Outcome for newborn babies declined admission to a regional neonatal intensive care unit

Between July 1979 and June 1980 the regional neonatal intensive care unit (NICU) at St Mary's Hospital, Manchester, received 170 requests from maternity units for the transfer of ill newborn babies. Most of the babies were suffering from respiratory failure. The initial request was declined in 65 babies because of overcrowding or lack of facilities at the NICU (n = 59), or because transfer was not justified on medical grounds (n = 6). Forty-two of the 65 babies were compelled to remain in the maternity unit because they could not be accommodated at hospitals with facilities for ventilating newborn babies. The neonatal survival rate of babies with respiratory failure who were transferred to the NICU was 66% whereas the survival rate of similar babies who were declined transfer was 30%. Our findings support the efficacy of intensive care for ill babies with respiratory failure and suggest that such facilities need to be more widely developed.     

Referrals to a regional neonatal intensive care unit.

Over a three year period 444 requests for the neonatal transfer of babies with acute medical problems were received at this regional neonatal medical unit. Despite an increase in available resources in the North Western Health Region the provision of intensive care remained inadequate with 38% of requests declined, and babies had to be referred elsewhere including to neighbouring health regions. The survival of those babies who had to remain at the hospital of birth (49%) was significantly lower than for those transferred to the regional centre (71%). Those babies declined admission had significantly lower gestational ages and birth weights than those accepted. For those babies with respiratory failure and birth weights of less than 1500 g within these two groups, however, there were no significant differences in birth weight, gestational age, or gender yet survival was significantly better for those transferred. Babies from multiple pregnancies caused particular problems if neonatal transfer was required.     

Evolution of neonatal intensive care in a district general hospital.

Before 1975 in Blackburn in the Premature Baby Unit monitoring facilities were limited. Ambient oxygen monitoring, blood gas analysis, and ventilation were not being performed. Gradually, special care was introduced and from 1978-80 all babies requiring intensive care and long term ventilatory care were transferred to the Regional Neonatal Intensive Care Unit. Not all babies with incipient or established respiratory failure, however, could be accepted, and those declined had unfavourable outcomes. In 1981 local intensive and ventilatory care was begun, and since then the survival of all babies has improved considerably. Our early neonatal mortality and neonatal mortality have fallen below the regional levels. In a district general hospital it is possible to achieve survival figures comparable with those of a regional centre.     

Early functional echocardiogram and inhaled nitric oxide: usefulness in managing neonates born following extreme preterm premature rupture of membranes (PPROM)

Aim: Poor neonatal outcome of preterm premature rupture of membranes (PPROM) <24 weeks' gestational age (GA) is probably a result of abnormalities in both airway and vascular developments, ventilation perfusion mismatch, and possibly persistent pulmonary hypertension of the newborn (PPHN). Perinatal mortality of 50–90% has been reported in the past, with recent literature reporting significant improvement in neonatal survival. We report our 8‐year experience in this group of infants using early diagnostic functional echocardiography (fECHO), high‐frequency ventilation (HFV) and inhaled nitric oxide (iNO). Methods: The obstetric and neonatal databases were searched to identify babies with PPROM (<20 weeks' gestation) or rupture earlier than 25 weeks for more than 14 days. Results: Twenty‐six infants were identified, of whom 20 were admitted to the neonatal intensive care unit (NICU; mean GA 27.8 weeks, mean birth weight (BW) 1207 g). Early echocardiographic data were available in 12/15 infants requiring mechanical ventilation of whom 10 had evidence of PPHN. All infants who received iNO therapy survived to discharge and only two infants died. Survival to discharge was 69% for the whole cohort of infants and 90% for infants admitted to the NICU. In contrast, for the cohort from pre‐iNO and ‐HFV era, the overall survival to discharge was 62% and 66% for the infants admitted to the NICU. Conclusion: Premature infants with PPROM and presumed severe hypoxemic respiratory failure because of hypoplastic lungs often have significant PPHN and may show improvement in oxygenation after treatment with HFV and iNO. Early fECHO results in earlier identification and treatment of infants with PPHN in this high‐risk group.     

Neonatal Outcome of Extremely Small Low Birth weight Liveborn Infants Below 901 g in a Swedish Population

ABSTRACT. In a regional population of 32120 liveborn newborn infants 65 (0.2%) had a birthweight ≤900 g (extremely small low birthweight = ESLBW) with mean gestational age 26.4 (range 22–31) completed weeks of gestation. The total 0–1 year survival rate was 48%. For the 42 infants treated in the Level III regional neonatal intensive care unit (NICU) the 0–1 year survival rate was 55% versus 34% for 23 infants not transferred to the Level III unit. In the ESLBW infants treated in the regional NICU the major complications were respiratory disorders requiring artificial ventilation (73%), bronchopulmonary dysplasia (26%), intracranial haemorrhages (40%), symptomatic persistent ductus arteriosus (36%) and sepsis (14%), persistent retinopathy of prematurity (8%). Duration of NICU treatment was 51 days (range 10–95) for survivors. Mode of delivery and rate of perinatal complications did not differ between survivors and non-survivors. Previous legal abortion occurred in 24%, fertility problems in 29% and 21% of the mothers, were immigrants. Otherwise no significant abnormalities were found in maternal or socioeconomic conditions. Factors deciding neonatal outcome in the tiniest babies seem to be a combination of prenatal circumstances and neonatal minute fine care procedures.     

Neonatal outcome of extremely small low birthweight liveborn infants below 901 g in a Swedish population

In a regional population of 32,120 liveborn newborn infants 65 (0.2%) had a birthweight less than or equal to 900 g (extremely small low birthweight = ESLBW) with mean gestational age 26.4 (range 22-31) completed weeks of gestation. The total 0-1 year survival rate was 48%. For the 42 infants treated in the Level III regional neonatal intensive care unit (NICU) the 0-1 year survival rate was 55% versus 34% for 23 infants not transferred to the Level III unit. In the ESLBW infants treated in the regional NICU the major complications were respiratory disorders requiring artificial ventilation (73%), bronchopulmonary dysplasia (26%), intracranial haemorrhages (40%), symptomatic persistent ductus arteriosus (36%) and sepsis (14%), persistent retinopathy of prematurity (8%). Duration of NICU treatment was 51 days (range 10-95) for survivors. Mode of delivery and rate of perinatal complications did not differ between survivors and non-survivors. Previous legal abortion occurred in 24%, fertility problems in 29% and 21% of the mothers were immigrants. Otherwise no significant abnormalities were found in maternal or socioeconomic conditions. Factors deciding neonatal outcome in the tiniest babies seem to be a combination of prenatal circumstances and neonatal minute fine care procedures.     

Regionalized perinatal care in developing countries.

Neonatal-perinatal ill health and mortality are overwhelmingly a burden of the developing world. As many as 90% of births, 98% of fetal deaths and 98% of neonatal deaths occur in less developed countries. Regionalized perinatal services were introduced in developed countries when most neonatal mortality was confined to very-low-birthweight babies who required intensive perinatal care to survive. A large proportion of newborn morbidity and mortality in developing countries, however, continues to occur among full-term and moderate-sized low-birthweight neonates who can be managed well in the community and at small hospitals. The model of regionalized perinatal care as practiced in developed countries is, at present, neither affordable nor relevant to the needs of many developing countries. It is possible to achieve considerably lower neonatal mortality rates in resource-poor settings by implementing home-based newborn care delivered by community health workers, and by promoting institutional perinatal care at simple facilities provided by trained midwives.     

Neurodevelopmental outcome of babies weighing less than 2001 g at birth: influence of perinatal transfer and mechanical ventilation.

From 1976 to 1980, 1034 children who had weighed less than 2001 g at birth were cared for at the North Western regional neonatal intensive care unit. Of these, 315 babies were neonatal referrals and 91 were born in the unit after antenatal transfer from their district hospital. Significantly fewer of the babies referred as neonates survived (n = 167, 53%) compared with 67 of the antenatal referrals (74%), and 490 of those born in the unit (78%). They also had a higher incidence of major handicaps (24 of 167, 14%) compared with six of 67 (9%) of the antenatal referrals and 35 of 490 (7%) of those born in the unit. To control for selection bias among neonatal referrals, the outcome of ventilated neonatal referrals was compared with that of ventilated babies born in the unit. The two groups were comparable for the incidence of a wide range of neonatal complications. No differences in rates of survival or handicap were found. We conclude that sick babies transferred after birth to regional neonatal intensive care units have similar short and long term outcomes to sick babies born in regional units.     

Chest radiographs of neonates with respiratory failure caused by congenital syphilis

Congenital syphilis still occurs in newborn babies and the prevalence has increased in recent years, especially in developing countries. This has led to an increase in the number of babies with congenital syphilis requiring intensive care for respiratory failure. The early recognition of this disease could lead to the institution of timely and appropriate treatment. In this study the radiological picture of syphilitic pneumonitis is described in 20 neonates admitted to our neonatal intensive care unit requiring ventilation for respiratory failure. The radiological picture of the babies with syphilis was compared to 20 babies with other causes of respiratory distress. The radiological picture in 17 babies demonstrated a coarse nodular pattern in addition to band-like opacities radiating from the hilar regions. The nodular opacities became confluent on follow-up radiographs. In 13 cases, the proximal humeri showed changes typical of congenital syphilis. Two of the three babies with syphilis who did not have the typical chest radiological picture had bony involvement visible on the chest radiograph. Both the sensitivity and specificity of radiographic diagnosis were 75% with a positive and negative predictive value of 75%. The diagnosis of congenital syphilitic pneumonitis can therefore be suspected on chest radiographs and should be included in the differential diagnosis of any baby who presents with an interstitial pattern on chest radiography.     

Nasal continuous positive airway pressure for neonatal back transfer

We report the use of nasal continuous positive airway pressure (nCPAP) for neonatal back transfer of 51 babies. nCPAP may be used to provide safe respiratory support during back transportation of infants. Babies transferred on nCPAP were significantly smaller and of younger postmenstrual age than historical comparators who had to wait for transfer until independent of nCPAP. nCPAP transferred babies spent significantly less time on the intensive care unit.     

无创经皮监测氧气和二氧化碳在新生儿的应用

无创经皮监测(transcutaneous monitoring,TCM)氧气和二氧化碳是新生儿重症监护室(neo-natal intensive care unit,NICU)的常用技术,具有连续性、无创性的特点,能直观反映危重新生儿呼吸和循环功能的变化,对新生儿监护意义重大.该文阐述TCM的使用方法,比较TCM与其他监测手段的优缺点,并介绍其在新生儿转运及NICU的应用.     

Maternal and neonatal profile and immediate outcome in ELBW babies

The present study was designed to ascertain the maternal and neonatal profile and immediate outcome of extremely low birth weight (ELBW) babies at a Level III neonatal intensive care unit (NICU). Case records of ELBW inborn babies delivered between August 2000 and August 2001 were analyzed by using a preset proforma. A total of 52 ELBW babies were admitted in NICU in the relevant period, out of which 30 (57%) survived. Maternal anemia and previous pre-term (PT) delivery were the common predisposing factors for PT delivery. Mean gestational age was 27.8 weeks and mean birth weight was 831 grams. Mortality was highest in babies less than 28 weeks gestation. Neonatal hyper-bilirubinemia (78%) and HMD/RDS (65%) were the commonest morbidity. Retinopathy of Prematurity (ROP) screening could be done in 35 babies (68%), out of which 22 were found to be normal.     

极低出生体质量儿脑损伤及高危因素分析

目的调查极低出生体质量儿脑损伤发病情况,分析其高危因素,以降低发病率,改善神经发育预后。方法回顾性分析181例极低出生体质量儿脑损伤发生情况,分析脑损伤组与无损伤组在基本情况、产科病理症、干预措施、合并症方面的差异,并对相关危险因素行Logistic回归分析。结果181例极低出生体质量儿中检出脑损伤78例,发生率43.09%。其中,脑室周围-脑室内出血(PVH-IVH)67例(Ⅰ级43例,Ⅱ级12例,Ⅲ级10例,Ⅳ级2例),发生率37.01%;脑室周围白质软化(PVL)12例,发生率6.63%,其中1例合并Ⅲ级IVH。胎龄越低,脑损伤发生率越高;脑损伤组与无损伤组在性别、胎数、出生体质量、分娩方式、宫内窘迫、胎膜早破、母亲妊高征、胎盘早剥、宫内发育迟缓(IUGR)方面差异均无统计学意义(P0.05)。在治疗措施方面,除氨茶碱两组无差异外,应用肺表面活性物质(PS)、经鼻持续正压通气(nCPAP)、常频通气、高频通气治疗在脑损伤发生率方面差异均有统计学意义(P0.05)。在合并症方面,两组在窒息、新生儿呼吸窘迫综合征(NRDS)、高碳酸血症、代谢性酸中毒、高血糖、贫血、动脉导管未闭(PDA)发生率差异有统计学意义(P0.05),在低血糖、败血症、血小板减少、呼吸暂停、肺出血、高胆红素血症差异无统计学意义(P0.05)。Logistic回归分析显示NRDS、PDA、高频震荡通气是脑损伤最重要的高危因素。结论极低出生体质量儿是脑损伤高危人群。应用PS、nCPAP、常频通气、高频通气以及窒息、NRDS、高碳酸血症、代谢性酸中毒、高血糖、贫血、PDA与脑损伤发生相关联,其中NRDS、PDA、高频震荡通气是重要高危因素。     

Clinical features of neonates treated in the intensive care unit for respiratory distress

The aim of this study was to determine the indications for hospitalization, clinical features, and risk factors in neonates treated in the intensive care unit (ICU) for respiratory distress. Patients who were treated in the neonatal intensive care unit (NICU) for respiratory distress between 1 January 2008 and 31 December 2008 were included in the study. The indications for hospitalization, duration of hospitalization, clinical features, risk factors, maternal age, number of pregnancies, duration of antibiotic treatment, and mortality rate were retrospectively obtained from hospital records and evaluated. The medical records of 240 neonates treated in the ICU during a one-year period were evaluated. Of the neonates, 64.6% were boys, 20.4% were premature, and 71.7% were born by cesarean section. The most frequent indication for hospitalization was tachypnea of the newborn (76.7%). Meconium aspiration syndrome and respiratory distress syndrome were also among the frequent indications for admission to the NICU. Recognition of risk factors for respiratory distress in neonates is crucial for development of prevention and early treatment strategies, and correct timing of elective cesarean sections is important for reduction in morbidity and mortality.     

Epidemiology, economics, and ethics in the NICU: reflections from 30 years of neonatology practice

Over the past 30 years, I have noted 4 epidemiological points, each of which, I believe, must inform future conversations between neonatal intensive care unit (NICU) physicians, parents, and policy makers. First, there are no credible arguments against NICU care that rely on invoking cost or distributive justice. NICU dollars are remarkably well targeted to children who will ultimately survive to be discharged, as opposed to die in the NICU. If any rationing arguments are to be made, then they should be directed against sick adults in intensive care units. Second, the vast majority of infants admitted to the NICU, even infants sick enough to require mechanical ventilation, will survive to be discharged home-and every caretaker knows this, every day. Again, these findings stand in sharp contrast to adult patients in intensive care, where discordant predictions of survival are the norm, not the exception. Third, medical caretakers are remarkably poor at predicting which infants will die in the NICU, using either serial illness severity algorithms or serial intuitions. Nearly half of all babies predicted to die in the NICU by either strategy will survive to be discharged nonetheless. Fourth, and finally, medical caretakers seem remarkably good at identifying burdensome outcomes (either death or survival with permanent serious neurological disability) while babies are still sick enough that an alternative (ie, withdrawal of the ventilator) is ethically possible. Only 5% of ventilated extremely low birth weight babies receiving ventilation who are predicted to die before NICU discharge will be alive and neurologically unscathed at 2 years of age.     

Feasibility of surgery for patent ductus arteriosus of premature babies in a neonatal intensive care unit.

Twenty-two premature neonates underwent surgical haemoclip closure of patent ductus arteriosus in a neonatal intensive care unit (NICU). Surgery was performed in the NICU in order to prevent hypothermia and interruption of care, and to avoid accidental vascular access removal and extubation. The results suggest that morbidity can be limited by performing the surgery in an NICU, and by switching from conventional to high-frequency mechanical ventilation in case of severe respiratory failure.     

Metabolism: Comparison of Outcome: Inborn and Outborn Infants Weighing Less Than 1,500 Grams

The fetal mortality, neonatal mortality and developmental outcome of 690 less than 1,500 gram infants born during 1974–78 in Denver, Colorado, USA, was studied. Comparisons were made of 393 babies born at University Hospital (UH) where an intensive intrapartum care program was established and 297 babies born in five metropolitan Denver hospitals (MDH) who did not have intensive care capability. They were usually transported to The Children's Hospital (CH), Denver, for neonatal intensive care. Fetal mortality was lower in the UH population than the MDH population; neonatal mortality in the UH and. MDH babies was not different above 700 grams; neonatal delay was least(8%) in the babies born to mothers transported to UH for delivery (UH-MT) and highest (21%) in the MDH babies who were transported to CH for neonatalintensive care. The authors conclude that fetal survival improved at UH andthat mental delay is least in babies born to mothers who are transported to UH for perinatal intensive care.     

How should we report neonatal outcomes?

The aim of neonatal care is to achieve long-term survival free of handicap. There is a need for standardised datasets linking perinatal care to outcome at 2 years corrected age for all babies who have gone through neonatal intensive care. Realistically this can only happen if all the data are collected by the units caring for the babies. This has not been possible previously using routinely collected data because of the poor quality of such information. Recent improvements in neonatal data collection along with the development of standardised neonatal and follow-up datasets make it possible that this could now be achieved from routine data collected as part of everyday clinical care. It is important that further links with maternity and child health systems are developed. The National Neonatal Audit Project, funded by the Department of Health, will hopefully develop the infrastructure to allow the storage, analysis and rapid reporting of pooled neonatal and follow-up data.     

新生儿重症监护室医院内感染的调查

目的：对我院新生儿重症监护室（NICU）医院内感染（简称院感）进行前瞻性研究,分析其危险因素,以指导临床防治,降低NICU院感发生率。方法：2006年2月至2007年1月收入我院NICU住院时间48 h以上的患儿为研究对象,收集其相关资料,计算院感发生率,多因素回归分析调查其危险因素。结果：入选患儿共计1 159例,院感发生共计169例次,发生率为14.58％,日感染率为19.52‰,肺部感染率为7.94％,居首位,其中呼吸机相关性肺炎(VAP)发病率为每1 000个呼吸机使用日48.8;院感致病菌主要为鲍氏不动杆菌、肺炎克雷伯杆菌、凝固酶阴性葡萄球菌、绿脓杆菌。多因素回归分析显示低出生体重（OR 2.130, 95% CI 1.466~3.094 ）、机械通气（OR 7.038,95% CI 3.901~12.698）、胸腔闭式引流(OR 7.004, 95% CI 1.841~26.653 )及布洛芬治疗(OR 2.907, 95% CI 1.303~6.487)是NICU内院感发生的危险因素。结论：肺部感染是我院NICU 最常见的院感;革兰阴性细菌是院感常见病原菌;低出生体重、机械通气、胸腔闭式引流、布洛芬治疗是NICU内院感的独立危险因素。［中国当代儿科杂志,2010,12（2）：81-84］     

Outcomes of very low birth weight infants in a newborn tertiary center in Turkey, 1997-2000

Our purpose was to determine mortality and morbidity rates and selected outcome variables for infants weighing less than 1500 g, who were admitted to the neonatal intensive care unit of our hospital from 1997 to 2000. The ultimate goal of the study was to define a model for developing a regional database. Information on all very low birth weight (VLBW) admissions to a tertiary level neonatal intensive care unit (NICU) in Ankara between January 1997 and December 2000 was prospectively collected by three neonatologists using a standard manual of operation and definitions. The data consisted of patient information including sociodemographic characteristics; antenatal history; mode of delivery; APGAR scores; need for resuscitation; admission illness severity (Clinical Risk Index for Babies-CRIB) and therapeutic intensity (Neonatal Therapeutic Intensity Scoring System-NTISS); selected NICU parameters and procedures such as respiratory support, surfactant therapy, and postnatal corticosteroid therapy; and selected patient outcomes such as intraventricular hemorrhage, septicemia, necrotizing enterecolitis, retinopathy of prematurity, and chronic lung disease. The number of VLBW admissions to the NICU was 133, with 51 (28.6%) referrals from other maternity centers. The mean birth weight and gestational age of the infants were 1175 +/- 252 g and 30.3 +/- 2.9 weeks, respectively. One hundred and seventeen of 133 cases (88.7%) received at least one antenatal care visit. The median CRIB and NTISS scores were 4.5 and 31, respectively. Antenatal steroids had been given to 74 (55.6%) infants. Surfactant treatment and respiratory support were given to 33 (24.8%) and 73 (54.8%) infants, respectively. Among selected outcomes, chronic lung disease (CLD), threshold retinopathy of prematurity (ROP), severe intraventricular hemorrhage (IVH > or = grade III), nosocomial infection and necrotizing enterocolitis (NEC) were encountered in 14 (12.6%), 9 (8.1%), 3 (2.2%), 34 (25.5%) and 35 (26.3%) of the infants, respectively. Overall survival rate was 83.5% (111/133); most of the deceased cases were under 750 g (12/22). It was prospectively shown that 111 (100%) of the surviving infants could be regularly followed in a newborn follow-up clinic to provide health maintenance, developmental assessment and support. Compared with reports from other developing countries, VLBW infants at our center had higher survival rates. Compared to developed countries, survival rate was lower, especially for extremely very low birth weight infants. There is interaction between birth weight and survival rate. Among selected neonatal outcomes, chronic lung disease, threshold retinopathy, severe intraventricular hemorrhage (IVH > or = grade III) and nosocomial infection rates at this center were comparable with some reports from developed nations.