Caring for parents of high-risk infants

Parental visiting, communication, and participation in ethical decisions: a comparison of neonatal unit policies in Europe

AIM

To compare neonatal intensive care unit policies towards parents' visiting, information, and participation in ethical decisions across eight European countries.

METHODS

One hundred and twenty three units, selected by random or exhaustive sampling, were recruited, with an overall response rate of 87%.

RESULTS

Proportions of units allowing unrestricted parental visiting ranged from 11% in Spain to 100% in Great Britain, Luxembourg and Sweden, and those explicitly involving parents in decisions from 19% in Italy to 89% in Great Britain. Policies concerning information also varied.

CONCLUSIONS

These variations cannot be explained by differences in unit characteristics, such as level, size, and availability of resources. As the importance of parental participation in the care of their babies is increasingly being recognised, these findings have implications for neonatal intensive care organisation and policy.

Outcome of extremely-low-birthweight infants

The overall 1-year survival rate of 261 infants born at 500 g-999g over a 7-year period was 46%. The survival rate of the 220 inborn infants, corrected for birth defects, would have increased from 47% to 57% if delivery room deaths were excluded and to 62% if postneonatal deaths had also been ignored. Survival improved progressively with increasing 100g weight groups. The disability rate in the 108 survivors who were at least 2 years old corrected for prematurity was 28% with little variation between the 100g weight groups. There were no significant trends in annual perinatal mortality, 1-year survival and disability rate in survivors over the study period for the inborn population. The male infants had significantly lower normal-survival rate than the female infants. Small-for-gestational-age infants, comprising 11% of the inborn group, had significantly better survival but a higher disability rate. Multiple births had significantly lower survival and normal-survival rates than had singleton births. Infants whose mothers were transferred for delivery at the perinatal centre before onset of labour had a significantly better survival rate than those whose mothers had 'booked' and those who were transferred in labour.

Survival and 2-year outcome of extremely preterm infants

The survival of 163 infants born within the hospital at 24-28 weeks gestation during a 4 1/2-year period and the morbidity in survivors at 2 years of age were reported. Hospital survival rates from 24-28 weeks at each week of gestation, excluding six infants with birth defects, were 36%, 32%, 57%, 70% and 74% respectively. The late outcome of children born at 24-26 weeks was compared with those born at 27-28 weeks. Of the 81 infants in the former group 46 (57%) died, nine (11%) survived with significant functional handicap and 26 (32%) were developing within the normal range. Of the 82 infants in the latter group, 28 (34%) died, eight (10%) survived with significant functional handicap and 46 (56%) were developing within the normal range. Although the mortality rate was significantly higher in the 24-26-weeks group, the physical disability and functional handicap rates in survivors were not statistically different between the two groups. Neither was developmental progress, as determined by psychological assessment, different.

Collaborative study of very-low-birthweight infants: Techniques of perinatal care and mortality

The neonatal units in two large maternity hospitals collaborated in a study of 440 liveborn infants weighting 500-1500 g born in 1977 and 1978: 377 (85.7%) were born in hospital. The overall survival rate was 70.5%, with a range of 67.5% to 71.5% for the inborn and outborn categories of infants in each hospital. In hospital A the survival rate of infants weighing greater than or equal to 1100 g was higher than that in hospital b, whereas the survival rate of infants weighing less than 800 g was higher in hospital B. Obstetric risk factors and obstetric management differed little between the hospitals, but there were several important differences in paediatric management; in particular, hospital B (with a better survival rate of infants weighing under 800 g) used ventilatory support and parenteral feeding much more frequently.

Improving prognosis for infants weighing 1000 g or less at birth

In the two years 1977 and 1978, 55 infants weighing less than or equal to 1000 g were admitted to the neonatal unit of the Queen Victoria Medical Centre. Overall neonatal survival was 60%; 44% of infants weighing 501-750 g and 67% of infants weighing 751-1000 g survived. One postneonatal death occurred at 51 days. Maternal risk factors were present in 80% of infants, although none had an effect on survival. Perinatal asphyxia, as indicated by an Apgar score less than or equal to 3 at five minutes, and base deficit greater than 10 mmol/l on admission, were associated with decreased survival. Mortality data with increasing postnatal age were used to produce a chart for sequential predication of neonatal survival. Intraventricular haemorrhage remained the most common necropsy finding. Follow-up of 32 survivors to date has shown no abnormalities, with the exception of one retrolental fibroplasia, and one porencephaly of unknown aetiology. We conclude that the prognosis for infants weighing less than or equal to 1000 g has continued to improve. From a review of the clinical and pathological characteristics in these infants however, it is obvious that this outcome requires complex organisation and costly resources in perinatal centres to which high-risk pregnancies must be transferred for optimal management both before and after birth.