Social determinants of health and the neonate in the neonatal intensive care

It is increasingly recognised that social determinants of health such as socioeconomic inequalities, parental education level, addiction behaviors, mental health difficulties and breast-feeding rates all influence immediate and long-term outcomes in neonatal intensive care unit (NICU) graduates. Awareness, recognition and appropriate management of these risks may help alleviate some of these effects. This review looks at various social determinants and their effects on patients and families in the NICU.     

Surveillance of infection in neonatal intensive care units

Monitoring infection rates is increasingly regarded as an important contributor to safe and high quality health care, especially in intensive care settings. Early-onset neonatal sepsis rates are an important indicator of ante- and intra-partum care, especially as medicalisation of obstetric practice increases. However, surveillance of late-onset neonatal sepsis is required to monitor the quality of Neonatal Intensive Care Unit (NICU)-related care. Infection surveillance on NICUs presents a number of unique challenges, including defining infections, the preponderance of coagulase-negative staphylococci as both pathogens and commensals, and allowing for the influence of important risk factors. Ideally an infection surveillance programme should permit benchmarking of infection rates, and multi-centre programmes have been reported to decrease the incidence of healthcare-associated infections on NICUs. However, further research is required to identify the most clinically- and cost-effective means of surveying NICU-acquired infections before a national programme can be implemented. Until then, considerable value can be obtained from local infection surveillance.     

Outcome of neonates transported between Level III centres depends upon centre of care

This study aimed to clarify whether the adverse outcomes seen in babies transported between New Zealand Level III intensive care nurseries were due to the transport itself or to possible differences in care in different centres. The outcomes of 34 infants inborn at National Women's Hospital, Auckland but transported to other centres were compared with those of 68 matched controls inborn at the receiving centres and with 68 controls inborn and cared for at National Women's Hospital. Transport was associated with a transient (non-significant) deterioration in respiratory status but no increase in chronic lung disease. However, infants cared for elsewhere, whether transported or control, had more periventricular haemorrhage than Auckland babies (23% and 29%vs 15%, P= 0.03) and worse neurodevelopmental outcome (70% and 66%vs 88% of those whose outcomes were known were normal at follow up, P= 0.002). We conclude that differences in care between centres may be more important than the transport itself in determining the long-term outcome of transported neonates.     

Adverse effects of neonatal transport between level III centres

Abstract The effect of neonatal transport between level III intensive care nurseries was studied by comparing the outcome of 40 infants inborn at a regional level III centre but transported to other level III nurseries for intensive care, with 80 matched inborn controls. Transport appeared to affect respiratory status adversely but transiently. However, transported infants grew less well than control infants (32% were below 3rd centile for weight at 36 weeks vs 15% of controls), were more likely to suffer periventricular haemorrhage (40 vs 21% of controls) and had a worse neurodevelopmental outcome (70% normal at follow up vs 83% of controls). It can be concluded that for infants inborn at the National Women's Hospital, Auckland, transport to another level III centre for intensive care is associated with an increased risk of adverse outcome.     

目标性监测在新生儿重症监护病房医院感染中的应用价值

目的探讨目标性监测对控制新生儿重症监护病房(NICU)感染发生率的作用。方法回顾分析2013年1月至2015年6月入住NICU患儿经目标性监测持续改进后的医院感染率的变化。结果研究期间符合入选条件患儿1 011例中发生医院感染59例,医院感染率为5.8%,日感染率为3.5%;以每半年分期,日感染率从2013年上半年的8.0%下降至2015年上半年的2.2%;呼吸机相关性肺炎例/1 000呼吸机使用日从2013年上半年的12.8‰下降至2015年上半年的0‰;中心静脉导管相关性血流感染例/1000中心静脉置管日从2013年上半年的4.5‰下降至2015年上半年的0‰,差异均有统计学意义(P0.05)。结论通过连续性目标性监测可及时掌握NICU医院感染动态变化和危险因素,便于采取持续有效的干预措施,降低NICU医院感染率。     

Development and growth in very preterm infants in relation to NIDCAP in a Dutch NICU: two years of follow-up

Aim: To study development and growth in relation to newborn individualized developmental and assessment program (NIDCAP®) for infants born with a gestational age of less than 30 weeks.
Methods: Developmental outcome of surviving infants, 25 in the NIDCAP group and 24 in the conventional care group, in a prospective phase-lag cohort study performed in a Dutch level III neonatal intensive care unit (NICU) was compared. Main outcome measure was the Bayley scales of infant development-II (BSID-II) at 24 months corrected age. Secondary outcomes were neurobehavioral and developmental outcome and growth at term, 6, 12 and 24 months.
Results: Accounting for group differences and known outcome predictors no significant differences were seen between both care groups in BSID-II at 24 months. At term age NIDCAP infants scored statistically significant lower on neurobehavioral competence; motor system (median [IQR] 4.8 [2.9–5.0] vs. 5.2 [4.3–5.7], p = 0.021) and autonomic stability (median [IQR] 5.7 [4.8–6.7] vs. 7.0 [6.0–7.7], p = 0.001). No differences were seen in other developmental outcomes. After adjustment for background differences, growth parameters were comparable between groups during the first 24 months of life.
Conclusion: At present, the strength of conclusions to be drawn about the effect of NIDCAP on developmental outcome or growth at 24 months of age is restricted. Further studies employing standardized assessment approaches including choice of measurement instruments and time points are needed.     

Mechanical ventilation of paediatric patients with asthma: Short and long term outcome

In the 7 years from 1982 to 1988, 10,639 children with acute asthma were admitted to the Royal Children's Hospital, Melbourne. Of these, 262 children (2%) were treated in the Intensive Care Unit. Twenty-seven required mechanical ventilation on 34 occasions, being 0.3% of hospital asthma admissions. Five patients died, four due to brain death following respiratory arrest prior to intubation. The main complications were (i) barotrauma, which occurred in five patients on seven occasions (20%); (ii) a reversible myopathy which occurred in three patients treated with high dose corticosteroids and muscle relaxants. Follow-up of patients ventilated in intensive care revealed that all but one of the initial survivors was alive 1-5 years later, all patients required subsequent readmission to hospital for treatment of acute asthma and 78% had persistent rather than episodic asthma. Although uncommon, an episode of ventilation has a major impact on the family's understanding and future management of acute asthma.     

Short-term outcomes of infants of substance-using mothers admitted to neonatal intensive care units in New South Wales and the Australian Capital Territory

AIM: Illicit substance use during pregnancy is associated with an increased rate of perinatal complications. Our study examines if outcome of infants of substance-using mothers (ISMs) in the neonatal intensive care unit (NICU) setting is similar to unexposed infants (controls). METHODS: A prospective state-wide NICU study comparing ISMs to control infants admitted to 10 NICUs during a 3-years period (2001-2003). An ISM was defined as an infant whose mother admitted to or was documented to have used substances of dependency (illicit or otherwise) during this pregnancy. RESULTS: There was a preponderance towards prematurity with ISMs comprising 5.1% (n=310) of 6120 high risk infants (6.2% (n=165) <32 weeks gestation and 6.8% (n=39) of 22-26 weeks gestation). More ISMs were outborn and had significantly lower mortality rate, particularly in the <32 week gestation subgroup (adjusted OR 0.517 95% CI 0.277-0.962, P<0.037). ISMs also demonstrated a non-significant trend towards an increased risk of neonatal morbidities. The pattern of rural and urban substance use was different, with a higher incidence of opiate use (49.3% vs. 26.9%, P<0.001) in urban areas. Most opiate using mothers (85.6%), irrespective of rural or urban residence, were enrolled in methadone programmes. ISMs had a higher incidence of antepartum haemorrhage and chorioamnionitis and fewer were given antenatal steroids. CONCLUSION: ISMs are common in the high-risk NICU population. Further studies are needed to confirm the lower mortality rate and long-term outcomes in these infants.     

Economic outcome for intensive care of infants of birthweight 500–999 g born in Victoria in the post surfactant era

Objective: To determine the incremental cost of improving the outcome for extremely low birthweight (ELBW, birthweight 500–999 g) infants born in Victoria after the introduction of exogenous surfactant (the post surfactant era). Methodology: This was a geographically determined cohort study of ELBW children in Victoria, Australia of consecutive livebirths born in three distinct eras: (i) 1979–80 (n= 351); (ii) 1985–87 (n= 560); and (iii) 1991–92 (n= 429). Exogenous surfactant was first used in Victoria in March, 1991. The consumption of nursery resources per livebirth, and the survival and sensorineural disability rates at 2 years of age for each era were investigated. Utilities were assigned as follows: 0 for dead, 0.4 for severe disability, 0.6 for moderate disability, 0.8 for mild disability, and 1 for no disability. Utilities were multiplied for more than one disability. Dollar costs were assumed to be $1470 ($A 1992) per day of assisted ventilation, and one dose of exogenous surfactant was assumed to be equivalent to one third of a day of assisted ventilation. Cost-effectiveness (additional costs per additional survivor or life-year gained) and cost-utility (additional costs per additional quality-adjusted survivor or life-year gained) ratios were calculated for the pre-surfactant era (1985–87 vs 1979–80), and for the post surfactant era (1991–92 vs 1985–87). Results: Considering only the costs incurred during the primary hospitalization, cost-effectiveness and cost-utility ratios were lower (i.e. economically better) in the post surfactant era than in the pre-surfactant era (pre-surfactant vs post surfactant; S7040 vs$4040 per life year gained; $6700 vs$5360 per quality-adjusted life year gained). Both ratios fell with increasing birthweight. In contrast with the pre-surfactant era, cost-utility ratios were less favourable than cost-effectiveness ratios in the post surfactant era. With costs for long-term care of severely disabled children added, both cost ratios were higher in the post surfactant era. Conclusion: The incremental cost during the primary hospitalization of improving the outcome for ELBW infants has fallen in the post surfactant era.     

Neonatal intensive care utilization and neonatal outcome of infants born to women aged 40 years and over in New Zealand

Background: Increased maternal age is associated with pregnancy complications and there are few data available on neonatal outcome and utilization of neonatal resources. Our first aim was to use national New Zealand data to determine if the outcomes following admission to NICU are different for infants born to women aged 40 years and over, compared with those born to women under 40 years of age. The second aim was to document trends in the requirement of neonatal intensive care in infants born to women aged 40 years and older. Method: Eligible infants were identified from registration with the Australian and New Zealand Neonatal Network for 1995–2004 inclusive. The relationship between maternal age and neonatal outcome was tested using univariate and multivariate analysis, and trends in the number of infants in maternal age groups below 35 years, 35–39 years and over 40 years were determined. Results: On multivariate analysis using logistic regression, maternal age over 40 years was not found to be associated with a significant increase in the odds ratio for the composite poor outcome. However, over the 10‐year period, there was an increase in the number of admissions and the percentage of admissions of infants born to women over 40 years of age. Conclusion: Although the number of infants admitted for neonatal care following birth to women over 40 years of age has increased, these infants do not appear to have an increased risk of severe abnormal outcome.     

Another outcome of neonatal intensive care: First year mortality and hospital morbidity

Objectives: To determine first year mortality and hospital morbidity after neonatal intensive care.
Methodology: Cohort study of 6077 surviving infants inborn in one regional hospital in 1988. Nine hundred and eighty-eight received neonatal intensive care and 103 were very low birthweight (VLBW).
Results For infants who required care in the neonatal intensive care unit (NICU), the relative risk of dying before their first birthday was 3.6 (95% confidence intervals [Cl] 1.5-8.8). This increased risk was associated with low birthweight (LBW) rather than requirement for NICU care. Of all inborn survivors, 10.4% were readmitted to hospital in the first year and 2.4% more than once. The readmission rate was 20% for NICU survivors and 30% for VLBW infants. The risk of hospitalization was independently associated both with NICU admission (odds ratio 2.3, Cl 1.9-2.9) and with VLBW (OR 1.8, Cl 1.1-3.0). The NICU survivors also had multiple admissions and prolonged hospital stays.
Conclusions Both low birthweight and neonatal illness requiring intensive care are important indicators of continuing medical vulnerability over the first year of life.     

Children with human immunodeficiency virus infection admitted to a paediatric intensive care unit in South Africa

BACKGROUND: Early data regarding the outcome of human immunodeficiency virus (HIV)-infected children in paediatric intensive care units (PICU) suggested mortality as high as 100%. Recent studies report mortality of 38%. Survival depends on the indication for admission. OBJECTIVES: To describe the prevalence, duration of stay, and outcome of HIV-infected patients in a single PICU over a 1-year period. Additional objectives included describing the indications for admission as well as the clinical and laboratory characteristics of HIV-infected infants and children requiring PICU admission. METHOD: Retrospective chart review of all children with serological proof of HIV admitted to PICU at Tygerberg Children's Hospital from 1 January to 31 December 2003. RESULTS: Of the 465 patients admitted, 47 (10%) were HIV-infected. For HIV-infected children the median age on admission was 4 months. The median duration of stay was 6 days, significantly longer than for the non-HIV group (p = 0.0001). Fifty-seven percent had advanced clinical and immunological disease. Seventeen died in PICU and four shortly afterwards, poor PICU outcome was significantly associated with HIV status (p = 0.001). Lower total lymphocyte count (p = 0.004) and higher gamma globulin level (p = 0.04) were paradoxically the only findings significantly associated with survival. Acute respiratory failure (ARF) accounted for 76% of admissions, including Pneumocystis jiroveci in 38%. Fifty-one percent had evidence of cytomegalovirus infection. CONCLUSIONS: HIV-infected children requiring PICU can survive despite the lack of availability of antiretroviral therapy.     

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Background: Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. Methods: A 3‐year retrospective cohort study was conducted to compare mechanically‐ventilated patients who received NMBA for at least 12 h with patients who did not (control group). Results: A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty‐four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator‐associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). Conclusion: Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator‐associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.     

Is intensive care for very immature babies justified?

Neonatal intensive care is generally considered justified in the majority of very premature infants, but there is some concern about the effectiveness of the techniques used at the margins of viability (22-24 wk of gestation). The controversy that exists in this area is largely due to a lack of agreed endpoints for geographically based populations where all live births are considered. Evaluation of outcome must also take the quality of neurological function in surviving infants into consideration, and in reviewing these data the reader is struck by the few reports providing information on a high proportion of survivors. To inform this debate, the "best data" for analysis are reviewed based on a number of criteria of quality for survival and outcome studies. Based on these data sets, < 25% of babies born alive at 24 wk and below survive without major disability. CONCLUSION: An objective review of "best data" will provide the basis of an informed debate on whether providing intensive care for all very immature babies is appropriate in developed countries.     

Airborne transmission from a neonate with Netherton syndrome during an outbreak of MRSA

We encountered a 4 month outbreak of methicillin‐resistant Staphylococcus aureus (MRSA) colonization or infection that was difficult to control despite implementation of standard prevention methods. A neonate with Netherton syndrome had accelerated scaling of the skin and continued positive results for MRSA from clinical samples. The results of air sampling suggested the possibility of airborne transmission. The MRSA outbreak stopped after the patient was transferred to an isolation room, suggesting that airborne MRSA can play a role in MRSA colonization. Isolation rooms should be considered in specific circumstances, as described in the present study.     

Neonatal intensive care provision in the United Kingdom 1992-3

Medical neonatal units in the United Kingdom were surveyed in 1994 to determine for 1992-3 the number of cots, medical and nursing staff, workload, the ability of units to retrieve data and to assess any changes that might have occurred since the NHS reforms. There was an 84% response rate. Many units were unable to provide workload and birthweight specific information. Cot occupancy, and therefore the exposure of individual neonatal nurses to babies requiring intensive care, increased in direct proportion to unit workload. In spite of this a third of all neonatal intensive care, even for babies of <1000 g, is provided by units with ventilator workloads of 50 or fewer babies a year. There was a 25% increase in intensive care level 1 (ICL1) cot provision between 1989 and 1993, but no change in the total number of cots. Consistent maintenance of a common dataset by all units undertaking neonatal intensive care would do much to assist future planning.     

A 6‐year prospective surveillance of healthcare‐associated infections in a neonatal intensive care unit from southern part of Turkey

Aim: To report the incidence of healthcare‐associated infections (HAIs), site of infection and bacterial epidemiology in the Neonatal Intensive Care Unit in a university hospital in Adana, Turkey, between 2001 and 2006. Methods: During these years, HAIs were collected by an active surveillance system. Results: Five hundred one of 2832 infants hospitalised more than 72 h had 1124 HAI. The HAI incidence and incidence density ranged between 14.1 and 29.7 infections/100 patients, and 10.9–17.3 infections/1000 patient days within the study period; 61.5% of HAIs were ventilator‐associated infections; 26.2% were bloodstream infections; 3.5% were urinary tract infections; 3.5% were necrotising enterocolitis (Stages II and III) and 1.4% was meningitis. The most frequent pathogens were gram‐negative pathogens (75.6% of all infections) followed by gram‐positive micro‐organisms (21.4%) and Candida species (3.0%). Birthweight, gestational age and Apgar scores were lower and overall mortality rate (32.9% vs. 19.7%) and number of inpatient days were higher in patients with HAIs (for all P < 0.001) when compared with those who did not have HAIs. Furthermore, HAI rate was inversely related to birthweight (P < 0.001). Conclusion: In this study, the overall infection rate is high compared with developed countries and predominant micro‐organisms are gram‐negative enteric rods. These results strongly suggest the need for improving measures for prevention and control of HAIs in this hospital.