Neonatal Intensive Care Facilities Research Articles

Characteristics of Neonatal Intensive Care Unit Patients in North Carolina: A Cross-Sectional Survey

A shortage of neonatal intensive care facilities has been encountered in some areas of the country including North Carolina. To examine possible solutions to this health care delivery problem, a cross-sectional survey of all the neonatal intensive care units in North Carolina was performed to examine characteristics of patients occupying the beds in these facilities. It was found that a substantial amount of chronic care is now occurring in neonatal intensive care beds, with 38% of occupants of neonatal intensive care beds being 31 days of age or older and 3% being mechanically ventilated at 91 days of age or older. In addition, according to criteria established for this study, a substantial number of "convalescent" patients (32%) were occupying beds in neonatal intensive care units. It is concluded that an increase in both intermediate/convalescent care beds and establishment of chronic care facilities in North Carolina, rather than an increase in intensive care beds in these units, would alleviate the shortage of neonatal intensive care facilities. Further, the characteristics of the population occupying neonatal intensive care unit beds should be considered by health planners in addition to occupancy rate, when new facilities are being established.

Cardiopulmonary Resuscitation of the Newborn

Approximately 3.5 million babies are born each year in approximately 5000 hospitals in the United States. Only 15% of these hospitals have neonatal intensive care facilities. Six percent of all newborns require life support in the delivery room or nursery, and this need for resuscitation rises to 80% in neonates weighing less than 1500 g at birth. Personnel who are skilled in neonatal resuscitation and capable of functioning as a team and an appropriately equipped delivery room must always be readily available. At least one person skilled in neonatal resuscitation should be in attendance at every delivery. Currently, a joint effort by the American Academy of Pediatrics and the American Heart Association has resulted in the development of a comprehensive course to train appropriate personnel in neonatal resuscitation throughout the United States. Neonatal resuscitation is also taught as part of a Pediatric Advanced Life Support course offered by the American Heart Association. In concert with the goals of the American Academy of Pediatrics and the American Heart Association, we strongly urge all personnel responsible for care of the newborn in the delivery room to become certified in neonatal resuscitation. The practical approach to neonatal resuscitation is the focus of this article.

Cardiopulmonary Resuscitation of the Newborn

Approximately 3.5 million babies are born each year in approximately 5000 hospitals in the United States. Only 15% of these hospitals have neonatal intensive care facilities. Six percent of all newborns require life support in the delivery room or nursery, and this need for resuscitation rises to 80% in neonates weighing less than 1500 g at birth. Personnel who are skilled in neonatal resuscitation and capable of functioning as a team and an appropriately equipped delivery room must always be readily available. At least one person skilled in neonatal resuscitation should be in attendance at every delivery. Currently, a joint effort by the American Academy of Pediatrics and the American Heart Association has resulted in the development of a comprehensive course to train appropriate personnel in neonatal resuscitation throughout the United States. Neonatal resuscitation is also taught as part of a Pediatric Advanced Life Support course offered by the American Heart Association. In concert with the goals of the American Academy of Pediatrics and the American Heart Association, we strongly urge all personnel responsible for care of the newborn in the delivery room to become certified in neonatal resuscitation. The practical approach to neonatal resuscitation is the focus of this article.

In‐Vitro Fertilization: A Neonatal Paediatrician's Perspective

EDITORIAL COMMENT: This thoughtful essay has no summary; we provide this comment to make sure readers do not miss the ‘conclusion’ or the important audit of the clinical results achieved at the Royal Women's Hospital Intensive Care nursery, 1986–1988. Neonatal paediatricians are not the only ones who question modern obstetric practice — there is often debate at stillbirth and neonatal death committees of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity attended by the editor as to the wisdom of many Caesarean sections performed at or before 26 weeks' gestation because of severe preeclampsia or severe fetal compromise — unfortunately many of these women require a classical Caesarean section because the lower segment is poorly developed. Of course there is no good news at mortality meetings and one must turn to the data from the perinatal units to see the overall survival rates for early deliveries. In Victoria in 1987, the perinatal mortality rate for infants with birth‐weight 500 g or above was 11.0 per 1,000 births (677 of 61,090), the neonatal death rate being 4.7per 1,000. However, the perinatal mortality rate was 738 per 1,000 births in the group of 294 infants with birth‐weight 500–999 g. In 1987 there were 46 deliveries by Caesarean section before 28 weeks' gestation and the results were 5 stillbirths, 14 neonatal deaths and 27 survivors. Results of intensive care of extremely low birth‐weight infants would suggest that the current Caesarean section rate in high risk pregnancies before 28 weeks' gestation should not be extended. One has only to read our newspapers to learn the problems of provision of resources for intensive care — individual parents and their paediatrician may press for increased availability of the new technology for any liveborn infant but there is a limit to what the State can afford — it could be argued that the neonatal intensive care facilities currently available in Australia are adequate.

Intraventricular hemorrhage in the premature infant--current concepts. Part I.

Although the incidence of periventricular-intraventricular hemorrhage (IVH) has decreased in recent years, the increasing survival rates for the smallest premature infants indicate that the lesion will continue to be a major problem in neonatal intensive care facilities. The neuropathology is characterized by an elemental lesion, bleeding into the subependymal germinal matrix, with subsequent rupture into the lateral ventricle. Important neuropathological consequences are germinal matrix destruction, posthemorrhagic hydrocephalus, and periventricular hemorrhagic infarction. The last of these appears to be a venous infarction and is a critical determinant of neurological outcome. Neuropathological accompaniments, not caused by the IVH, include periventricular leukomalacia and pontine neuronal necrosis. The pathogenesis of IVHs is related to intravascular, vascular, and extravascular factors. Intravascular factors involve primarily control of blood flow and pressure in the microcirculation of the germinal matrix. Particular pathogenetic importance can be attached to fluctuations in cerebral blood flow, abrupt increases in flow, decreases in flow with injury to matrix vessels, increases in cerebral venous pressure, and, in selected infants, disturbances of platelet function and coagulation. Vascular factors relate to the microcirculation of the matrix, the site of the initial bleeding. A maturation-dependent alteration in vascular integrity and a vulnerability of matrix vessels to ischemic injury appear important. Extravascular factors include those relevant to mesenchymal and glial support for matrix vessels and to local fibrinolytic activity in the germinal matrix. The latter may be a manifestation of the proteolytic activity now recognized to be of general importance in developmental remodeling of the mammalian central nervous system.

Management of serious alloimmunization in pregnancy.

In the past 40 years, tremendous advances in the treatment of hemolytic disease have been made. The perinatal mortality has been reduced considerably. Rh immunoprophylaxis has decreased the incidence of Rh immunization to around 6 per 100,000 live births. Nevertheless, treatment of severe hemolytic disease is still essential. Increased reliability of diagnostic procedures have made early detection and optimal treatment of hemolytic disease possible. Treatment by plasmapheresis is still controversial. Although believed to be beneficial by some authors, conclusive evidence of its efficacy has not been obtained. With preterm induction of birth at 32 weeks of gestation, the chances for survival are 95%. Improvement of techniques and the use of modern real-time ultrasound equipment have made intrauterine intraperitoneal transfusion, in experienced hands, a relatively safe and successful procedure. Intravascular transfusion appears beneficial in early pregnancy. Combination of both techniques will probably be the answer for the future. The development of neonatal intensive care facilities has made a major contribution to the survival of children with haemolytic disease. The relative low incidence of haemolytic disease has made it imperative that treatment should take place in centers where experience and special skill are available.

Spontaneous preterm labour and delivery at under 34 weeks' gestation.

The management and outcome of 242 infants delivered between 26 and 34 weeks' gestation in an obstetrical and neonatal regional referral centre as a result of spontaneous preterm labour were recorded prospectively. Results of the survey show that the decision to intervene and delay delivery will depend on the availability of neonatal intensive care facilities. Infants likely to require intensive neonatal care should be transferred in utero to a centre with these facilities. The use of steroids reduces the mortality of preterm infants. The maximum effect occurs between 30 and 32 weeks' gestation, and there is no benefit after 34 weeks. If the weight is over 1500 g the mode of delivery of the preterm infant presenting by the breech does not influence outcome; if under 1500 g a caesarean section improves survival over those infants born by vaginal breech delivery.

PERINATAL OUTCOME IN WESTERN AUSTRALIA, 1968 TO 1975; 1. PERINATAL MORTALITY AND BIRTHWEIGHT

Trends in perinatal mortality and low birth-weight in Western Australia were analysed by means of a linked file of perinatal death and birth registration papers for the years 1968 to 1975. Stillbirth rates fell only slightly, and there was no improvement in low birthweight stillbirth rates. There was increased ascertainment of low birthweight stillbirths after 1968 when the definition changed. Neonatal mortality fell markedly after 1971, much of the fall being due to a shift in the birthweight distribution towards heavier babies, particularly in males. The proportion of babies with birthweights of less than 2500 g fell from nearly 6% to 5.3%. The impact of changes in the obstetric care of premature labour were minimal up to 1975, with rural (away from specialist care) low birthweights rates differing only slightly from metropolitan rates. Social and demographic differences probably account for the major differences in stillbirth rates between areas. Neonatal mortality rates in low birthweight babies showed a definite advantage for babies living close to neonatal intensive care facilities. However, decisions to expand neonatal intensive care facilities to rural areas need to take into account other adverse perinatal risk factors.

Evaluation of Neonatal Periventricular-Intraventricular Hemorrhage

Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. 1 The other major types of hemorrhage, ie, subdural hemorrhage, primary subarachnoid hemorrhage, and intracerebellar hemorrhage, are either very uncommon or not of major clinical importance. The enormous importance of periventricular-intraventricular hemorrhage is linked to the evolution of neonatal intensive care and, as a consequence, the dramatic improvements in survival rates for small pre-mature infants. Because periventricular-intraventricular hemorrhage is characteristic of such infants, the occurrence of the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. The adaptation of the computerized tomographic (CT) scan to the evaluation of the small premature infant in the mid-1970s led to the recognition of the remarkably high incidence of the lesion. Thus, in two large studies in which small premature infants were subjected to CT scan routinely in the first week of life, the incidence of periventricular-intraventricular hemorrhage

Intraventricular Hemorrhage in Premature Infants

Four major varieties of intracranial hemorrhage can be recognized in the neonatal period: (1) subdural hemorrhage, (2) primary subarachnoid hemorrhage, (3) intracerebellar hemorrhage, and (4) periventricular-intraventricular hemorrhage.1 Subdural hemorrhage, often related to obstetrical trauma, now is an uncommon lesion in most medical centers. Primary subarachnoid hemorrhage, although very common, is rarely of major clinical importance, because of its venous origin and self-limited course. Intracerebellar hemorrhage, commonly observed at postmortem examination of the small premature infant but rarely documented during life, is of uncertain clinical significance. Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. The enormous importance of this lesion is linked to the remarkable improvements in recent years in neonatal intensive care and, as a consequence, in survival rates for small premature infants. Because periventricular-intraventricular hemorrhage is characteristic of the premature infant (particularly the infant less than approximately 32 weeks gestation), the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. INCIDENCE The remarkably high incidence of periventricular-intraventricular hemorrhage is demonstrated dramatically by studies in which premature infants were subjected to computed tomography (CT) scan routinely within the first week of life (Table 1). Thus, 40% to 45% of all such infants exhibited periventricular-intraventricular hemorrhage.2,3

Evaluation of neonatal periventricular-intraventricular hemorrhage. A major advance.

Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. 1 The other major types of hemorrhage, ie, subdural hemorrhage, primary subarachnoid hemorrhage, and intracerebellar hemorrhage, are either very uncommon or not of major clinical importance. The enormous importance of periventricular-intraventricular hemorrhage is linked to the evolution of neonatal intensive care and, as a consequence, the dramatic improvements in survival rates for small pre-mature infants. Because periventricular-intraventricular hemorrhage is characteristic of such infants, the occurrence of the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. The adaptation of the computerized tomographic (CT) scan to the evaluation of the small premature infant in the mid-1970s led to the recognition of the remarkably high incidence of the lesion. Thus, in two large studies in which small premature infants were subjected to CT scan routinely in the first week of life, the incidence of periventricular-intraventricular hemorrhage

Intraventricular Hemorrhage in Premature Infants

Four major varieties of intracranial hemorrhage can be recognized in the neonatal period: (1) subdural hemorrhage, (2) primary subarachnoid hemorrhage, (3) intracerebellar hemorrhage, and (4) periventricular-intraventricular hemorrhage.1 Subdural hemorrhage, often related to obstetrical trauma, now is an uncommon lesion in most medical centers. Primary subarachnoid hemorrhage, although very common, is rarely of major clinical importance, because of its venous origin and self-limited course. Intracerebellar hemorrhage, commonly observed at postmortem examination of the small premature infant but rarely documented during life, is of uncertain clinical significance. Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. The enormous importance of this lesion is linked to the remarkable improvements in recent years in neonatal intensive care and, as a consequence, in survival rates for small premature infants. Because periventricular-intraventricular hemorrhage is characteristic of the premature infant (particularly the infant less than approximately 32 weeks gestation), the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. INCIDENCE The remarkably high incidence of periventricular-intraventricular hemorrhage is demonstrated dramatically by studies in which premature infants were subjected to computed tomography (CT) scan routinely within the first week of life (Table 1). Thus, 40% to 45% of all such infants exhibited periventricular-intraventricular hemorrhage.2,3

Regionalization

Regionalization

EPIDEMIOLOGY OF RESPIRATORY DISTRESS SYNDROME (RDS)

Neonatal mortality due to RDS or hyaline membrane disease (HMD) has never been precisely determined, but merely estimated on the basis of small samples skewed by local factors and not representing the national picture. Due to the long lead time for collection and coding of death certificates, the necessary data for 1968 have only recently become available from the National Center for Health Statistics. These statistics, the first national figures for RDS, were stored on magnetic tapes which were then computer processed by us. Our analysis showed RDS or HMD to be the underlying cause of death in 8273 cases and a major contributing factor in 2724 more, a total of 19.3% of all neonatal deaths. The RDS mortality rates for whites compared to non-whites were 2.30 vs. 2.68 per 1000 live births and 32.4 vs. 19.5 per 1000 premature (less than 2.5 kg) births, respectively. RDS deaths were evenly distributed throughout the year. The male/female ratio was 1.76 compared to 1.41 for all neonatal deaths. Age at death conformed to clinical experience: 46% on day 1, 26%-day 2, 15%-day 3, 5%-day 4, and 2% on day 5. Comparison of RDS mortality rates with overall neonatal mortality rates for each state showed general agreement except for a few states in which the RDS rates were significantly different. These data will be useful in planning regional neonatal intensive care facilities and will provide a baseline for later evaluation on a national basis of newer therapeutic methods.