gestation have been reported among live births in the 1990s within tertiary perinatal care centres in the USA and Australia. Decisions about medical management at these gestational ages can no longer be based merely on whether survival is possible. Relevant moral considerations include the primacy of the newborn's best interests, parental autonomy, physicians' duties of beneficence and non-maleficence, and distributive justice. There is significant variability between developed nations in the survival of extremely premature infants among cohorts born within perinatal tertiary care centres. This is, at least to some degree, the result of differences in the aggressiveness of obstetrical and neonatal management at these gestational ages. There is also great variability in the prevalence of major neurodevelopmental disability among survivors. Moreover, the prevalence of major disabilities does not inform quality-of-life considerations adequately. Despite similar gestational age ranges over which the benefit:burden ratio of aggressive obstetric and neonatal care is questioned in developed countries, there is marked variation in the frequency with which it is provided within these ranges. This is understandable given the relevant moral values and the different ways in which competing values will be balanced by different individuals, cultures and societies; the increasing survival of extremely premature infants, but the persistence of high (but widely variable) prevalences of major disabilities reported among survivors and even higher prevalences of mild-to-moderate neurodevelopmental sequelae; our imperfect ability to estimate an individual extremely premature infant's prognosis; and the complexities of estimating the quality of life from the individual's own perspective.

Chronic lung disease in infancy following prematurity

Survival of extremely preterm infants has improved with modern neonatal intensive care. Chronic lung disease of prematurity, however, remains an important clinical problem and this article reviews the changing presentation and discusses new concepts of its aetiology.

Learning disability

Learning disability is common, affecting 1-2.5% of the general population in the Western world, and encompasses many different conditions. It usually leads to major functional impairment and lifelong need for support and interventions, not the least important of which are medical and health-care services. Rapid progress is being made in the understanding of the cause and pathogenesis of many learning disability syndromes, and these advances are likely to improve targeted interventions in the next decade. Many countries have abolished a learning disability specialty for medical professionals, but there is a great need to revive this niche of medical knowledge. We know little about quality of life and effects on families of people with learning disability, and research is needed to address these issues.

Defining the nature of the cerebral abnormalities in the premature infant: a qualitative magnetic resonance imaging study

OBJECTIVES

The aim of this study was to define qualitatively the nature and extent of white and gray matter abnormalities in a longitudinal population-based study of infants with very low birth weight. Perinatal factors were then related to the presence and severity of magnetic resonance imaging (MRI) abnormalities.

METHODS

From November 1998 to December 2000, 100 consecutive premature infants admitted to the neonatal intensive care unit at Christchurch Women's Hospital were recruited (98% eligible) after informed parental consent to undergo an MRI scan at term equivalent. The scans were analyzed by a single neuroradiologist experienced in pediatric MRI, with a second independent scoring of the MRI using a combination of criteria for white matter (cysts, signal abnormality, loss of volume, ventriculomegaly, corpus callosal thinning, myelination) and gray matter (gray matter signal abnormality, gyration, subarachnoid space). Results were analyzed against individual item scores as well as the presence of moderate-severe white matter score, total gray matter score, and total brain score.

RESULTS

The mean gestational age was 27.9+/-2.4 weeks (range, 23-32 weeks), and mean birth weight was 1063+/-292 g. The greatest univariate predictors for moderate-severe white matter abnormality were lower gestational age (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.7; P<.01), maternal fever (OR, 2.2; 95% CI, 1.1-4.6; P<.04), proven sepsis in the infant at delivery (OR, 1.8; 95% CI, 1.1-3.6; P=0.03), inotropic support (OR, 2.7; 95% CI, 1.5-4.5; P<.001), patent ductus arteriosus (OR, 2.2; 95% CI, 1.2-3.8; P=.01), grade III/IV intraventricular hemorrhage (P=.015), and the occurrence of a pneumothorax (P=.05). There was a significant protective effect of intrauterine growth restriction (OR, 0.51; 95% CI, 0.23-0.99; P=.04). Gray matter abnormality was highly related to the presence and severity of white matter abnormality. A unique pattern of cerebral abnormality consisting of significant diffuse white matter atrophy, ventriculomegaly, immature gyral development, and enlarged subarachnoid space was found in 10 of 11 infants with birth gestation <26 weeks. Given the later outcome of these infants, this pattern may have very high risk for later global neurodevelopmental disability.

CONCLUSIONS

This MRI study confirms a high incidence of cerebral white matter abnormality at term in an unselected population of premature infants, which is predominantly a result of noncystic injury in the extremely immature infant. We confirm that the major perinatal risk factors for white matter abnormality are related to perinatal infection, particularly maternal fever and infant sepsis, and hypotension with inotrope use. We have defined a distinct pattern of diffuse white and gray matter abnormality in the extremely immature infant.

Functional outcome at adolescence for infants less than 801 g birth weight: perceptions of children and parents

OBJECTIVE

To compare functional, emotional, and academic status of adolescents who had been extremely low birth weight (ELBW) with those who were full term.

STUDY DESIGN

Twenty-six adolescents who were born in 1983 to 1984 at less than 801 g birth weight were compared with 26 adolescents born at term. Adolescent-perceived status was assessed using the Behavior Assessment System for Children (BASC-SR) and the Self-Perception Profile. Parents' perceptions were assessed using BASC Parent Report, Family Impact Questionnaire, and Functional Status Measure. Health status was obtained through written requests to primary care providers and parent interviews. Academic and attendance information was obtained through school records.

RESULTS

Compared to the term adolescents, the ELBW group had significantly lower function related to health status, increased need for special education, and tended to score lower on academic performance measures. However, ELBW adolescents' perceptions regarding their scholastic, athletic, or social competencies did not differ from the term group or national normative data. Parents of ELBWs reported lower adaptive skills, but no other behavioral differences from the term group.

CONCLUSION

ELBW survivors and their parents perceived outcome at adolescence positively in spite of evident limitations. Mechanisms that ELBW families use to cope may be important determinants for successful, long-term outcome.

Trends in the incidence of testicular germ cell tumors in the United States

BACKGROUND

Recent reports have suggested that the increasing rates of testicular germ cell tumors in some populations have begun to plateau. This study was conducted to examine whether rates among white men in the United States have begun to stabilize and whether rates among black men in the United States have remained low.

METHODS

Testicular germ cell tumor incidence data from in the Surveillance, Epidemiology, and End Results Program were analyzed for the years 1973-1998. Trends were examined separately for seminoma and nonseminoma. Using age-period-cohort analyses with 5-year age intervals and 5-year calendar-period intervals, changes in the slope of the trends in birth-cohort and calendar-period effects were examined.

RESULTS

Among white men, rates of seminoma continued to increase, but the rate of increase steadily declined throughout the 26-year time span. Nonseminoma rates among whites increased more slowly during the first three time intervals, then plateaued in the final interval. Rates of both seminoma and nonseminoma in black men fluctuated throughout the first three time intervals. In the final interval, the rates of seminoma increased almost 100%, whereas the rates of nonseminoma increased more modestly. Age-period-cohort modeling of the incidence data in white men found that, whereas the dominant effect was that of birth cohort, there also was a period effect.

CONCLUSIONS

Among white men in the United States, the incidence of testicular germ cell tumors varied by histology, with a continuing increase in risk only for seminoma. Among black men in the United States, the surprising increases seen between 1988 and 1998 were likely to be a calendar-period effect.