Neonatal Intensive Care Practices Research Articles

Systematic reviews in perinatal medicine.

We are now in the era of Evidence-based Medicine and many people involved in purchasing and supporting health care together with the general public are demanding that clinical practice be based upon sound scientific evidence of efficacy and safety. It is now possible to evaluate many interventions in perinatal medicine by examining the results of systematic reviews. For example, interventions that are effective for neonatal respiratory failure have recently been published. The practice of neonatal intensive care is approximately 90% evidence based but there is still room for improvement. Much more work needs to be done in preparing systematic reviews for the Cochrane Library. European reviewers in perinatal medicine, comprising pregnancy and childbirth and neonatology, would be welcomed. Perhaps for the new millennium we will be able to boast that the practice of perinatal medicine is totally evidence-based.

Consideration of the Use of Health Status, Functional Outcome, and Quality-of-Life to Monitor Neonatal Intensive Care Practice

Measures of health status, functional abilities, and quality-of-life are being used increasingly to evaluate health care practice, and to measure outcomes from the patient's perspective. There is thus a need to reassess the use of growth and neurodevelopmental status that have traditionally been used as measures of outcome after neonatal intensive care. The quality of neonatal intensive care constitutes only one factor among many that determine the functional health and quality-of-life of survivors of neonatal intensive care. These include genetic disposition, intrauterine events, the effects of sociodemographic factors on the health and development of the child, and on the parents' assessment of their child's functioning. To obtain health status, functional and quality-of-life measures, parents need to act as proxy for the child during infancy and childhood. The parents' cultural, social, and educational background and the specific experience of the parent with children may influence their responses. Furthermore, their perspective may differ from that of the child. Measures that have been used or have the potential to measure health status, functioning, and quality-of-life include the National Health Interview Survey, the National Health Insurance Study, the Functional Status II, the Multi-Attribute Health System, the Functional Independence Measure for Children, the Vineland Adaptive Behavior Scales, the Adolescent Child Health and Illness Profile, and the Child Health Questionnaire for children, infants, and toddlers. Knowledge of the validity of the use of these measures among survivors of neonatal intensive care is, however, sparse. Studies have shown that the collection of a standard core of data from various national sources with specific criteria for defining severe disability at 2 years of age is feasible in Great Britain. However, questionnaires or available national databases provide global and epidemiologic information on outcomes rather than identifying the specific pathogenesis or rates of impairments. To determine the possible deleterious effects of new therapies, specific diseases or impairments will need to be identified rather than the global effect on functioning or health related quality-of-life. Examination of the proximal neonatal impairments that predispose to later disability, such as rates of periventricular hemorrhage or retinopathy of prematurity, are probably better measures for evaluating quality of neonatal care rather than distal impairments such as cerebral palsy, growth impairments, or reactive airway disease. The ultimate goal of neonatal intensive care is to provide survival without impairment. Objective measures of specific impairments and their residual disability are thus better measures of the quality of neonatal intensive care than subjective assessments of children and their families.

Evaluation of Neonatal Intensive Care Technologies

The development and dissemination of neonatal intensive care technology has been associated with improved survival for critically ill newborn infants, particularly those with birth weights of less than 1,500 grams (3 pounds, 5 ounces). Despite these advances, there are concerns about the long-term health status of surviving infants and the costs of their initial and subsequent care. In this article, the authors review current evidence for the effectiveness of neonatal intensive care and discuss several approaches to evaluating neonatal intensive care technology. They discuss a four-step process originally proposed by Roper for assessing and improving neonatal intensive care practices which includes (1) monitoring of practices, outcomes, and costs; (2) analysis of variation in practices, outcomes, and costs; (3) assessment of the efficacy of individual interventions, and (4) feedback and education to alter clinical behavior. The authors conclude that organized networks of neonatal intensive care units can play a crucial role in this process.

Surfactant replacement therapy in utero for prevention of hyaline membrane disease in the preterm baboon

A previous study of intraamniotic administration of surfactant in preterm rabbit fetuses demonstrated that exogenous surfactant can be taken up into the lungs from amniotic fluid in quantities sufficient to alter pulmonary mechanical properties. On the basis of these findings we chose to test the hypothesis that intraamniotic administration of surfactant to the preterm baboon 24 hours before delivery will prevent the development of clinical and pathological aspects of hyaline membrane disease. Characteristics of hyaline membrane disease in the preterm baboon model include atelectasis, the formation of hyaline membranes in the airways and distal air saccules, overexpansion of distal airways, and disruption of airways by barotrauma associated with neonatal intensive care practices. Nine preterm baboons were treated with either saline solution (n = 4) or surfactant (n = 5) by intraamniotic injection on 136 to 137 days' gestation. One day later fetuses were delivered by cesarean section and maintained for 24 hours with standard neonatal intensive care techniques. All neonates completed the protocol, and surfactant-treated animals had better clinical courses as documented by Pao2/PAO2 (p < 0.05), FIO2 (p < 0.005), and Paco2 (p < 0.05). Significant radiographic differences (p < 0.02) were noted to be the result of surfactant treatment. No differences in ventilator pressures or neonatal cardiovascular parameters were found. Significant differences in pulmonary pathologic conditions (p < 0.01) were also found, but all animals had some degree of pathologic pulmonary changes associated with hyaline membrane disease. Therefore a single treatment with surfactant in utero significantly improved the clinical course but did not completely prevent hyaline membrane disease in an established animal model.

Rate of bronchopulmonary dysplasia as a function of neonatal intensive care practices

Some differences among neonatal intensive care units (NICUs) in incidence of bronchopulmonary dysplasia may reflect variations in medical care practices. After adjusting for differences in the inherent risk of bronchopulmonary dysplasia among 223 infants of less than 1751 gm birth weight who were admitted to three Harvard-affiliated NICUs, we used multivariate analysis to explore the extent to which medical care practices during the first days of life varied with the rate of bronchopulmonary dysplasia. In our analyses, variables were grouped by three major hypotheses: oxygen toxicity, barotrauma, and fluid overload. The NICU designated 1 (the one with the highest rate of bronchopulmonary dysplasia) used much higher than expected colloidal volumes during the first 4 days of life; in contrast, in the NICU designated 3 (the one with the lowest rate of bronchopulmonary dysplasia), infants consistently received lower than expected amounts of colloidal solution. Signs of patent ductus arteriosus were also much more frequent than expected during this time at NICU 1; rates were much lower than predicted at NICU 2 and were near predicted values at NICU 3. Maximum inspired oxygen fraction during the first 4 days varied significantly in a direction inconsistent with the oxygen toxicity hypothesis. Maximum arterial oxygen tension was significantly less than expected at the hospital with the lowest rate of bronchopulmonary dysplasia (NICU 3). None of six medical care practices indicating potential for barotrauma varied with NICU expect for positive end-expiratory pressure, which varied in a direction suggesting a protective effect against bronchopulmonary dysplasia. These findings agree best with the hypothesis that differences in hydration during the first days of life account for some of the difference among NICUs in bronchopulmonary dysplasia occurrence.

529 ARE WE PRODUCING MORE LONG TERM PATIENTS IN NEONATAL INTENSIVE CARE?

There is concern that neonatal intensive care practice has resulted in an increased census of chronically ill infants. These infants may limit available acute tertiary care beds and cause staffing problems. We used our computer database to analyze epidemiologic characteristics of ICN admissions from 1976 through 1983. With well-established regionalized perinatal care, admission characteristics have remained relatively constant: 344 ± 45(S.D.)admissions/year, 54.2 ± 6.3% infant referrals, 31.8 ± 3.2% maternal-fetal referrals. There was no trend in the yearly distribution of admissions by birth weight or gestational age. There was no trend to increasing average length of stay (LOS) by year (14.7 days, range 13.4-17.1). Mortality and discharges to community hospitals have varied only slightly (10.7 ± 2.4%, 37.7 ± 3.2% respectively). Discharges directly home decreased from 44.6% to 22.8% while discharges to the pediatric ward increased 3.6% to 11.3% (1976 vs. 1983). Infants with LOS>28 days or to> 38 weeks corrected gestational age accounted for 6.1 ± 1.7% of admissions and 33 ± 9.8% of hospital days. Infants with LOS>12 weeks accounted for 2.3 ± 1.1% and 19.4 ± 10.1% of admissions and hospital days, respectively. While the percentages of hospital days represented by long term infants in 1983 were at the upper end of the ′76-′83 range, there was no trend even if pediatric ward LOS was included. We cannot show an increase in long term babies.

Iatrogenic hazards of neonatal intensive care in extremely low birthweight infants.

Yu, V. Y. H., Hewson, P. H. and Hollingsworth, E. (1979). Aust. Paediatr. J., 15, 233–237. Iatrogenic hazards of neonatal intensive care in extremely low birthweight infants. The history of neonatal paediatrics has evidenced over‐enthusiasm in the introduction of innovations in management which are almost always accompanied by unforseen hazards. We have scrutinised present practices in the intensive care of 55 infants weighing &lt; 1000 g at birth, which might be responsible for the current trends in iatrogenic disease patterns. Umbilical arterial catheterization was associated with a 29% complication rate. Hyperoxia was documented in 81% of infants during oxygen therapy. Retrolental fibroplasia was present in 1 survivor. Blood sampling for microbiochemical and haematological monitoring increased the need for replacement blood transfusions. Postnatally acquired cytomegalovirus infection occurred in 4 infants, 3 of whom were probably infected from transfused blood. Complications associated with current nutritional management included hyperglycaemia, hypocalcaemia and hyponatraemia. Iatrogenic factors might have contributed to the occurrence of necrotizing enterocolitis, patent ductus arteriosus and cholestatic jaundice. We conclude that current neonatal intensive care practices need ongoing scrutiny and great caution should be taken in introducing new advances.