Perinatal intensive care

Outcome for infants at high risk of major handicap

Perinatal intensive care had been introduced in University College Hospital, London, by 1966. In the succeeding 10 years, 28-day mortality rates fell among infants of birth weight 1500 g or less. Among the survivors, the incidence of major handicap was 10% or less and the mean IQ increased to within the range expected for a normal population. Of the children aged 8 years or more 76% had no handicaps and were attending normal schools; 18% had minor handicaps or problems for which they were receiving extra help in normal schools; and only 6% were attending special schools. Throughout the 10 years of the study, the overall prognosis for these infants of very low birth weight improved significantly. Results among other high-risk groups were equally encouraging. Analysis of variance of the data from the infants who weighed 1500 g or less at birth indicated that perinatal complications, particularly illnesses associated with abnormal neurological signs or acidaemia in the infants around the time of birth, were the principal factors determining the condition of the survivors at follow-up. Thus, it is likely that additional refinements in the management of the perinatal period may result in further improvements in the prognosis of these and other high-risk newborns.

Neonatal intensive care and the prevention of major handicap

During the past 20 years there has been a great increase in the understanding of deranged physiological mechanisms in certain groups of newborn infants that were, in the past, at high risk for death or major handicap. Much information of direct clinical relevance has come from the study of experimental animals, particularly about the changes that occur in the lungs and circulation at birth. Work in progress on an animal model of intraventricular haemorrhage suggests that this, like many other causes of brain damage, is a potentially preventable condition. Technological advances, such as continuous blood-gas analysis, make the prevention of handicapping conditions simpler, but the application of modern methods can be expensive. Current evidence shows that neonatal intensive care saves lives, and that the incidence of major handicap in the survivors is reduced. Society will have to decide how much money should be put into this area of medicine, and it will also have to help neonatal paediatricians with the difficult ethical dilemmas that they are now having to face.

Neurodevelopmental outcome in babies weighing less than 2001 g at birth

From 1976 to 1980, 1034 infants with birth weights of 500-2000 g were cared for in the neonatal medical unit; 724 were discharged. Twenty (2.8%) subsequently died and 654 (90.3%) were followed up at a median age of 3 years 3 months. Fifty five (7.6%) survivors had major neurodevelopmental handicaps not attributable to congenital anomalies. Increasing prevalence of major handicap was found with decreasing birth weight and gestation. Children with birth weights of less than 1251 g had a higher incidence of all major disabilities. Handicapped children with a birth weight less than 1251 g were more likely to have blindness, deafness, multiple disabilities, and more severe cerebral palsy. There were 146 (20.2%) children with minor disabilities: neurological impairments (n = 11), borderline results on psychometric testing (n = 18), visual impairments (n = 52), hearing impairments (n = 40), and speech impairments (n = 71). Children weighing less than 1251 g at birth had a higher incidence of minor visual and hearing impairments. In 389 children the mean Griffiths quotient was 101.6 (SD 17.2) (range 50-147), and 158 children had a mean Wechsler preschool and primary intelligence quotient of 101.8 (13.2) (range 56-127): these quotients did not vary with birth weight or gestation but did vary with socioeconomic group, schooling, and family structure. During the study period an improving prognosis in terms of both survival and handicap was observed in children weighing less than 1251 g at birth.

Obstetric care of the very premature fetus

A group of 27 premature fetuses, between 27 and 35 weeks of gestation, were studied in the fetal intensive care unit. Both late deceleration of fetal heart rate and loss of beta to beat variation were associated with significantly lower Apgar scores. Four of 5 of the very premature fetuses who died of asphyxia soon after birth, showed evidence of asphyxia in the fetal heart rate trace before birth. Because of the improved short- and long-term outlook for the liveborn very premature fetus, active obstetric intervention when intrauterine asphyxia is diagnosed may furthther improve survival rate.