Changes in the delivery room care of the extremely small infant (less than 750 g). Effects on morbidity and outcome

Association between intelligence quotient scores and extremely low birth weight in school-age children

BACKGROUND

Extremely low birth weight (ELBW) has been associated with poor cognitive development in children. We performed this research to establish the association between ELBW and the influence of biological and socioeconomic factors in the intelligence quotient (IQ) score in school-age children.

METHODS

This study comprised 184 children with mean and standard deviation of 6.9 +/- 0.8 years of age. The children were divided into four groups based on their birth weight as follows: group A (n = 25), < or =1000 g; group B (n = 52), 1001-1500 g; group C (n = 66), 1501-2500 g; and group D (n = 41), > or =2501 g. The Stanford-Binet after the Terman-Merril Intelligence Scale was used to determine IQ scores.

RESULTS

Mean and standard deviation (SD) of IQ values were 95.3 +/- 11.3 for group A, 103.1 +/- 14.4 for group B, 105.1 +/- 12.3 for group C, and 106.8 +/- 11.7 for group D (p = 0.003). Frequencies of children with scores below normal distribution were the following: 28% in group A; 10% in group B; 15% in group C, and 5% in group D (chi(2) = 0.04). Bronchopulmonary dysplasia and parental education were associated with lower IQ scores (p <0.05).

CONCLUSIONS

IQ scores of children born with ELBW were significantly lower when compared to children born with a higher birth weight. Additional studies are important to determine whether these neurodevelopmental delays persist into adulthood, and whether there are additional factors associated with catch-up and recovery.

Preschool outcome of less than 801-gram preterm infants compared with full-term siblings

OBJECTIVE

Extremely low birth weight (ELBW) infants are at greater risk for neurodevelopmental delay than full-term infants. Outcomes may be compromised secondary to abnormal brain development associated with complications of prematurity. Long-term cognitive outcome has also been reported to be significantly influenced by postnatal factors. The objective of this study was to clarify the effects of prematurity separate from environmental factors on growth and neurodevelopmental outcomes by comparing ELBW children with their full-term siblings.

METHODS

The study consisted of 25 ELBW children, a subset selected from a larger population of infants who were <801 g birth weight and enrolled in a longitudinal follow-up project from birth and their 25 full-term, full-weight siblings. Twenty-three sets of siblings were evaluated at 5 years of age and 2 sets at 3 years of age with standardized medical, social, cognitive, motor, and language testing. Physical and neurodevelopmental outcomes were compared between groups, controlling for gender and socioeconomic status (SES).

RESULTS

At follow-up, ELBW children were lighter, were shorter, and had smaller head circumference. The ELBW children had lower Stanford-Binet IQs (85 +/- 12 [mean +/- SD] and 95 +/- 11), with lower Stanford-Binet subtests except short-term memory and quantitative reasoning, lower spelling scores on the Wide Range Achievement Test, and lower Peabody motor quotients (79 +/- 11 and 92 +/- 17). Preschool Language Scale quotients were not different, but other receptive language measures were lower for ELBW children. High SES seemed to modify the impact of preterm status on cognitive and language but not motor scores. The mean IQ for high-SES ELBW children was equivalent to that of the low-SES term siblings.

CONCLUSIONS

Preschool-age cognitive and language functioning in ELBW children seemed to be affected by both prenatal and birth influences (preterm status) and postnatal influences (SES variables). Motor scores were significantly related to preterm status but not to SES.

Biology versus environment in the extremely low-birth weight infant

This article examines the role of biologic and environmental factors in determining the long-term outcomes of extremely low-birth weight infants. Research focusing on follow-up to at least 4 years of age is reviewed. Methodologic issues related to sampling, the use of control groups, and diagnostic criteria are also discussed. The use of cumulative models of risk for examining the relative contribution of environmental and biologic factors is presented.

Use of high-technology care among women with high-risk pregnancies in the United States

OBJECTIVE

Infant mortality has been reduced dramatically with the development of perinatal regionalized high-technology care. Our objective was to assess use of high technology care among women with high-risk pregnancies in the urban and rural United States.

METHODS

The 1988 National Maternal and Infant Health Survey was linked to the 1988 American Hospital Association survey of all obstetrical hospitals. Hospitals were classified into five levels of care based on services and staffing. Women were classified as having high-risk pregnancies using two definitions: (1) gestational age < 34 weeks and birthweight < 1500 g (High Risk I) and (2) the first definition or an antenatal high-risk medical diagnoses (High Risk II). Analyses assessed the proportion of high-risk women delivering in appropriate locations in the rural and urban United States and explored how personal characteristics, insurance status, and use and source of prenatal care influenced where high-risk women delivered.

RESULTS

71.2% of High Risk I and 55.9% of High Risk II women delivered in a high-technology facility (Level IIA or III). Fifty percent of HRI rural women delivered in tertiary high-technology hospitals and 39% of HRII rural women delivered in a high-technology hospital. High-risk urban women were two to three times more likely to deliver in a high-technology facility compared to their rural counterparts. The multivariate analysis showed that Black high-risk women were more likely to deliver in a high-technology setting and that receipt of prenatal care in a private setting lowered the odds of delivering in a high-technology setting when other factors were controlled.

CONCLUSIONS

In an era where regionalized perinatal care was not threatened by managed care, a large proportion of high-risk women received care in less than optimal settings. Rural high-risk women delivered in high-technology hospitals less often than their urban counterparts. The multivariate analyses implied that the potential barriers to care may be more important among those considered more socially advantaged, who may be more at the mercy of managed care. The current reimbursement environment, which discourages referral to specialists and high-technology care, could result in less access today.

Favourable neurological outcomes following delivery room cardiopulmonary resuscitation of infants < or = 750 g at birth

OBJECTIVE

To study short- and long-term outcomes of infants < or = 750 g birthweight who received cardiopulmonary resuscitation (CPR) in the delivery room.

METHODOLOGY

A retrospective analysis of all inborn live births < or = 750 g birthweight from 1990 to 1996. Cardiopulmonary resuscitation was defined as positive pressure ventilation via an endotracheal tube and chest compressions. Univeriate analysis were conducted comparing patients according to the use of CPR or positive pressure ventilation alone.

RESULTS

Cardiopulmonary resuscitation was administered to 16 infants: four received chest compressions only and 12 also received adrenaline. Cardiopulmonary resuscitation recipients had significantly lower Apgar scores at both 1 and 5 min, and had delayed onset of spontaneous respiration (P < 0.01). Seven patients died, and eight of nine survivors were free of major neurodevelopmental abnormalities at follow up. All CPR recipients with a 5 min Apgar score of < or = 5 and delayed onset of spontaneous respiration beyond 5 min had poor outcomes.

CONCLUSION

Contrary to the majority of published evidence, delivery room CPR in our extremely small infants was not associated with a high risk of severe neurodevelopmental disability.

Influence of obstetric management on outcome of extremely preterm growth retarded infants

AIM

To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events.

METHODS

A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/2 to 10 1/2 years).

RESULTS

One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age.

CONCLUSIONS

Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

Parents' experience surrounding the death of a newborn whose birth is at the margin of viability

OBJECTIVE

To describe the experience of parents surrounding the death of a newborn weighing less than 500 g at birth.

DESIGN

Descriptive, using an eidetic phenomenologic approach.

SETTING

Interviews were conducted in the parents' homes or by telephone between 4 and 15 weeks after the loss.

PARTICIPANTS

Eight parents (five mothers and three of their husbands) who had experienced the death of a newborn weighing less than 500 g at birth.

MAIN OUTCOME MEASURES

The lived parental experience of the death of a newborn consists of a number of parental processes, responses, and activities that occur over time.

RESULTS

Five themes were generated from the data: (a) realization that the loss is occurring; (b) initial response to the loss; (c) decision making at the time of the loss; (d) components of supportive relationships with others; and (e) the adjustment at home.

CONCLUSIONS

The findings demonstrate the unique experience of having a newborn who is born at the margin of viability and support the need for individualized, caring-based interventions for parents.

Parenteral nutrition for hospitalized infants: 20th-century advances in venous access

OBJECTIVE

To review the literature related to venous access for parenteral infant feeding.

DATA SOURCES

Sources included medical, nursing, and nutrition literature from 1900 to 1994.

STUDY SELECTION

One hundred ten studies were reviewed. Studies were selected based on historical significance and contribution to current practice.

DATA EXTRACTION

Data relating to the development of parenteral nutrients or evolution of parenteral techniques were extracted.

DATA SYNTHESIS

The central venous catheter was a significant development in meeting the nutritional needs of hospitalized infants.

CONCLUSION

Delivery of parenteral nutrition through percutaneous, peripherally inserted central venous catheters provides the least trauma and greatest benefit.

Secular changes in the outcomes to eighteen to twenty-four months of age of extremely low birth weight infants, with adjustment for changes in risk factors and severity of illness

OBJECTIVES

To analyze secular changes in the rates of death and of major impaired outcome in surviving outborn infants who weighted < or = 800 gm at birth and were admitted in 1980 to 1989, with adjustment for changes in risk factors and severity of illness around the time of birth; and to identify changes in these factors that might explain changes in outcomes.

DESIGN

Retrospective cohort study with follow-up to a minimum of 18 months of postterm age. After preliminary screening, multivariate models of association between risk/severity of illness factors and outcomes were constructed, validated, and used to adjust outcomes (death and major impairment to 18 to 24 months of age).

SETTING

Regional neonatal intensive care unit for referral of "outborn" infants.

PATIENTS

Two hundred eighty-seven consecutively admitted infants who weighted < or = 800 gm at birth (97% follow-up).

RESULTS

The death rate during the 1980s did not fall significantly (p adjusted for risk factors = 0.115). The major impairment rate fell (odds ratio, 0.24 (95% confidence interval, 0.10, 0.60); p = 0.002, adjusted for delivery route and respiratory failure measures), mainly because of a reduced rate of blindness, not attributable to cryotherapy. The risk factors that improved and were possibly related to the reduced impairment rate were blood pH and glucose concentration, and serum sodium concentration in the first 48 hours of life.

CONCLUSIONS

Despite an increasing selection for referral of less mature and more severely ill outborn babies near the "limit of viability," and despite more aggressive care, the rate of major impairment fell significantly during the 1980s. This trend was enhanced by adjustment for severity of illness. The fall was attributable to a reduced rate of blindness, and was associated with evidence of improved control of physiologic balance after birth.

Neonatal salvage by week's gestation in pregnancies complicated by HELLP syndrome

OBJECTIVE

For clinical management and counseling purposes, we determined the neonatal salvage by weeks' gestation and birth weight of pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets).

METHODS

All patients who delivered with a diagnosis of HELLP syndrome between January 1, 1980 and December 31, 1991 at a single tertiary care medical center were evaluated for neonatal outcome and survival. The syndrome was diagnosed in the presence of severe preeclampsia/eclampsia accompanied by laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia.

RESULTS

During the study interval, 58,670 live-born deliveries occurred, of which 527 (0.11%) had HELLP syndrome. In this population, 143 patients delivered fetuses at less than 30 weeks' gestational age. Based upon gestational age intervals, neonatal salvage was 0% at 23 weeks in 13 deliveries, 17% (intact salvage 8.5%) at 24 weeks, 31% (intact salvage 15%) at 25 weeks, 75% (intact salvage 65%) at 26 weeks, 80% (intact salvage 70%) at 27 weeks, and 83% at 28 and 29 weeks (intact salvage 70 and 76%). Based on birth weight intervals, neonatal salvage was 0% at less than 600 g, 34% at 600-700 g (intact salvage 17%), 69% at 700-800 g (intact salvage 53%), and 84% or more at greater than 800 g. These pregnancy outcomes are similar to those in this institution in patients without HELLP syndrome. Disease severity was distributed evenly among the 143 patients at less than 30 weeks' gestation. Apart from gestational age, there was no significant relation between the severity of the HELLP disease process and ultimate neonatal salvage.

CONCLUSIONS

Intact neonatal salvage in pregnancies complicated by HELLP syndrome is poor at weights less than 700 g and gestation of 25 weeks or less, but is more optimistic in pregnancies of greater than 700 g and 26 weeks' gestation or later. Aggressive efforts to enhance perinatal outcome, by operative delivery if indicated for fetal compromise, appear especially appropriate in gestations of greater than 700 g and 26 weeks' gestation or later, provided that adequate intensive care nursery facilities and neonatal expertise are available.

The changing pattern of infant mortality in the US: the role of prenatal factors and their obstetrical implications

Infant mortality is one of the leading public health problems in the United States today. During the first half of this century the decline in infant mortality resulted largely from a reduction in postneonatal deaths (2-11 months after birth). Since 1950, two-thirds of all infant deaths have occurred in the neonatal period (1st month after birth). Since 1981, the rate of decline in the infant mortality rate has slowed due to a deterioration in the distribution of birthweights and a slowed improvement in birthweight-specific mortality rates. The role of birthweight is central to this issue, because low birthweight (LBW, < 2500 g) is a major determinant of death in the first year of life, particularly during the neonatal period. Stated another way, less than 0.5% of infants with birthweights > 2500 g die during the first year of life compared to 10.2% of infants with birthweights < 2500 g and 45.3% with birthweights < 1500 g (very low birthweight, VLBW). These effects are magnified when evaluated on a race-specific basis: the rate of LBW is twice as high and the rate of VLBW is three times as high for black infants compared to white infants. Reducing the rates of VLBW and LBW, particularly among blacks, holds the greatest potential for future reductions in infant mortality in the United States. The important role of maternal factors in the antecedents of infant mortality (VLBW, LBW, intrauterine growth retardation, preterm birth) have been clearly and repeatedly demonstrated. Some of these factors, such as maternal race, adverse obstetrical history and low level of education, are not amenable to change during pregnancy. Other factors, such as cessation of smoking, higher maternal weight gain and the initiation of early prenatal care have been shown to improve the course and outcome of pregnancy and subsequently result in reduced infant mortality.

Evaluation of care for the preterm infant: review of literature on follow-up of preterm and low birthweight infants. Report from the collaborative Project on Preterm and Small for Gestational Age Infants (POPS) in The Netherlands

Since the introduction of neonatal intensive care in the 1960s, mortality in very preterm and very low birthweight infants has been decreasing steadily. Consequently, interest in the outcome of surviving infants is growing. Restriction of health care resources has stressed the need for information concerning the effect of individual treatment components on mortality and morbidity. Concern about the quality in apparently normal survivors has been increasing as well. The current flood of papers on these subjects illustrates the interest in these issues. The first part of this paper reviews the methodology used in follow-up studies in the past decades. It aims at methodological problems that hamper comparison between studies and preclude unequivocal conclusions. New treatment techniques seldom were but should be evaluated by randomised trials. To monitor the combined effects of changing obstetric and neonatal techniques on perinatal outcome, studies in geographically defined populations are recommended using data from early pregnancy until at least preschool age. Comparability of outcomes could be enhanced by international agreement on standardisation of assessment methods and outcome measures. In the second part the results concerning gestational age- and birthweight-specific mortality, impairments and disabilities and the risk factors for such disorders are discussed. Increased survival of even the tiniest infants is clearly established. This increase in survival has not yet been accompanied by an apparent increase in major morbidity. However, many minor impairments are reported, occurring often in combination and predisposing these children to deviations of normal development. Important changes in the manifestation of brain damage appear to occur during development. These findings stress the importance of long-term follow-up studies.

Hospital care techniques resulting in intact survival of a 380-g infant

Intact survival of infants delivered before completion of the 26th week of gestation or weighing less than 500 g is a well known phenomenon. We recently cared for an infant whose birth weight was 380 g, making her one of the smallest survivors in the United States. Her hospitalization (including expenses), the techniques of our minimal intervention protocol and her 20-month (corrected) follow-up are presented together with a discussion of the moral, economic and social implications involved in the care of such an infant.

The lowest birth-weight infants and the US infant mortality rate: NCHS 1983 linked birth/infant death data

The National Center for Health Statistics Linked Birth and Infant Death Data Set, 1983 birth cohort, shows that infants weighing less than 750 g, comprising only 0.3% of all births, account for 25% of deaths in the first year of life and for 41% of deaths in the first week. If interventions had prevented the death of these very small babies, the infant mortality rate would have been 8.3 per 1000 live births instead of 10.9, and the Black/White mortality differential would have been reduced by 25%.

Changing two-year outcome of infants weighing 500 to 999 grams at birth: a hospital study

Survival and neurodevelopmental outcome to 2 years were determined for two cohorts of infants weighing 500 to 999 gm at birth, born in a tertiary maternity hospital. Live births increased over time from an annual average of 48.7 in the first era (January 1977 to March 1982) to 64.6 in the second era (January 1985 to December 1987), largely from referrals of additional mothers with pregnancy complications. In the first era, 33.6% (86/256) of infants survived to 2 years; the survival rate improved significantly to 45.9% (89/194) in era 2. After adjustment for birth weight, the odds ratio for survival in era 2 versus era 1 was 1.39 (95% confidence interval = 1.12, 1.73; p less than 0.01). One known survivor in each era was not seen at 2 years of age. In the first era, 59.3% (51/86) of 2-year-old children were free of disability compared with 68.5% (61/89) in era 2 (NS), but the Mental Development Index of the Bayley Scales improved significantly, from 90.0 in era 1 to 98.0 in era 2. For infants weighing less than 800 gm at birth, not only did the 2-year survival rate improve, adjusted for birth weight (odds ratio = 1.53; 95% confidence interval = 1.06, 2.20; p less than 0.05), but there was also a significant reduction in neurologic disabilities in survivors (p = 0.03). For infants weighing 800 to 999 gm at birth, there was a significant improvement in the survival rate, adjusted for birth weight (odds ratio = 1.37; 95% confidence interval = 1.04, 1.79; p less than 0.05), but the rate of neurologic disabilities was unchanged. Increased survival in our tertiary maternity center was achieved without increasing the annual number of severely disabled 2-year-old survivors.

The use of health services in the first 2 years of life in a nationwide cohort of very preterm and/or very low birthweight infants in The Netherlands: rehospitalisation and out-patient care

In a prospective collaborative survey on very preterm (less than 32 weeks) and/or very low birthweight (VLBW) infants (less than 1500 g) in The Netherlands, the use of health services was studied by examining the incidence of and reasons for rehospitalisation and the use of out-patient care, i.e. visits to medical specialists and physical therapists. Out of 1338 liveborn infants originally enrolled in the survey, 998 survived the initial hospital stay. Their use of health services was studied during four period: discharge-3 months, 3-6, 6-12 and 12-24 months corrected for expected date of delivery. A total of 320 infants (34%) was readmitted on 481 occasions. The main reasons for rehospitalisation were surgical procedures, of which inguinal herniorrhaphy was the most prominent, and respiratory tract disorders: 149 admissions (31%) and 147 (31%) admissions respectively. The remaining reasons for rehospitalisation occurred less frequently. In a multivariate analysis, both sex and the length of the initial hospital stay were shown to be significantly associated with an increased risk of rehospitalisation. During the study period, 671 children (67%) attended a medical specialist other than their paediatrician, and 313 children (31%) attended a physical therapist. The use of out-patient services was higher in the first than in the second year of follow-up. The use of health services depended very much on the neurodevelopmental status of the child. In the second year of life, a similar rehospitalisation rate and use of out-patient services was found in the non-impaired children as in children from the general Dutch population.

Improved outcome for infants weighting less than 750 grams at birth: effects of advances in perinatal care, infection prevention and maternal transport for fetus

Between 1980 and 1987, we investigated the outcome for 20 infants with birth weights less than 750 g, admitted to the neonatal unit of Kyushu University Hospital. All infants were delivered at the hospital. Seven infants (35%) survived and were discharged. Comparing the first and second 4 year periods, the survival rate improved from 17% (1 of 6 infants) to 43% (6 of 14 infants). Intensive perinatal care, prevention of infection and early transport of mothers of high-risk babies improved the outcome. In the long-term, among the 7 survivors, 1 had psychomotor retardation, 1 had epilepsy and the other 5 were normal neurologically. Growth in height and weight of these children remained below the -2SD levels until 2 years of age, thereafter they began to catch up. Growth in head circumference increased to a level above the -2SD value from 2 years of age. With intensive perinatal care, the outcome for infants weighting less than 750 g is improving, and good results may be expected.

Peak inspiratory pressure requirements in infants born weighing less than 750 g

The possibility that peak inspiratory pressure requirements or the arterial:alveolar oxygen ratio can predict the clinical outcome in infants weighing less than 750 g at birth was explored in a consecutive series. Nine of 10 infants (90%) with a peak inspiratory pressure requirement of more than 18 cm H2O at 48 hours or more than 16 cm H2O at 72 hours from age subsequently died later of respiratory causes (defined as death after 72 hours of pulmonary interstitial emphysema, bronchopulmonary dysplasia, or cor pulmonale). Twenty of 21 remaining infants (95%) survived until discharge. Using these data a 95th centile for peak inspiratory pressure requirement during the first 72 hours of life was constructed. The potential value of this centile in predicting later death of respiratory causes was examined in a separate series. Twelve of 15 infants (80%) whose peak inspiratory pressure requirements remained below the 95th centile, or were not ventilated (n = 6), survived. In contrast, 11 of 12 (92%) infants whose requirements crossed the 95th centile died later of respiratory causes. The infants who died had more radiological changes and higher mean arterial carbon dioxide pressure than survivors suggesting that the severity of the initial lung disease rather than the way that ventilation was managed determined prognosis. Peak inspiratory pressure requirement was more useful than arterial:alveolar oxygen ratio in clearly distinguishing between survivors and infants who died later of respiratory causes.

Survival and outcome of infants weighing less than 800 grams at birth

This study reports on two aspects of outcome in a sample of infants whose birth weights ranged from 500 to 799 gm. First, maternal and early neonatal variables were analyzed by means of stepwise logistic regression. Five-minute Apgar score and initial pH were the only variables that predicted mortality at p less than or equal to 0.05. Second, the surviving infants were examined at ages ranging from 17 months to 7 years. The majority (72%) had neurologic and/or developmental examinations in the suspect or abnormal range and required rehabilitation or early intervention services.

Evolution of the prematurity before the 32nd week from 1980 to 1985 in a tertiary perinatal center in Lille, France

127 infants were born alive before the 32nd week of gestation in the H. Salengro obstetrical unit from the University Hospital of Lille from January 1980 to December 1985. During this period the annual number of deliveries was constant, 2700. Two periods were considered, 1980-1982 and 1983-1985. The number of such premature infants increased slightly: from 56 to 71. The most striking feature was the dramatic increase in infants born after induction of delivery for fetal reasons. Another finding is the statistically significant lowering of gestational age and birthweight of the spontaneously born infants. These trends counterweight the efficacy of the policy of prevention. When considering the morbidity and the mortality, hyaline membrane disease still plays a preeminent role in this population.

Outcomes of extremely-low-birth-weight infants between 1982 and 1988

Infants with birth weights under 750 g are disproportionately represented in perinatal mortality and morbidity rates. We reviewed the outcomes of 98 infants delivered at our perinatal center between July 1982 and June 1985 (period 1) whose lengths of gestation were 20 or more weeks and whose birth weights were under 750 g, and compared them with the outcomes of 129 such infants born between July 1985 and June 1988 (period 2). The frequency of cesarean section increased from 12 to 19 percent between the two periods. During the entire six-year period, 12 percent of the infants with birth weights under 500 g were intubated, as compared with 28 percent of those between 500 and 599 g, 60 percent of those between 600 and 699 g, and 90 percent of those between 700 and 749 g. The frequency of endotracheal intubation increased between the two periods only for infants with birth weights above 500 g (P less than 0.02). Despite more aggressive treatment, survival did not change, although the mean time to death among infants transferred to the neonatal intensive care unit increased from 73 to 880 hours. Among all live-born infants with birth weights under 750 g, the rate of survival was 20 percent during period 1 and 18 percent during period 2, but 48 and 43 percent of those transferred to the neonatal intensive care unit survived in the two periods reviewed. Neonatal morbidity also did not change. Among survivors at a corrected age of 20 months, 4 of 18 born during period 1 and 7 of 14 born during period 2 had moderate-to-severe neurodevelopmental impairment. When all live-born infants of less than 28 weeks' gestation were considered, only 8 percent of those born at 23 weeks survived, as compared with 16 percent of those born at 24 weeks, and 53, 63, and 72 percent of those born at 25, 26, 27 weeks, respectively. Thus, despite a tendency to perform more cesarean sections and active resuscitations, no improvement in the survival of babies with lengths of gestation below 25 weeks or birth weights under 750 g was observed. The probability of survival is very poor if the length of gestation is less than 24 weeks or the birth weight less than 600 g.

Changing outcome of extremely premature infants (less than or equal to 26 weeks' gestation and less than or equal to 750 gm): survival and follow-up at a tertiary center

Management of extremely premature infants is controversial because limits of viability are not established. From 1981 to 1987, 175 infants were admitted to the neonatal intensive care unit at Minneapolis Children's Medical Center with gestational ages less than or equal to 26 weeks and birth weights less than or equal to 750 gm. To assess current prognosis and to analyze trends over time, survival data and developmental characteristics of surviving infants were reviewed. During the study period, antenatal obstetric management was assertive, with liberal indications for tocolysis and expectant management for preterm prolonged membrane rupture, with the goal of delivery of infants in a nonasphyxiated condition. Ninety-one percent of infants were inborn and were managed aggressively after birth with full neonatal support. Survival increased from 21% in 1981-1982 to greater than 50% in 1986-1987 and occurred as early as 23 weeks' gestation. Seventy-one percent of all deaths occurred within 48 hours of birth, and late death (greater than 28 days) was uncommon. At follow-up, 23% of survivors were impaired, a proportion that remained relatively constant during the study period. Improvements in survival were not associated with an increased proportion of impaired infants. Survival with good outcome is attainable at gestational ages and birth weights previously considered nonviable. For obstetricians, neonatologists, and parents, knowledge of such current data can play an important role in making appropriate management decisions for both mother and infant.

Infants weighing 1,000 g or less at birth. Outcome at 8-11 years of age

34 long-term survivors of a five-year period (1977-1981) weighing 1,000 g or less at birth were followed-up at 8-11 years of age. Three (8.8%) children had severe functional handicap, 7 (20.6%) had moderate impairments with the need of special schooling. Twenty-four (70.6%) attended normal school but 7 (20.6%) with need of special help. The rate of survival was 30% at the single regional intensive centre where this cohort of infants were cared for. Handicapped infants differed significantly from infants with good prognosis in their neonatal requirements for oxygen therapy and in pathological conditions such as birth asphyxia and recurrent apneic spells but no differences in birthweight, gestational age, route of delivery, maternal age, social class, proportions below the tenth percentile and sex were found.

Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographically defined region from 1981 to 1984 compared with 1977 to 1980

In this article we report the survival and morbidity rates for all live-born infants weighing 501 to 1000 gram at birth and born to residents of a defined geographic region from 1977 to 1980 (n = 255) compared with 1981 to 1984 (n = 266). During these periods, there were no changes in the proportion of infants delivered at the tertiary care center or community hospitals (171/84 vs 194/72); use of the tertiary care center increased only slightly, from 84% to 91%; and changes in neonatal management were mainly in improvements in diagnostic and monitoring techniques. When infants were grouped according to birth weights in 100 gm increments, survival improved significantly only for infants weighing between 501 and 600 gm at birth (2% vs 20% p less than 0.001). There were no differences in the overall survival rates to hospital discharge (46% vs 48%). The prevalence of neurosensory impairments was 24% in period 1 and 17% in period 2. There was a significant improvement in the proportion of infants considered to have disabilities by a functional classification assigned at 3 years corrected age (50% vs 27%, p less than 0.001), but only for infants weighing more than 800 gm at birth (49% vs 22%, p less than 0.001). Infants delivered at the community hospitals had a higher prevalence of neurosensory impairments compared with infants delivered at the tertiary care center (period 1, 35% vs 21%, not significant; period 2, 37% vs 14%, p less than 0.05). These data are encouraging; further efforts should be directed toward assessing which, if any, components of perinatal care are contributing to the improvement in morbidity rates.

Outcome at school age of children with birthweights of 1000 grams or less

A follow-up study was done of extremely low-birthweight infants (less than or equal to 1000g) born between 1976 and 1979, a period when aggressive intervention was not routine practice. The survival rate was 19 per cent. 44 of the 46 survivors were followed to a mean age of 6 1/2 years. By five years of age 23 of the 44 children had been admitted to hospital, mainly for surgery and respiratory problems. Eight of 31 five-year-old children were growth-retarded and five of 26 were microcephalic. Among 44 children, ophthalmological problems were found in nine cases and neurosensory impairments (cerebral palsy, deafness) in seven. 12 children were mentally handicapped or had impaired intelligence (IQ or DQ less than 85). Over-all, 14 of the 44 children had impairments, severe in four cases and moderate in 10. Mean verbal IQ was significantly lower than mean performance IQ. Among 37 children in school or in remedial programs, nine required special education and another 12 in regular classes either failed or had very poor results, or needed extra professional help. Only 16 of the children had no significant problems in school. These findings indicate that extremely low birthweight (less than or equal to 1000g) represents a major risk to life, health (hospital admissions), long-term growth, neurosensory integrity, cognitive development and learning potential.

Survival after cardiopulmonary resuscitation in babies of very low birth weight. Is CPR futile therapy?

We conducted a retrospective study of outcome after cardiopulmonary resuscitation (CPR) in babies of very low birth weight. Of 158 such babies (birth weight, less than 1500 g) admitted to a neonatal intensive care unit in 1985, 49 (31 percent) underwent CPR. Low birth weight, low Apgar scores, birth asphyxia, pulmonary interstitial emphysema, hyaline membrane disease, and severe intraventricular hemorrhage were associated with the need for CPR. None of the 38 babies who received CPR in the first three days of life survived. Four of the 11 babies who received CPR after the first 72 hours survived. Three of the four survivors had residual neurologic deficits. Survival rates after CPR in infants of very low birth weight are lower than those in older children or adults. CPR may therefore be considered a nonvalidated therapy in this population. If the results of our study are confirmed, CPR should not be instituted automatically in very-low-birth-weight babies as though it were a validated treatment. Instead, it should be administered upon parents' advance informed consent to experimental treatment.

Development and validation of a multivariate predictor of mortality in very low birth weight

Accurate prognosis is critical to the design of all prospective research aimed at improving survival. Predictions based on birth weight, gestational age, or any other single variable, fail to take into account the potentially important contribution of other factors. In order to develop a practical and accurate multivariate model, we studied all singleton pregnancies resulting in viable liveborn infants who weighed less than or equal to 1500 g at birth during 1984 and 1985 at the New York Hospital-Cornell Medical Center. When gestational age, birth weight, and/or crown-heel length were considered, no maternal characteristics were significant predictors of mortality. The model with the maximal predictive accuracy (84.5%) used birth weight and 5-minute Apgar score to calculate a probability of mortality. This prognostic model was then validated in a separate cohort of singletons born in 1986. We conclude that clinical trials should require stratification before randomization, using the calculated probability of mortality, rather than birth weight or gestational age alone. Given the ability of models, such as the one presented here, to generate reasonable estimates of mortality, this information might also be used in the clinical setting to assist parents and physicians in individualized decision-making processes for a given infant.

Development and care of the premature infant's skin

Recent advances in neonatal care have greatly decreased mortality and morbidity in premature infants. Those who survive, however, often have significant cutaneous abnormalities. This has led to enhanced understanding and care of the premature infant's skin. Future dermatologic research may develop methods both to control epithelial maturation and to deliver therapy through the skin.

Open sky vitrectomy for total retinal detachment in retinopathy of prematurity

Open sky vitrectomy was performed on 23 eyes in 18 children between 4 and 35 months of age with stage V retinopathy of prematurity (ROP). Postoperatively, the retina was reattached in the posterior pole in eight eyes (34.7%). Follow-up ranged between 7 and 55 months (average, 16 months). Prognostic factors based on preoperative findings and surgical observations are analyzed.

Prognosis for infants born at 23 to 28 weeks' gestation

The survival and neurodevelopmental outcome of 356 extremely preterm infants born at 23 to 28 weeks' gestation were reported by week of gestation. Their corrected 1 year survival improved from 7% at 23 weeks to 75% at 28 weeks. The overall incidence of impairment was 19% and of major disability 12%. Boys had a significantly lower normal survival than girls. Multiple births had a significantly lower survival and higher incidence of impairment than singleton births. Predictions of outcome were made before delivery, after resuscitation, and at 1 week to aid the development of guidelines on when perinatal intensive care is justified, whether obstetric intervention for fetal reasons is warranted, and what initial and ongoing prognoses to give to parents. Intensive care for progressively smaller and more immature infants, many of whom were previously considered non-viable, needs to be carefully monitored by every perinatal centre.