The relationship between Caesarean section and neonatal mortality in very-low-birthweight infants born in Washington State, USA

We examined the associations between Caesarean section and neonatal mortality in singleton liveborn very-low-birthweight (VLBW) infants (500-1499 g) born during 1984-95 in Washington State, USA, using data from the Washington State birth certificate files. The infants included in this study had no life-threatening congenital malformations and had not been delivered by a repeat Caesarean without a trial of labour (n = 5182). For infants weighing 500-749, 750-999, 1000-1249 and 1250-1499 g, the neonatal mortality rates were 57.8%, 18.6%, 9.7% and 4.7%, respectively, and the Caesarean section rates were 28.4%, 47.8%, 48.0% and 44.6%. The adjusted odds ratios (ORs) for neonatal death associated with Caesarean section were 0.55 [95% confidence interval 0.38, 0.78] for the 500-749 g infants (n = 1059), and 1.15 [0.91, 1.45] for the larger (750-1499 g) infants, after adjustment for birth year, type of hospital, birthweight, presence or absence of labour, breech/malpresentation, and other obstetric indications for Caesarean section (prolapsed cord, placenta praevia, eclampsia, pre-eclampsia and chronic hypertension). However, when the larger (750-1499 g) vertex-presenting (n = 3248) and breech/malpresenting (n = 809) infants were considered separately, the adjusted ORs were 1.42 [1.05, 1.91] and 0.37 [0.23, 0.58] respectively. In contrast, among infants weighing 500-749 g, the ORs were not modified by presentation. The results were similar when we restricted analyses to infants without the above obstetric indications for Caesarean section. Because such an observational study is liable to unmeasurable biases and incomplete reporting of obstetric complications, these OR estimates may be subject to residual confounding. In their present state, these recent population-based data support the view that Caesarean sections do not enhance the neonatal survival of larger (> 750 g) VLBW babies when obstetric complications are absent. The possibility of a protective effect of Caesarean section on the survival of breech/malpresenting infants and infants weighing 500-749 g deserves further studies.     

Mortality among very low-birthweight infants in hospitals serving minority populations

OBJECTIVE: We investigated whether the proportion of Black very low-birth-weight (VLBW) infants treated by hospitals is associated with neonatal mortality for Black and White VLBW infants. METHODS: We analyzed medical records linked to secondary data sources for 74050 Black and White VLBW infants (501 g to 1500 g) treated by 332 hospitals participating in the Vermont Oxford Network from 1995 to 2000. Hospitals where more than 35% of VLBW infants treated were Black were defined as "minority-serving." RESULTS: Compared with hospitals where less than 15% of the VLBW infants were Black, minority-serving hospitals had significantly higher risk-adjusted neonatal mortality rates (White infants: odds ratio [OR]=1.30, 95% confidence interval [CI] = 1.09, 1.56; Black infants: OR = 1.29, 95% CI = 1.01, 1.64; Pooled: OR = 1.28, 95% CI=1.10, 1.50). Higher neonatal mortality in minority-serving hospitals was not explained by either hospital or treatment variables. CONCLUSIONS: Minority-serving hospitals may provide lower quality of care to VLBW infants compared with other hospitals. Because VLBW Black infants are disproportionately treated by minority-serving hospitals, higher neonatal mortality rates at these hospitals may contribute to racial disparities in infant mortality in the United States.     

Neonatal Morbidity Count Is Associated With a Reduced Likelihood of Achieving Recommendations for Protein,Lipid, and Energy in Very Low Birth Weight Infants: A Prospective Cohort Study

Background: Serious morbidity may elevate nutrient requirements and affect adherence to feeding guidelines for very low birth weight (VLBW) infants. An understanding of factors affecting nutrient intakes of VLBW infants will facilitate development of strategies to improve nutrient provision. Our aim was to examine the impact of neonatal morbidity count on achieving recommended nutrient intakes in VLBW infants. Methods: VLBW infants enrolled in the Donor Milk for Improved Neurodevelopmental Outcomes trial (ISRCTN35317141, n = 363) were included. Serious morbidities and daily parenteral and enteral intakes were collected prospectively. Results: Median intakes of infants with and without ≥1 morbidity met protein recommendations (3.5–4.5 g/kg/d) by week 2, although not maintained after week 4. Infants with ≥1 morbidity (vs without) were 2 weeks slower in achieving lipid (4.8–6.6 g/kg/d; week 4 vs 2) and energy (110–130 kcal/kg/d; week 5 vs 3) and 1 week slower in achieving carbohydrate recommendations (11.6–13.2 g/kg/d; week 4 vs 3). Adjusted hazard ratios of first achieving recommendations on any given day in infants with any 1 or 2 morbidities were 0.6 (95% confidence interval [CI], 0.5–0.9) and 0.6 (0.4–0.9), respectively, for protein; 0.5 (0.4–0.7) and 0.3 (0.2–0.5) for lipid; and 0.5 (0.4–0.7) and 0.3 (0.2–0.4) for energy. Conclusion: Morbidity is associated with a decreased likelihood of achieving lipid and consequently energy recommendations. This and the decline in protein intakes after the early neonatal period require further investigation to ensure optimal nutrition in this vulnerable population.     

Maternal characteristics associated with place of delivery and neonatal mortality rates among very-low-birthweight infants,Georgia

To determine whether the Healthy People 2000 objective to deliver very-low-birthweight (VLBW) infants at subspecialty perinatal care centres was met, and if improvements in the regional perinatal care system could reduce neonatal mortality further for 2010, we examined place of delivery for VLBW infants, associated maternal characteristics and the potential impact on neonatal mortality. We used linked birth and death records for the 1994-96 Georgia VLBW (i.e. 500-1499 g) birth cohorts. Among 4770 VLBW infants, 77% were delivered at hospitals providing subspecialty perinatal care. The strongest predictor of birth hospital level was the mother's county of residence, defined using three levels: residence in a county with a subspecialty hospital, residence in a county adjacent to one with such a hospital or residence in a non-adjacent county. Eighty-nine per cent of infants born to women who resided in counties with subspecialty care hospitals delivered at such hospitals, compared with 53% of infants born to women who resided in a non-adjacent county. Women were also more likely to deliver outside subspecialty care if they had less than adequate prenatal care [adjusted odds ratio (AOR) 1.5, P-value = 0.0001]. The neonatal mortality rate varied by level of perinatal care at the birth hospital from 132.1/1000 to 283/1000 live births, with the highest death rate for infants born at hospitals offering the lowest level of care. Assuming that the differences in mortality were due to care level of the birth hospital, potentially 16-23% of neonatal deaths among VLBW infants could have been prevented if 90% of infants born outside subspecialty care were delivered at the recommended level. These findings suggest that a state's support of strong, collaborative, regional perinatal care networks is required to ensure that high-risk women and infants receive optimal health care. Improved access to recommended care levels should further reduce neonatal mortality until interventions are identified to prevent VLBW births.     

Neonatal intensive-care unit admission of infants with very low birth weight --- 19 States, 2006

Neonatal mortality is disproportionately common among infants with very low birth weight (VLBW) (<1,500 g [3.3 lbs]). In 2006, the mortality rate among infants with VLBW was 240.4 per 1,000 live births. Because neonatal intensive care has been shown to reduce mortality among infants with VLBW, current standards call for neonatal intensive-care for all infants with VLBW; however, the proportion of infants with VLBW who are admitted to a neonatal intensive care unit (NICU) is not known, nor are the predictors for NICU admission. To estimate the prevalence of admission to NICUs among infants with VLBW and assess factors predicting admission, CDC analyzed birth data from 2006 for 19 states. This report summarizes the results of that analysis, which found that overall, 77.3% of infants with VLBW were admitted to NICUs (range: 63.7% in California to 93.4% in North Dakota). Among infants with VLBW born to Hispanic mothers, 71.8% were admitted to NICUs, compared with 79.5% of those with non-Hispanic black mothers and 80.5% of those with non-Hispanic white mothers. Multivariate analysis of the data indicated that preterm delivery, multiple births, and cesarean delivery all were independently associated with greater prevalence of NICU admission among infants with VLBW. Wide variation was observed among states in the prevalence of NICU admission of infants with VLBW; these state data should be assessed further, and barriers to NICU admission should be identified and addressed.     

Geographic Accessibility to Health Services and Neonatal Mortality Among Very-Low Birthweight Infants in South Carolina

Introduction Mortality for infants born with very-low birthweight (VLBW, 500–1499 grams) is markedly higher than for babies born with normal birthweight (2500–4000 grams). Although these high-risk infants show better outcomes in advanced care settings, only 80 % of VLBW infants born in South Carolina (SC) are delivered in hospitals with a level-III neonatal intensive care unit (NICU). The purpose of this research project was to assess geographic access to delivery hospitals and risk of neonatal death among singleton VLBW infants born in SC. Methods The linked birth and death records of a cross-sectional, population-based study of singleton VLBW infants born in SC between 2010 and 2012 were used (n = 2030). We assessed the impact of travel time from maternal residence to delivery hospital. Logistic regression modeling was performed with adjustments for maternal, newborn, and hospital characteristics. Results The neonatal mortality rate among singleton VLBW infants was 11.03 deaths per 100 live births in 2010–2012. We did not find a significant association between travel time to delivery hospital and neonatal mortality after adjusting for confounders. However, we found that a 1-week increase in gestational age (odds ratio (OR): 0.61) and non-Hispanic black mothers (versus non-Hispanic white mothers) (OR: 0.68) were associated with lower odds of neonatal death, whereas non-NICU admission at birth (OR: 5.90) was associated with increased odds of death. The results of the sensitivity analyses including both singleton and multiple births did not yield significant results for travel time and neonatal mortality in VLBW infants. Discussion Although we found no significant association between travel time and neonatal mortality in singleton VLBW births in SC, we identified significant factors consistent with those found in previous studies that may affect neonatal mortality.     

Candidal versus bacterial late-onset sepsis in very low birthweight infants in Israel: a national survey

Candidal infections are one of the common causes of late-onset sepsis (LOS) among very low birthweight (VLBW) infants, and are associated with substantial morbidity and mortality. The aim of this study was to evaluate the perinatal and neonatal risk factors for fungal LOS compared with bacterial LOS in VLBW infants. This was a population-based observational study of VLBW infants in 28 neonatal intensive care units across Israel, with information on 11,830 infants born between 1995 and 2002 from the Israeli National VLBW infant database. The study population comprised 3054 infants with one or more episodes of LOS. Univariate analysis and logistic regression models were used to compare perinatal and neonatal risk factors between infants with fungal sepsis only (N=179) and those with bacterial sepsis only (N=2630). The mean birthweight and gestational age of infants with candidal LOS were significantly lower (940 g; 27.1 weeks) than those in the bacterial LOS group (1027 g; 28.3 weeks) (P<0.001). Logistic regression analysis showed that candidal sepsis, in contrast to bacterial sepsis, was independently associated with decreasing gestational age and bronchopulmonary dysplasia (BPD). In addition, BPD only [odds ratio (OR) 1.84; 95% confidence intervals (CI) 1.03-3.23] and BPD with postnatal steroid therapy (OR 2.66; 95% CI 1.59-4.46) were independently associated with an increased risk for candidal sepsis.     

极低出生体重儿早期死亡的围生期危险因素分析

【目的】 探讨极低出生体重(very low birth weight,VLBW)儿早期死亡的围生期高危因素。 【方法】 选取在本院新生儿科住院的143例VLBW儿为研究对象。生后7 d 的结果:生存或死亡作为应变量,根据分层分析模型将围产期高危因素(自变量)分为远端、中间和近端3层,然后采用单因素和多因素Logistic 回归对所有变量进行分析。 【结果】 VLBW婴儿早期死亡率为13.29%(19/143)。变量经多因素Logistic 回归调整后显示,远端因素中母亲分娩时合并脐带脱垂者明显增加了VLBW 婴儿早期死亡的危险(AOR:8.69,95%CI:1.128 ~ 67.002);中间因素中胎龄<28周或生后5 min Apgar 评分<7分的VLBW 婴儿有明显高的早期死亡的危险(AOR:11.47,13.55;95%CI:2.066~63.712,3.156~58.221);近端因素中婴儿合并颅内出血者亦有明显高的早期死亡危险(AOR:4.56,95%CI:1.088~19.170)。 【结论】 VLBW婴儿早期死亡率高,是一个严重的公共健康问题。出生时窒息是死亡的最危险因素,通过提高产科质量、加强产科和新生儿科合作,降低窒息的发生是减少此类患儿早期死亡的关键。     

Method of Delivery and Neonatal Mortality among Very Low Birth Weight Infants in the United States

OBJECTIVE: To examine the association between method of delivery (primary cesarean section vs. vaginal) and neonatal mortality risk (as well as causes of death) among very low-birth weight first-born infants in the United States. More specifically, to examine this association separately for breech/malpresenting and vertex-presenting infants, while adjusting for selected maternal characteristics, and pregnancy, labor and delivery complications. METHODS: The study population was derived from the 1995-1998 birth cohort linked birth/infant death data sets. Binary and multinomial logit regression analyses were performed to assess the relationship in four very low-birth weight categories. RESULTS: Among breech/malpresenting neonates, compared to those delivered vaginally, infants delivered by a primary cesarean section had significantly lower adjusted relative risks of death for all very low-birth weight categories and the decrease in relative risk tended to be larger with each increasing birth weight category. However, for vertex-presenting neonates, results are mixed, suggesting decreased relative mortality risks associated with primary cesarean section, which were significant for 500-749 g, not significant for 750-999 g, and barely significant for 1,000-1,249 g. In contrast, for vertex-presenting neonates weighing 1,250-1,499 g, there was a significantly increased adjusted relative risk associated with primary cesarean section. Differences in cause-specific neonatal mortality by method of delivery and presentation status were also discussed. CONCLUSIONS: Primary cesarean section appears to be associated with decreased neonatal mortality risks in each very low-birth weight category for breech/malpresenting infants, but results are mixed for vertex-presenting infants. Causal inferences should be avoided because this was an observational study by design.     

Apnea and its possible relationship to immunization in ex-premature infants

This study compared the characteristics of infants hospitalized with apnea that participated in a vaccine trial compared with two control groups which consisted of 100 infants randomly selected from the same vaccine trial and 52 consecutively born very low birth weight (VLBW) infants. A total of 23 infants were admitted with apnea of whom 19 weighed <1500 g at birth and all were born at <37 weeks gestation. More of the VLBW infants in the apnea group had neonatal neurological complications compared with the VLBW control group (p=0.005). Ten of 11 children with apnea within 72 h of immunization were possibly related to vaccination.     

Two‐Year Follow‐up of a Randomized Controlled Nutrition Intervention Trial in Very Low‐Birth‐Weight Infants

Background: Very low‐birth‐weight (VLBW) infants are at risk for neurodevelopment impairment. This study assessed the effect of early aggressive parenteral nutrition (PN) on long‐term outcome in VLBW infants. Materials and Methods: Directly after birth, VLBW infants (birth weight <1500 g, n = 142) were randomized to 5 different PN regimes. Controls (n = 46) received glucose and standard‐dose amino acids (AAs; 2.4 g/[kg·d]) from birth onward and pure soybean oil fat emulsion (SOY) on the second day of life. Two intervention groups received glucose, standard‐dose AAs, and lipids from birth onward: SOY (n = 24) or mixed fat emulsion (MIX, n = 25). The 2 other intervention groups received glucose, high‐dose AAs (3.6 g/[kg·d]), and lipids from birth onward: SOY (n = 24) or MIX (n = 23). The primary outcome of this follow‐up study was the composite outcome of “death or major disability” at 2 years corrected age. Secondary outcomes were death, major disabilities, neurodevelopmental scores, and anthropometry. Results: Follow‐up rate was 92% (n = 134). Thirty‐five (26%) infants had died or had a major disability, with no differences between intervention groups and controls. Increased odds for death were observed in the standard‐dose AA‐MIX group (odds ratio, 5.4; 95% confidence interval [CI], 1.1–27.0). Neurodevelopmental scores and incidence of major disabilities did not differ between groups. Growth in the high‐dose AA‐MIX group was enhanced compared with growth in controls at 2 years corrected age (+0.51 [0.01–1.02] weight SDS). Conclusion: This randomized controlled hypothesis‐generating study demonstrated no beneficial effect of early high‐dose AA administration and mixed fat emulsions on survival and neurodevelopmental outcome in VLBW infants, although growth was enhanced.     

Neonatal Serum Phosphorus Levels and Enamel Defects in Very Low Birth Weight Infants

Background: Very low birth weight (VLBW) infants miss out on the period of greatest mineral accretion that occurs during the last trimester of pregnancy and are at higher risk of enamel defects. No studies have well described the relationship between neonatal nutrition and dental outcomes in preterm, VLBW infants. The objective of this study was to assess the differences in nutrition biomarkers, feeding intake, and comorbidities among VLBW infants with and without enamel defects. Methods: A retrospective chart review of VLBW infants recruited for an ongoing longitudinal dental study between 2007 and 2010 was done. Participants were classified as cases and controls according to the presence/absence of developmental defects of enamel at 8 and/or 18–20 and/or 36 months. Demographics and medical and nutrition data were abstracted from 76 subjects' medical charts. Results: Of the 76 VLBW subjects, 62% had enamel defects (hypoplasia and/or opacity). The only significant variable in the logistic regression analysis was that infants with a 1‐mg/dL increase in serum phosphorus levels had a 68% reduction in the odds of having enamel hypoplasia (odds ratio, 0.322; P = .024). Conclusion: Neonatal lower serum phosphorus levels are significantly associated with enamel hypoplasia in VLBW infants younger than 3 years.     

Impact of early weight loss on growth of Caesarean delivered babies: how long does it last?

Background We hypothesized that Caesarean delivered babies might experience excessive weight loss during neonatal period. Aim To investigate amount of weight loss among Caesarean delivered babies with exclusive breastfeeding and to identify role of relative weight change (RWC) in early postnatal period on the growth of infants in subsequent months. Methods We studied healthy infants born ≥36 completed weeks, by Caesarean section between September 2008 and August 2009, with Apgar scores >7. Weight measurements were performed at birth, at 24 h postpartum and at days 2, 4, 7, 14, 30 and monthly up to 6 months. Predictive roles of RWC at each assessment on detecting excessive weight loss and poor weight gain in 1st month, as well as bodyweight z scores in subsequent months were assessed. Results We studied 160 infants (88 female, 72 male) with a mean gestational age of 38.01 ± 1 weeks and birthweight of 3239 ± 421 g. Overall, 22.5% of infants lost >10% of birthweight; 11.9% at day 2, 16.9% at day 4 and 6.6% at day 7. Degree of weight loss was not related with parity, gestational age, birthweight or type of anaesthesia. Predictive values of RWCs in detecting poor weight gain in 0–30 days were: 2nd day; limit =?9.4%, specificity = 91.5%, 4th day; limit =?10.2%, specificity = 89.4%, 7th day; limit =?6.3%, specificity = 85%, sensitivity = 78%, 14th day; limit =+0.8%, specificity = 91.5%, sensitivity = 83.3%. Adjusting for birthweight z scores, RWC at 14th day had a significant influence on 1st and 2nd month bodyweight z scores. Bodyweight z scores were significantly correlated with the z scores of bodyweight in 1–5 months but not with that of 6 months. Conclusion Incidence of excessive weight loss is very high among Caesarean delivered babies. RWC at earlier measurements proves satisfactory in predicting poor infant growth. Management strategies based on identifying infants at risk could prevent excessive weight loss and improve future growth of those infants.     

Low-dose vancomycin prophylaxis reduces coagulase-negative staphylococcal bacteraemia in very low birthweight infants

Very low birthweight (VLBW) infants undergoing neonatal intensive care are at risk of infection with coagulase-negative staphylococci (CONS). This study investigates the efficacy of twice daily, 1 h infusions of vancomycin (5 mg kg) in reducing CONS infection in VLBW infants receiving parenteral nutrition. Of 72 infants in the study, 37 were randomized to vancomycin and 35 to the control group. Clinical variables and mortality were similar in both groups. In the vancomycin group, 11 infants had one or more episodes of CONS bacteraemia compared with 17 in the control group. Two babies in the treatment group had more than one episode of CONS bacteraemia, compared with nine in the control group (P = 0·02). There were 13 episodes of CONS bacteraemia in the vancomycin group compared with 29 in the control group. When only positive blood-cultures associated with a rise in C-reactive protein were considered, there were six episodes of CONS bacteraemia in the vancomycin group compared with 18 in the control group. Similarly there were five infants with one or more CONS infections compared with 11 in controls and one with more than one episode compared with six in the control group (P = 0·05). Prophylaxis with intermittent low-dose vancomycin infusions may help reduce recurrent CONS bacteraemia in VLBW infants receiving parenteral nutrition.     

How Close Are We to Achieving Energy and Nutrient Goals for Very Low Birth Weight Infants in the First Week?

Background: Emerging evidence suggests intakes of protein and energy as early as the first week of life in preterm very low birth weight (VLBW) infants are associated with improved neurodevelopment. In response, many neonatal intensive care units (NICUs) have launched new, more aggressive early feeding guidelines. The aim of this study was to evaluate enteral and parenteral energy and macronutrient intakes during the first postnatal week in VLBW infants admitted to NICUs that have introduced more aggressive early feeding guidelines. Materials and Methods: Estimated energy and macronutrient intakes were prospectively collected from VLBW infants fed exclusively mother's own milk and/or parenteral nutrition and compared with expert recommendations. Days to reach full enteral feeds (150 mL/kg/d) and discharge anthropometrics were examined. Results: By days 6 and 7, median protein and lipid intakes, respectively, reached recommended values (3.5 and 3.0 g/kg/d). However, by day 8, many infants remained below recommended intakes for protein (34%), lipid (34%), carbohydrate (68%), and energy (71%). Late‐onset sepsis was associated with a decreased likelihood of reaching full enteral feeds on any given day (hazard ratio, 0.2; 95% confidence interval, 0.1–0.5; P ≤ .0009). There was no significant relationship between week 1 nutrient intakes and anthropometrics at discharge. Conclusion: Despite the introduction of more aggressive early feeding guidelines and improved energy and nutrient intakes compared with literature values, many VLBW infants remain below recommended nutrition goals in the first week.     

Association Between the 7‐Day Moving Average for Nutrition and Growth in Very Low Birth Weight Infants

Background: Very low birth weight (VLBW) infants remain at risk for postnatal growth restriction. Clinicians may have difficulty identifying growth patterns resulting from nutrition interventions, impeding prompt management changes intended to increase growth velocity. This study aimed to quantify the association between growth and nutrition intake through 7‐day moving averages (SDMAs). Methods: The first 6 weeks of daily nutrition intake and growth measurements were collected from VLBW infants admitted to a level 4 neonatal intensive care unit (2011–2014). The association between SDMA for energy and macronutrients and subsequent 7‐day growth velocities for weight, length, and head circumference were determined using mixed effects linear regression. Analyses were adjusted for fluid intake, infant characteristics, and comorbid conditions. Results: Detailed enteral and parenteral caloric provisions were ascertained for 115 infants (n = 4643 patient‐days). Each 10‐kcal/kg/d increase over 7 days was independently associated with increased weight (1.7 g/kg/d), length (0.4 mm/wk), and head circumference (0.9 mm/wk; P < .001, for weight and head circumference; P = .041 for length). Each 1 g/kg/d macronutrient increase was also associated with increased weight (protein, P = .027; fat and carbohydrates, P < .001), increased length (fat, P = .032), and increased head circumference (fat and carbohydrates, P < .001). Conclusions: The SDMA identifies clinically meaningful associations among total energy, macronutrient dosing, and growth in VLBW infants. Whether SDMA is a clinically useful tool for providing clinicians with prompt feedback to improve growth warrants further attention.     

Neonatal care of premature infants]

Perinatal intensive centers deal with preterm infants of the region. Therefore, the rate of preterm deliveries at the Department of Obstetrics and Gynecology, Medical University of Pécs was high in 1997, about the double of the national rate (18.7%). Among prematures the rate of very low birth weight (VLBW) infants (less than 1500 g) was about 40%, moreover, the rate of extremely low birth weight infants (less than 1000 g) was 39% within the latter group. Related to the new regulation concerning preterm delivery the number of immature infants (weighing less than 750 g) with poor outcome increased. The most characteristic disease of preterm infants is the idiopathic respiratory distress syndrome (IRDS). This could be prevented by maternal steroid treatment, a therapy accepted worldwide, however, not so common in Hungary. Direct fetal steroid therapy may be applied also in selected cases. In the treatment of IRDS surfactant products made a breakthrough. Several factors (maternal tocolytic and fluid therapy, Cesarean section) influence the cardiopulmonary adaptation which may be monitored with impedance cardiography. Late hyponatremia and metabolic acidosis may develop in 1/3 of VLBW infants. Besides the fluid therapy the introduction of enteral feeding must be planned carefully and examination of gastric emptying with ultrasound is useful. The development of osteopenia may be prevented by passive exercise of the preterm infant. Anemia is common and human recombinant erythropoietin is available for treatment. Screening of vision, hearing, and neurodevelopmental follow up are integral parts of neonatal care. As a result of the above mentioned preventive and therapeutic interventions neonatal mortality has decreased significantly in Hungary in the past decades.     

Perinatal mortality and its relationship to the reporting of low-birthweight infants.

OBJECTIVES: This study examined changes in the reporting of very low-birthweight infants in Alabama from 1974 to 1994 and the impact on perinatal mortality rates. METHODS: Linked live birth, neonatal death, and stillbirth records of infants born weighing less than 1500 g were compared. RESULTS: The changes in mortality over time ranged from a drop from 100% to 92% in the under-500-g group to a drop from 39% to 4% in the 1000-to 1499-g group. The percentage of total births weighing less than 500 g increased by 155%; the percentage of 1000- to 1499-g births increased by only 7%. As a result, the percentage of neonatal mortality attributable to live births below 500 g increased from 3% to 32%. CONCLUSIONS: Increased reporting of births below 500 g has masked improvements in neonatal mortality.     

Intrauterine infection and the risk of cerebral palsy in very low-birthweight infants

Summary. Very low-birthweight infants constitute more than one-quarter of all new cases of cerebral palsy. We performed a case–control study of associations between antenatal maternal infection and cerebral palsy in very low-birthweight infants. Cases and controls were selected from a cohort of 1238 consecutive infants who: (1) had birthweights between 500 and 1500 g and no major congenital anomaly; (2) were born 1 January 1986 to 31 December 1993 to a mother residing in 1 of 17 counties in north-west North Carolina; and (3) were delivered at the only tertiary obstetric referral centre in those same 17 counties. A total of 984 of these infants (79%) survived to 1 year of age (adjusted for degree of prematurity) and were scheduled for a multidisciplinary examination; 815 (83%) came as scheduled. Excluding two cases attributable to post-neonatal events, 62 cases of cerebral palsy were identified. Controls were the two infants, without cerebral palsy, born closest in time to each case. Medical records were reviewed by a nurse who was not aware of which subjects were cases. Among possible markers of intra-amniotic infection, those associated most strongly with cerebral palsy were chorioamnionitis diagnosed by an obstetrician (odds ratio [OR] adjusted for gestational age [95% confidence limits] = 2.6 [1.0, 6.5]), antepartum maternal temperature > 37.8°C (OR = 2.6 [1.1, 6.0]), uterine tenderness (OR = 2.6 [0.8, 9.3]), maternal receipt of antibiotics (OR = 2.2 [1.0, 4.7]) and neonatal sepsis in the first week of life (OR = 2.9 [0.9, 8.9]). All of these associations were stronger for diplegia than the other clinical subtypes of cerebral palsy. The association with chorioamnionitis and spastic diplegia persisted when adjusted for maternal magnesium sulphate receipt, maternal betamethasone receipt, method of delivery (vaginal vs. abdominal), acidosis on the neonate‘s initial arterial blood gas, systolic blood pressure < 30 mmHg and the diagnosis of major neonatal neurosonographic abnormality.     

Life expectancy of extremely preterm infants

Extremely preterm infants [gestational age (GA) between 24-28 weeks] should be delivered optimally in an institute where neonatal intensive care unit (NICU) is available and their short- and long-term care is ensured. At the Department of Obstetrics and Gynecology, Medical School, University of Pécs, 7499 infants were born between 1st of January, 2000 and 31st of December, 2004. During this period the rate of preterm deliveries was 20% (1499/7499). Among preterm infants the incidence of extremely preterm babies (GA 28 weeks or less) was 18% (272/1499), the rate of profoundly preterm infants (GA less than 25 weeks) was 3.2% (48/1499). Advancing with gestational age the survival rate is increasing. At the department, the rate of handicapped infants among extremely premature babies was 15.3%. The majority of the handicapped infants were profoundly preterm, meanwhile, more than 50% of infants born at the 26 gestational weeks were free of symptoms influencing social activities. It is important to stress the prognostic value of the screening for hearing loss (otoacoustic emission), visual problems, and intracranial bleeding for the early detection and cure of the possible complications of prematurity.