Trends and variations in use of antenatal corticosteroids to prevent neonatal respiratory distress syndrome: recommendations for national and international comparative audit. Scottish Neonatal Consultants' Collaborative Study Group, International Neonatal Network

Variations and Determinants of Mortality and Length of Stay of Very Low Birth Weight and Very Low for Gestational Age Infants in Seven European Countries

The EuroHOPE very low birth weight and very low for gestational age infants study aimed to measure and explain variation in mortality and length of stay (LoS) in the populations of seven European nations (Finland, Hungary, Italy (only the province of Rome), the Netherlands, Norway, Scotland and Sweden). Data were linked from birth, hospital discharge and mortality registries. For each infant basic clinical and demographic information, infant mortality and LoS at 1 year were retrieved. In addition, socio-economic variables at the regional level were used. Results based on 16,087 infants confirm that gestational age and Apgar score at 5 min are important determinants of both mortality and LoS. In most countries, infants admitted or transferred to third-level hospitals showed lower probability of death and longer LoS. In the meta-analyses, the combined estimates show that being male, multiple births, presence of malformations, per capita income and low population density are significant risk factors for death. It is essential that national policies improve the quality of administrative datasets and address systemic problems in assigning identification numbers at birth. European policy should aim at improving the comparability of data across jurisdictions.

Respiratory distress syndrome after elective caesarean section in near term infants: a 5-year cohort study

OBJECTIVE

to assess the incidence of respiratory distress syndrome (RDS) in late preterm (34(0/7)-36(6/7)) and just term (37(0/7)-37(6/7)) infants born via elective caesarean section (CS) in a tertiary care maternity facility.

METHODS

retrospective cohort study between 2005 and 2009. Hundred and eighty-eight near term infants, divided in two groups: group A: 125 late preterm (34(0/7)-36(6/7)) and group B: 63 just term (37(0/7)-37(6/7)), from elective CS (except CS after pre-mature rupture of membranes and foetuses presenting congenital malformation) were included.

RESULTS

In group A the overall incidence of RDS (RDS at or shortly after birth, requiring respiratory support or oxygen therapy) was 44% (n = 55) vs. 15.9% (n = 10) in group B (p < 0.01). The incidence of SRDS (requiring admission in the neonatal intensive care unit (NICU)) in group A was 13.6% (n = 17) and 3.2% (n = 2) group B (p < 0.01). The risk decreased significantly as gestational age (GA) increased: for RDS, 50.9% at 34 weeks of gestation (WG), 52.5% at 35 WG, 21.5% at 36 WG, and 15.9% at 37 WG; for admission, 30.2% at 34 WG, 25% at 35 WG, 9.4% at 36 WG, and 6.3% at 37 WG. Among late preterm infants with RDS, 30.9% (n = 17) developed severe RDS (SRDS).

CONCLUSIONS

Late preterm infants born via elective CS are at high risk for RDS and NICU admission. The risk is influenced by each additional week spent in utero. As the incidence of CS is increasing within this population, new preventative strategies must be sought.

Annual league tables of mortality in neonatal intensive care units: longitudinal study. International Neonatal Network and the Scottish Neonatal Consultants and Nurses Collaborative Study Group

OBJECTIVE

To assess whether crude league tables of mortality and league tables of risk adjusted mortality accurately reflect the performance of hospitals.

DESIGN

Longitudinal study of mortality occurring in hospital.

SETTING

9 neonatal intensive care units in the United Kingdom.

SUBJECTS

2671 very low birth weight or preterm infants admitted to neonatal intensive care units between 1988 and 1994.

MAIN OUTCOME MEASURES

Crude hospital mortality and hospital mortality adjusted using the clinical risk index for babies (CRIB) score.

RESULTS

Hospitals had wide and overlapping confidence intervals when ranked by mortality in annual league tables; this made it impossible to discriminate between hospitals reliably. In most years there was no significant difference between hospitals, only random variation. The apparent performance of individual hospitals fluctuated substantially from year to year.

CONCLUSIONS

Annual league tables are not reliable indicators of performance or best practice; they do not reflect consistent differences between hospitals. Any action prompted by the annual league tables would have been equally likely to have been beneficial, detrimental, or irrelevant. Mortality should be compared between groups of hospitals using specific criteria-such as differences in the volume of patients, staffing policy, training of staff, or aspects of clinical practice-after adjusting for risk. This will produce more reliable estimates with narrower confidence intervals, and more reliable and rapid conclusions.

Antenatal corticosteroid prescribing: setting standards of care

OBJECTIVE

Despite widespread recognition that prenatal administration of corticosteroids dramatically reduces perinatal mortality and morbidity, clinical practice in this area remains less than ideal. We therefore reviewed our practice to identify reasons for this and to determine attainable standards of care.

DESIGN

Retrospective case record review.

SETTING

Level three maternity unit in Edinburgh, UK.

POPULATION

All women admitted at gestations of 24 to 34 weeks and 6 days inclusive, and all women receiving corticosteroids in one institution, over a 10-month period.

MAIN OUTCOME MEASURES

The number and clinical features of women delivering before and after 35 weeks of pregnancy who had received corticosteroids.

RESULTS

Seven hundred and two women were admitted during the study period; case records were available for 688 of these. One hundred and ninety-two women (28%) delivered before 35 weeks of gestation, of whom 123 (64%) had received dexamethasone. Of 69 women who received no steroids 30 (43%) were in hospital for more than 24 hours before delivery. Overall, 29% of women receiving dexamethasone delivered after 35 weeks of gestation and 42 (24%) women treated with dexamethasone received more than one course. While the grade of admitting doctor did not affect prescribing, there were other significant differences that may help guide future practice.

CONCLUSIONS

This study provides some guidance for optimising corticosteroid prescribing and for the development of clinical practice guidelines. Approximately 80% of women should be able to receive at least some corticosteroids prior to delivery before 35 completed weeks of pregnancy.