Breast-feeding in neonatal intensive care

Objective : To determine the incidence of breast-feeding in very preterm babies while in neonatal intensive care.
Methodology : A retrospective records analysis of all 151 babies with gestational age less than 35 weeks admitted to the neonatal intensive care unit (NICU) of a major teaching hospital in 1993.
Results : On discharge 64% of babies were having some breast milk (45% having breast milk alone, 19% both breast milk and formula), and 38% some breast-feeding (17% being solely breast-fed, the other 21% combining breast-feeding with either bottle-feeding or an intragastric tube [IGT]). Breast milk was the first milk for 41% of babies, with 83% having breast milk at some stage.
Increasing gestational age was associated with a decreased likelihood of first milk being breast milk (73% of those less than 29 weeks compared to 21% of those aged 33–34 weeks, P <0.001), but with increased rates of breast-feeding (23 compared to 59%, P = 0.01) and breast milk consumption (42 compared to 73%, P = 0.04).
Conclusions : Breast-feeding rates in NICU are well below those found on discharge for full term babies. Both maternal and staff-related factors contribute to this. More and better education of mothers, doctors and nurses as well as changes to some unit practices could increase these rates.     

Audit of drug usage in a regional neonatal intensive care unit

Abstract Drug utilization has been audited prospectively for all infants cared for in a regional neonatal intensive care unit for a 3-month period. Twenty-five infants had a birthweight less than 1500 g and 54 had a birthweight greater than 1500 g. The total number of different drugs used was 76 and the mean number received was 8.6 with a range of 0-30. Infants with birthweights less than 1500 g received a mean of 14.5 drugs and infants with birthweights greater than 1500 g received a mean of 4.8 drugs. Almost two-thirds (63%) of doses were given orally, 20% intravenously and 10% via an umbilical artery catheter. Three drugs, one of which was received by 13% of infants, carried manufacturers'inserts advising against use in premature infants or the newborn.     

Cost-analysis of neonatal intensive and special care

In the present economic climate and with increasing expenditure on neonatal intensive care, there has been a demand for economic evaluation and justification of neonatal intensive care programmes. This study assesses the inhospital costs of neonatal intensive care. Fixed and variable costs were calculated for services and uses of an Intensive/Special Care Nursery for the year 1985 and corrected to 1987 Australian dollar equivalents. Establishing a new neonatal intensive care unit of 43 costs in an existing hospital with available floor space including operating costs for a year were estimated in Australian dollars for 1987 at $6,408,000. Daily costs per baby for each were $1282 ventilator, $481 intensive, $293 transitional and $287 recovery, respectively. The cost per survivor managed in the Intensive/Special Care Nursery in 1985 showed the expected inverse relationship to birthweight being $2400 for greater than 2500 g, $4050 for 2000-2500 g, $9200 for 1500-1999 g, $23,900 for 1000-1499 g and $63,450 for less than 1000 g. Further analysis for extremely low birthweight infants managed in 1986 and 1987 demonstrated costs per survivor of $128,400 for infants less than 800 g birthweight and $43,950 for those 800-999 g. This methodology might serve as a basis for further accounting and cost-evaluation exercises.     

Cost of neonatal intensive care

ABSTRACT. An analysis was made of the costs of provision for the intensive care of inborn babies in an inner city hospital equipped to deal with high risk obstetrics. Costs showed the expected inverse proportion to birthweight. The larger number of more mature babies nevertheless contributed almost 2/3 of the total cost. The adjusted cost/survivor ("adjusted'to reflect the fact that only the survivors benefit) was $39,845 for babies less than 801 g; $26,100 for those between 801 g and 1,000 g; $14,137 between 1,001 g and 1,500 g and $4,782 over 1,500 g. The largest single expense was in nursing salaries which constituted 60–80% of the total outlay.
No data are available for precise comparison. The figures are presented as a basis on which to begin forming judgements of the cost effectiveness of newborn intensive care.     

A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units

To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.

Method:

A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.

Results:

Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208–1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies ( n =66, and nine of them also had incomplete records) and incomplete records ( n =82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.

Conclusion:

The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.     

Death in neonatal intensive care

The aim of this study was to review the frequency of decisions to withdraw treatment from neonates who had died in a large neonatal intensive care unit the reasons for these decisions, and the procedures followed. A 12 month retrospective review of medical and nursing records was undertaken. There were 67 deaths; treatment was withdrawn from 52 infants who were dead or dying, from 9 infants on the basis of a severe congenital abnormality, and from 6 infants with severe acquired brain damage. The decision-making process and the management of treatment withdrawal are reviewed. It is concluded that withdrawal of treatment resulting in death occurs frequently in the neonatal intensive care service of National Women's Hospital, Auckland, New Zealand, but is usually a recognition of the inevitable. Truly elective withdrawal of treatment is uncommon in the immature infant, but does occur in the context of multiple abnormalities or severe birth asphyxia, where it follows a formal procedure.     

Bacterial endocarditis in neonatal intensive care

OBJECTIVES: To ascertain the incidence of bacterial endocarditis in a level III neonatal nursery. To document the clinical features, assess survival, and evaluate the role of central venous catheters in neonates with bacterial endocarditis. METHODOLOGY: Index cases were identified by retrospective review of the echocardiographic records of infants admitted to the neonatal nursery from 1983 to 1995. Data obtained by review of the clinical records of these infants, and case-matched controls. RESULTS: From January 1983 to December 1995, 12,249 infants were admitted to the Special Care Nursery. Eight infants with endocarditis were identified, an incidence of 0.07%. Presenting symptoms and signs were often vague and nonspecific. Gestation less than 32 weeks, birthweight less than 1500 g, thrombocytopenia and neutropenia or neutrophilia were common features. Infants with endocarditis had a significantly higher Clinical Risk Index for Babies score than those without endocarditis. The tricuspid valve was involved in seven infants, six of whom had a percutaneous central venous catheter in situ before diagnosis. Mitral valve involvement occurred in two infants, neither of whom had central lines inserted. However, compared to infants without endocarditis, the placement of a central venous line was not of statistical significance. Seven of the eight infants survived following prolonged antibiotic therapy. CONCLUSIONS: Bacterial endocarditis is a rare but serious condition which is usually not fatal. In the premature newborn infant, presenting signs and symptoms are often nonspecific. Endocarditis should therefore be considered in the unwell very low birthweight infant.     

Spectral analysis of noise in the neonatal intensive care unit

Objective  To perform spectral analysis of noise generated by equipments and activities in a level III neonatal intensive care unit (NICU) and measure the real time sequential hourly noise levels over a 15 day period. Methods  Noise generated in the NICU by individual equipments and activities were recorded with a digital spectral sound analyzer to perform spectral analysis over 0.5–8 KHz. Sequential hourly noise level measurements in all the rooms of the NICU were done for 15 days using a digital sound pressure level meter. Independent sample t test and one way ANOVA were used to examine the statistical significance of the results. The study has a 90% power to detect at least 4 dB differences from the recommended maximum of 50 dB with 95 % confidence. Results  The mean noise levels in the ventilator room and stable room were 19.99 dB (A) sound pressure level (SPL) and 11.81 dB (A) SPL higher than the maximum recommended of 50 dB (A) respectively (p < 0.001). The equipments generated 19.11 dB SPL higher than the recommended norms in 1–8 KHz spectrum. The activities generated 21.49 dB SPL higher than the recommended norms in 1–8 KHz spectrum (p< 0.001). The ventilator and nebulisers produced excess noise of 8.5 dB SPL at the 0.5 KHz spectrum. Conclusion  Noise level in the NICU is unacceptably high. Spectral analysis of equipment and activity noise have shown noise predominantly in the 1–8 KHz spectrum. These levels warrant immediate implementation of noise reduction protocols as a standard of care in the NICU.     

A framework for ethical decision making in neonatal intensive care

Intensive care for neonates with high risks of severe impairment and the possibility of a prolonged dying process represents a frequent ethical issue in neonatal units. The aim of this paper is to present a framework for structured decision making that has been developed in a neonatal intensive care unit and to demonstrate its impact on the healthcare team and on survival of critically ill neonates. This framework attempts to integrate the best interests of the infants and their parents, the possibilities of high-tech neonatal intensive care interventions, and the perspective of the nurses and doctors. An external evaluation of 84 sessions over 3 y revealed a beneficial effect on the quality of the decision-making process itself and on the quality of the teamwork in the unit. Survival time was shorter (median 2 d, interquartile range 1-7 d) in 26 infants that died after structured decision making compared with 26 controls matched for gestational age, malformation and intracranial haemorrhage (median 7 d, interquartile range 4-15 d).

Conclusion: The introduction of this framework for structured decision making involving doctors and nurses improved the quality of the teamwork. It shortened futile intensive care, and thereby suffering for both infants and parents.     

Bacterial changes in neonatal intensive care unit

Organisms routinely cultured from throat swabs and infectious agents of sepsis and/or meningitis were reviewed. During the last 12 years, Klebsiella pneumoniae and Escherichia coli have been replaced by Staphylococcus aureus and Pseudomonas aeruginosa as the predominant isolates from throat swabs after admission. These change in the etiologic pattern of infectious agents of sepsis and/or meningitis, i.e., K. pneumoniae, E. coli, S. aureus, P. aeruginosa and staphylococcus epidermidis, were in agreement with the organisms isolated from the throat swabs after admission. The S. aureus isolated from throat swabs after admission showed a decrease in the bacterial activity of cloxacillin, cephazolin and cefotaxime since 1978.     

A review of chest physiotherapy in neonatal intensive care units in Australia

Clinical techniques and protocols for chest physiotherapy vary greatly from one Neonatal Intensive Care Unit to another. In 1988 a questionnaire designed to investigate differing techniques used was distributed to Neonatal Intensive Care Units (NICU) around Australia. Fourteen of the 15 questionnaires were completed and returned. The results revealed that the methods of chest treatment and the indicators for commencing chest treatment were similar throughout NICU. Both physiotherapists and nursing staff played a role in the performance of chest treatment in all but one unit where it was the responsibility of nursing staff. However, the area in which there was most variability between NICU was the individual treatment protocols employed pre- and postextubation of the neonate. A review of literature over the past 10 years also demonstrates variability in chest physiotherapy. It was concluded that further well-controlled studies with larger sample sizes are needed to validate the use of chest physiotherapy for the neonate, especially in relation to the techniques and specific protocols employed.     

Linguistic skills at 6 1/2 years of age in children who required neonatal intensive care in 1986-1989

Linguistic skills at 6 1/2 y of age, corrected for gestational age at birth, were examined in a cohort of 230 children who had required neonatal intensive care (NIC) in 1986-89, and in 71 fullterm neonatally healthy control children (C) matched to the NIC children born at < 32 gestational weeks. Ten linguistic areas were assessed. The 10th percentile score of the controls was identified in each linguistic area and used for comparisons. In 77.5% of the controls and 63.5% of the NIC children, no score was lower than the 10th percentile score of the controls. Scores lower than the 10th percentile score were more common in NIC children born at term or at 23-31 wk, and within this group of children those born at 23-27 wk, than in controls. Conclusion: In preterm children of < 32 wk the results in the linguistic areas of imitation of articulatory positions, comprehension of logical grammatical constructions, phonemes and word fluency differed from those of the matched controls, and in NIC children born at > or = 32 weeks the results for imitation of articulatory positions, articulatory patterns and sentences, auditory discrimination and word fluency were poorer than those of the controls.     

End-of-life decisions in delivery room and neonatal intensive care unit

Background: The increase in neonatal survival in recent decades has been followed by an increase in later disabilities. This has given rise to many new ethical issues. In different countries, efforts are being made to define ethical guidelines regarding withholding or withdrawing intensive care and end-of-life decisions in critically ill newborn infants. These guidelines have to be differentiated from ethical decision-making models which structure the process of decision making for an individual child. Such a framework has been in existence in our clinic for 10 years. Aim: The aims of this study were to evaluate how end-of-life decisions are taken in our perinatal centre and to analyse whether these decisions are consistent with our framework for structured ethical decision making. Methods: 199 consecutive neonatal deaths over 5 y were evaluated. Results: In 157 cases (79%), end-of-life decisions were taken according to our ethical framework; in the remaining 42 cases (21%), the baby died before this could be done. In 92% of cases, parents were involved in the decision and, in all cases but one, agreed with the decision. A patient's life was never intentionally and actively terminated.

Conclusion: In contrast to earlier years, in-hospital death in our clinic is nowadays usually preceded by structured and documented medical end-of-life decisions.     

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.