We examined the neonatal mortality rates of low-birth-weight infants (501 to 2250 g) born between 1976 and 1978 in three kinds of hospitals in New York City: those with newborn-intensive-care units (Level 3), those with capabilities for the care of most premature infants (Level 2), and those without any special facilities for premature newborns (Level 1). Among 13,560 singleton low-birth-weight infants, the adjusted neonatal mortality rate for Level 3 hospitals was 128.5 per thousand live births — significantly lower (P<0.001) than the rates for both Level 2 (168.1) and Level 1 units (163.0). The association of level of care with mortality could not be accounted for by differences between groups in social or demographic status, in prenatal care, or in medical complications of pregnancy. We infer that birth at a Level 3 center lowers neonatal mortality in low-birth-weight infants. However, only 34 per cent of the patients in this study were born in such units. (N Engl J Med. 1982; 307:149–55.)

Newborn intensive care and neonatal mortality in low-birth-weight infants: a population study.

Status and Prestige in Australia.

Within the past 15 years, regional neonatal-intensive-care programs have been introduced and have expanded rapidly. The efficacy of some of the individual interventions that constitute neonatal intensive care has been validated in randomized, controlled clinical trials. It is therefore generally assumed that neonatal-intensive-care programs that incorporate these maneuvers are effective in reducing death and disability. However, the overall effectiveness of these programs has not been tested experimentally. Moreover, much of the non-experimental evidence supporting their value is based on the experience of referral units and does not measure the impact on the populations they serve. A definitive economic evaluation of neonatal intensive care has not yet been reported, despite the high cost of such programs. We conclude that neonatal-intensive care programs require further evaluation with rigorous scientific methods.

Evaluation of neonatal-intensive-care program.

The growth and development of the prematurely born infant

Background Whilst the use of supplemental oxygen has a long history in neonatal care, resulting in both significant health care benefits and harms, uncertainty remains as to the most appropriate range to target blood oxygen levels in preterm and low birth weight infants. Potential benefits of higher oxygen targeting include more stable sleep patterns and improved long term growth and development. However, there may be significant deleterious pulmonary effects and health service use implications resulting from such a policy. Objectives In preterm or low birth weight infants, does targeting ambient oxygen concentration to achieve a lower versus higher blood oxygen range, or administering restricted versus liberal supplemental oxygen, influence mortality, retinopathy of prematurity, lung function, growth or development? Search strategy The standard search strategy of the Neonatal Review Group was used. An additional literature search was conducted of the MEDLINE and CINAHL databases in order to locate any trials in addition to those provided by the Cochrane Controlled Trials Register (CENTRAL/CCTR). Selection criteria All trials in preterm or low birth weight infants utilising random or quasi-random patient allocation, in which ambient oxygen concentrations were targeted to achieve a lower versus higher blood oxygen range, or restricted versus liberal oxygen was administered, were eligible for inclusion. Data collection and analysis The methodological quality of the eligible trials was assessed independently by each author for the degree selection, performance, attrition and detection bias. Data were extracted and reviewed independently by the each author. Data analysis was conducted according to the standards of the Cochrane Neonatal Review Group. Main results The restriction of oxygen significantly reduced the incidence and severity of retinopathy of prematurity without unduly increasing death rates in the meta-analysis of the five trials included in this review. The one trial that specifically addressed the question of lower versus higher PaO2 found no effect on death, but did not report (in sufficient detail to warrant inclusion) the effect of this intervention on eye or other outcomes. The effects of either of these oxygen administration policies on other clinically meaningful outcomes including chronic lung disease and long term growth, neurodevelopment, lung or visual function were not reported in any of the available trials. Reviewer's conclusions The results of this systematic review confirm the commonly held view of today's clinicians that a policy of unrestricted, unmonitored oxygen therapy has potential harms, without clear benefits. However, the question of what is the optimal target range for maintaining blood oxygen levels in preterm/LBW infants was not answered by the data available for inclusion in this review.

/pdf/restricted-versus-liberal-oxygen-exposure-for-preventing-ovzgbelr3t.pdf

Restricted versus liberal oxygen exposure for preventing morbidity and mortality in preterm or low birth weight infants

SUMMARY

A group of 238 infants, weighing between 1000g and 1500g and born consecutively in one hospital between 1966 and 1970, were entered in a controlled trial in an attempt to determine whether intensive care of very low-birthweight (VLBW) infants affects long-term survival and the incidence of severe handicap. The infants were allotted on an alternate basis to either intensive care or routine care. The methods of intensive and routine care are described in detail. All the VLBW infants received the same basic nursery care.



The 160 infants discharged home are being reviewed up to the age of eight years by a multidisciplinary team. Two of these infants have died, one unexpectedly and the other from a congenital defect.



Infants with respiratory distress who were treated intensively in the latter part of the study had an increased survival rate and the possible reasons for this are discussed. The study also shows that the unexpected death of a VLBW infant after discharge from hospital is not now a common occurrence.



RESUME

Etude longitudinale de nourrissons de tres faible poids de naissance



Un groupe de 238 nourrissons, pesant a la naissance entre 1000g et 1500g, nes sequentiellement dans un meme hopital entre 1966 et 1970, ont fait l'objet d'un examen de controle dans le but d'etablir si des soins intensifs aux nourrissons de tres faible poids de naissance (TFPN) modifient la survie a long terme et la frequence des handicaps severes. Les nourrissons ont ete classes sur l'opposition soins intensifs—soins de routine. Les methodes de soins intensifs et de soins de routine sont decrits en detail. Tous les nourrissons TFPN recurent les memes soins de pouponniere.



Les 160 nourrissons renvoyes chez eux ont ete examines a l'âge de huit ans par une equipe multidisciplinaire. Deux de ces enfants etaient morts, l'un de facon inattendue et l'autre d'une anomalie congenitale.



Les nourrissons avec detresse respiratoire, traites intensivement durant la derniere periode de l'etude, ont un taux de survie accru et les raisons en sont discutees. L'etude montre egalement que la mort inattendue d'un nourrisson TFPN apres la sortie hospitaliere n'est pas actuellement un fait frequent.



ZUSAMMENFASSUNG

Langzeitstudie von Kindern mit sehr niedrigem Geburtsgewicht



238 Sauglinge mit einem Gewicht von 1000 bis 1500g, die von 1966 bis 1970 in einem Krankenhaus geboren worden waren, wurden in einer kontrollierten Studie zusammen gefasst. Ziel dieser Untersuchung war es herauszufinden, ob die Intensivpflege bei Kindern mit sehr niedrigem Geburtsgewicht (VLBW) einen Einfluss auf die Langzeituberlebenschance und auf das Vorkommen von Behinderungen hat. Die Kinder wurden alternierend der Intensivepflegeeinheit oder der Routinepflegeeinheit zugeteilt. Die Durchfuhrung der Intensiv- und der Routineversorgung wird im Einzelnen dargestellt. Alle VLBW-Kinder bekamen dieselbe allgemeine pflegerische Betreuung.



Die 160 Kinder, die nach Hause entlassen wurden, werden bis zum achten Lebensjahr durch ein Untersuchungsteam verschiedener Disziplinen nachuntersucht. Zwei dieser Kinder sind gestorben, eins unerwartet, das andere auf Grund angeborener Missbildungen.



Sauglinge mit Atemproblemen, die in den letzten Jahren intensiv versorgt wurden, hatten eine erhohte Uberlebensrate; die moglichen Grunde dafur werden diskutiert. Die Studie zeigt ausserdem, dass der plotzliche Tod eines VLBW-Kindes nach der Entlassung aus dem Krankenhaus nicht mehr sehr haufig vorkommt.



RESUMEN



Estudio longitudinal de lactantes con muy bajo peso al nacer



Un grupo de 238 lactantes, pesando de 1000 at 1500g, y nacidos consecutivamente en un hospital entre 1966 y 1970, fueron integrados en un ensayo de control con el intento de determinar si los cuidados intensivos aplicados a ninos con muy bajo peso al nacer (PMBN) afectan a la supervivencia a largo plazo y a la incidencia de minusvalidos graves. Los ninos fueron incluidos en uno de dos grupos: con cuidados intensivos o con tratamiento rutinario. Se describen con detalle los metodos de tratamiento de rutina e intensivo. Todos los ninos con PMBN recibieron los mismos cuidados basicos de enfermeria.



Los 160 ninos dados de alta estan siendo revisados hasta los ocho anos de edad por un equipo multidisciplinario. Dos de los ninos fallecieron, uno de forma inesperada y otro por un defecto congenito.



Los lactantes con distress respiratorio que fueron tratados intensivamente en la ultima parte del estudio tuvieron un margen de supervivencia mayor y, las posibles razones de ello son objeto de discusion. El estudio muestra tambien que la muerte inesperada de un lactante con PMBN despues de dado de alta no es hoy en dia un hecho corriente.

A longitudinal study of very low-birthweight infants. I: study design and mortality rates.

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A longitudinal study of very low-birthweight infants. I: study design and mortality rates.