Views on neonatal care of newborns weighing less than 500 grams

The limit of viability is intensely debated. Newborns below 500 g birthweight are often small for gestational age with an increased risk of short- and long-term mortality and morbidity. The level of given neonatal care must be individualized. A long-term follow-up for newborns with extremely low birthweight is urgently needed.     

Premature infants weighing less than 1000 grams: mortality, morbidity and short-term neurologic outcome

The outcome of 60 premature infants weighing less than 1,000 g at birth and consecutively born during the years 1986 to 1988 is reported. Forty-two (70%) of them were inborn. The overall mortality rate was 42%, but only 26% in the inborn group instead of 78% in the outborn group (P less than 0.001). The mortality rate was higher for the appropriate for gestational age infants (56%) than for the growth retarded infants (14%, P less than 0.01). The main neonatal problems were the following: hyaline membrane disease (63%), patent ductus arteriosus (7%), bronchopulmonary dysplasia (8%), necrotizing enterocolitis (15%), intraventricular hemorrhages (45%) and periventricular leukomalacia (12%). Twenty percent (7/35) of the surviving infants showed abnormal neurodevelopmental outcome, with only one (3%) having major handicap. No correlation was found between gestational age and neuro-developmental outcome.     

Outcome and hospital cost for infants weighing less than 500 grams: a tertiary centre experience in Taiwan

AIM: To determine the outcome and hospital cost for infants weighing < or =500 g at a tertiary centre in Taiwan. METHODS: We retrospectively reviewed the medical records of infants who were born alive with birthweight < or =500 g at the National Taiwan University Hospital from 1997 to 2004. Their outcome and hospital cost were analysed. RESULTS: A total of 168 infants were included for analysis that 146 of them died after compassionate care in the delivery room and 22 received postnatal resuscitation. The infants who received resuscitation were more likely to have higher birthweights, older gestational ages and multiple births compared with those who received compassionate care. After resuscitation, five of the infants died and 17 were admitted to neonatal intensive care unit (NICU) for further management. Subsequently, 12 infants died and five infants survived to discharge. Two infants were discharged against advice and died within days. After exclusion of those receiving compassionate care, the NICU survival rate was 22.7% and the long-term survival rate was 13.6%. The most common early morbidities were respiratory distress syndrome, intraventricular haemorrhage and patent ductus arteriosus, whereas the late morbidities included cholestatic jaundice, retinopathy of prematurity and chronic lung disease. The average total hospital costs for the NICU survivors with birthweight < or =500 g was US $42,411 and the average hospital cost per day was US $350. CONCLUSION: Exclusive compassionate care was given to the majority of the infants weighing < or =500 g in Taiwan. The survival rate remained low in these marginally viable infants.     

Growth and development of infants weighing less than 800 grams at birth

A prospective study of infants weighing less than 800 g at birth and cared for in a single neonatal intensive care unit between 1977 and 1980 was conducted. Neonatal mortality was 80%; neurodevelopmental outcome was assessed in 16 of the 18 survivors. Mean birth weight for these 16 was 730 g; mean gestational age was 26 weeks. Perinatal asphyxia, respiratory distress, apnea, mechanical ventilation, and chronic pulmonary disease were commonplace. Symptomatic intracranial hemorrhage, seizures, sepsis, or meningitis did not occur in survivors. Of the 16 infants, 13 (81%), including all three with birth weight less than 700 g, were without major CNS handicaps and were developing appropriately at 6 months to 3 years of age. Only one of the 16 had clearly subnormal mental development. None had a major visual or hearing impairment. Apgar scores at one and five minutes were significantly related to outcome; apnea, mechanical ventilation, and chronic pulmonary disease were not. These data suggest that a remarkably hopeful outcome is possible for the few survivors of extremely low birth weight.     

Patterns of fungal colonization in preterm infants weighing less than 1000 grams at birth

BACKGROUND: Colonization with Candida spp. is an important risk factor for systemic infection in very low birth weight (VLBW; <1500 g) and extremely low birth weight (ELBW, <1000 g) infants. ELBW infants are at a higher risk than VLBW infants for fungal sepsis and its associated mortality, but few studies have examined fungal colonization exclusively in ELBW infants. METHODS: Fungal colonization data were analyzed retrospectively in 50 high risk ELBW infants. Weekly surveillance fungal cultures of the skin, gastrointestinal tract, respiratory tract and umbilicus had been performed from birth through the first 6 weeks of life. Colonization was analyzed for time of initial colonization, site, species and spread of Candida from one site to another. RESULTS: Candida was isolated from surveillance cultures in 31 of 50 (62%) infants. Colonization was inversely proportional to gestational age. Initial week of both the fungal colonization of the skin [1 (0-6) week, median (range)] and gastrointestinal tract [2 (0-6)] preceded colonization of the respiratory tract [3 (1-6)] (P = 0.0001). Among infants colonized by only 1 of the species, colonization at 2 or more sites occurred similarly with Candida albicans (77%) and Candida parapsilosis (85%), whereas colonization at 3 or more sites occurred more frequently with C. albicans (69%) compared with C. parapsilosis (23%) (P = 0.047). CONCLUSIONS: Fungal colonization occurs on the skin and gastrointestinal tract before the respiratory tract. In addition, C. albicans is more likely than C. parapsilosis to colonize multiple sites.     

Theophylline treatment in the extubation of infants weighing less than 1,250 grams: a controlled trial

The role of theophylline in weaning infants weighing less than 1,250 g at birth from mechanical ventilation was evaluated. Infants were randomized into control or theophylline treatment groups when they required minimal ventilatory support (peak inspiratory pressure 12 cm H2O, positive end-expiratory pressure 2 cm H2O, rate 12 breaths per minute, and FiO2 less than 0.3), and they were extubated 24 hours later. Infants required reintubation if they had (1) PaCO2 greater than 55 mm Hg and pH less than 7.20, (2) FiO2 greater than 0.5, or (3) apnea associated with a heart rate less than 100 beats per minute that required frequent stimulation (more than 20 episodes during a 16-hour period). Among 32 infants (birth weight less than 1,000 g) who reached minimal ventilatory support before seven days after delivery, 13 of 18 (72%) control infants required reintubation, whereas only four of 14 (28%) theophylline-treated infants required reintubation. On the other hand, among infants (birth weight less than 1,000 g) who reached minimal ventilatory support after seven days following delivery, only one of six (17%) of the control group required reintubation and no improvement could be seen with theophylline treatment. Similarly, among control infants (birth weight 1,001 to 1,250 g), only ten of 45 (23%) required reintubation after reaching low intermittent manditory ventilation settings. In summary, most infants recovering from respiratory distress syndrome who had birth weights (1) greater than 1,000 g or (2) less than 1,000 g and who were older than seven days could be successfully extubated from minimal ventilatory support without theophylline treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Tiniest Babies Registry: A registry of survivors born weighing less than 400 grams

The Tiniest Babies Registry was launched in the year 2000 as a web-based registry for patients who survived to discharge after being born with birth weights below 400 grams. The registry began with 15 patients and by January 2022 had grown to 291, ranging in birth weight from 212 to 399 grams and in gestational age from 21 to 34 weeks. Three patients were born in the 1930s, and no others were born until 1985. The greatest number in a single year was 21 in 2010. The infants were born in 16 countries, but 166 of 291 (57%) were born in the U.S. All except 10 of the infants were small for gestational age at birth. No systematic data on the long-term outcomes of these patients is available, but the information submitted by selected registry participants indicates they are at increased risk for continued delays in growth and development.     

Consistency and change in the development of premature infants weighing less than 1,501 grams at birth

Ninety-four infants with birth weights less than 1,501 g were evaluated on neurologic functioning and mental abilities at 1 year and, again, at 3 to 4 years of age. Results of the examination showed high correspondence in neurologic status and in mental ability between infancy and the preschool period, particularly for children who were diagnosed as clearly normal or abnormal at 1 year. In addition, poorer performance in a test of infant mental ability (which relies primarily on sensorimotor skills), in motor skills, and in neurologic functioning, respectively, were linked to lower IQ, difficulties in expressive language, and articulation deficits at the preschool age. Socioeconomic status predicted 3-year IQ scores and changes in mental ability scores but was not a factor in determining either preschool age neurologic status or changes in neurologic status in the children studied. Socioeconomic status of the children was less predictive of preschool outcome than results of the 1-year examinations.     

Reduction of mortality, morbidity, and respiratory distress syndrome in infants weighing less than 1,000 grams by treatment with betamethasone and ritodrine

The efficacy of betamethasone has been questioned in infants of less than 28 week's gestation. From January 1983 to June 1986, 86 infants weighing 600 to 1,000 g were born at our center. Control of labor was attempted with ritodrine in all patients with less than or equal to 5 cm cervical dilation. If control were obtained, betamethasone was given 30 minutes later. Significant differences were found between the 33 infants born after 24 hours of betamethasone and those delivered before in terms of survival 90.1% v 56.6% (P = .001), respiratory distress syndrome 27.2% v 73.6% (P = .0001), and need for intermittent positive pressure ventilation 42.4% v 81.1% (P = .0005). The average hospital stay for beta-treated infants was 82 days v 99 days for nontreated infants. The average exposure to O2 after betamethasone was 12.7 days v 20.2 days, (P = .01), although need for intermittent positive pressure ventilation was similar (23 days) in the two groups. In infants who survived greater than 48 hours, the incidence of patent ductus arteriosus in the beta-group was 18.8% (6/32) v 44.4% (16/36) in the nontreated group (P = .04). Our data suggest that in infants weighing less than 1,000 g, control of labor with ritodrine for a minimum of 24 hours and administration of betamethasone can reduce significantly not only the incidence of respiratory distress syndrome but also mortality and morbidity.     

High-frequency ventilation in the treatment of infants weighing less than 1,500 grams with pulmonary interstitial emphysema: a pilot study

Pulmonary interstitial emphysema is one of the most serious complications of the respiratory distress syndrome. Its presence significantly increases morbidity and mortality. Preliminary reports have demonstrated the success of high-frequency ventilation in the treatment of pulmonary interstitial emphysema. In a previous investigation, we were able to develop a formula for predicting death in infants weighing less than 1,500 g with pulmonary interstitial emphysema. Using this subgroup of severely affected infants, we studied the efficacy of high-frequency ventilation in nine infants. Using the Volumetric Diffusive Respirator, we observed improvement in all respiratory values measured (pH, PCO2, and PO2), a significantly decreased mean airway pressure (MAP), and improvement in neonatal mortality. Complications of severe bleeding diatheses, hypotension, bronchopulmonary dysplasia, and necrotizing tracheobronchitis were observed. Our investigation was the first to systematically choose infants who might benefit from high-frequency ventilation and to compare them with similar infants with known outcomes. We realize that the study was rescue in nature using historical controls, but we felt compelled to assure the safety of the device before randomizing less sick infants. High-frequency ventilation appears to be effective in the acute management of low birth weight infants with pulmonary interstitial emphysema.     

Two year longitudinal followup of premature infants weighing less than or equal to 1,200 grams at birth: sequelae of intracranial hemorrhage

Intracranial hemorrhage (ICH) is a major problem for the premature infant, occurring in more than one-third of surviving infants weighing less than or equal to 1,500 g at birth. The literature on perinatal ICH, as it relates to neurodevelopment outcome, is briefly reviewed, and preliminary results from our two-year followup of 75 less than or equal to 1,200-g infants are summarized. An analysis of pathophysiology, diagnosis, classification, and followup indicates that risk for ICH and its sequelae increases as gestational age and birth weight decrease. Hydrocephalus apparently no longer presents significant risk beyond that conveyed by the original hemorrhage. However, persistent posthemorrhagic ventriculomegaly and/or periventricular abnormalities serve as significant "markers" of risk for neuromotor delay through two years of age. In contrast, recovery of normal ventricular morphology by term gestational age apparently indexes a degree of recovery from ICH and predicts a more normal developmental outcome through the first two postnatal years.     

Prolonged mechanical ventilation and intracranial hemorrhage: impact on developmental progress through 18 months in infants weighing 1,200 grams or less at birth

In this prospective, longitudinal study, the relative impact of intracranial hemorrhage and prolonged mechanical ventilation on developmental progress during the first 18 months of life of infants weighing 1,200 g or less at birth was examined. A total of 159 surviving infants were divided into two groups: infants with and those without intracranial hemorrhage. These groups were then subdivided into groups of infants receiving prolonged mechanical ventilation (greater than 21 days) and those mechanically ventilated for 21 days or less, thus creating four subgroups. Group 1 (intracranial hemorrhage and prolonged mechanical ventilation) and group 3 (intracranial hemorrhage and no prolonged mechanical ventilation) showed no statistically significant differences for severity of intracranial hemorrhage, persistence of ventriculomegaly, or presence of periventricular leukomalacia. A repeated-measures analysis of variance demonstrated a main effect for prolonged mechanical ventilation on outcome as measured by the Bayley Mental Development Index and Bayley Psychomotor Development Index at 4, 8, 12, and 18 months of age (corrected for prematurity). Forward stepwise regression revealed prolonged mechanical ventilation to the best predictor of Bayley indexes at all ages except 4 months of age, for which the Psychomotor Development Index was best predicted by length of hospitalization. No main effect for intracranial hemorrhage was demonstrated, but the motor performance of infants with intracranial hemorrhage declined significantly with age. By contrast prolonged mechanical ventilation was associated with uniformly poor performance at every age and serves as a powerful marker for poor developmental progress during the first 18 months of life in infants weighing 1,200 g or less at birth.     

Inguinal hernia: a common problem of premature infants weighing 1,000 grams or less at birth.

Thirty percent of 37 consecutive surviving premature infants weighing 1,000 gm or less at birth were noted to develop inguinal hernias. Incarceration occurred in two infants. One infant suffered a cardiac arrest during repair of the hernia. In view of the increased survival now being reported in these tiny prematures, it is important that physicians recognize the high incidence and potential hazards of this congenital anomaly in surviving premature infants weighing 1,000 gm or less at birth.