Proportion Of Babies Research Articles

The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

BackgroundThe rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.MethodsA retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.ResultsA total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0[1-4]. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.ConclusionsBesides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.

Pregnancy and -thalassemia: an Italian multicenter experience

Recent advances in the management of thalassemia have significantly improved life expectancy and quality of life of patients with this hemoglobinopathy, with a consequent increase in their reproductive potential and desire to have children. We describe the methods of conception and delivery, as well as the course and outcome of pregnancy including transfusions, iron overload and chelation in 46 women with thalassemia major (58 pregnancies) and in 11 women with thalassemia intermedia (17 pregnancies). Conception was achieved after gonadotrophin-induced ovulation in 33 of the women with thalassemia major and spontaneously in all of those with thalassemia intermedia. Among the women with thalassemia major, 91% of the pregnancies resulted in successful delivery of 45 singleton live-born neonates, five sets of twins and one set of triplets. No secondary complications of iron overload developed or worsened during pregnancy. When considering only the singleton pregnancies, the proportion of babies with intrauterine growth retardation did not differ from that reported in the general Italian population. The high prevalence of pre-term births (32.7%) was mostly related to multiple pregnancies and precautionary reasons. Pregnancy was safe in most women with thalassemia major or intermedia. However, women with thalassemia intermedia who had never previously been transfused or who had received only minimal transfusion therapy were at risk of severe alloimmune anemia if blood transfusions were required during pregnancy. Provided that a multidisciplinary team is available, pregnancy is possible, safe and usually has a favorable outcome in patients with thalassemia. In women with hypogonadotropic hypogonadism, gonadal function is usually intact and fertility is usually retrievable.

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Are Babies Getting Bigger: An Analysis of Birth Weight Trends in New South Wales, 1990–2005

During the past decade, increases in babies' birth weight have been reported in Canada and Sweden. Many investigators believe such increases are widespread and are occurring in other countries. The increase has been attributed in part to increases in maternal body mass index, a decrease in smoking during pregnancy, and gestational weight gain. Little confirmatory data for increases in birth weight are available in Australia. This population-based study investigated whether there was an increase in the proportion of babies born large for gestational age (LGA) in New South Wales (NSW) between 1990 and 2005 and identified potential factors associated with any observed increase. Data were collected from the NSW Midwives Data Collection, a surveillance system of all births in NSW. The study population was 1,273,924 live-born singletons delivered at term. Logistic regression analysis was used to investigate the association between LGA, defined as >90th centile for sex and gestational age, and the potential explanatory variables over time. Over the 16-year study period, the proportion of babies born LGA increased among male infants from 9.2% to 10.8% (18% increase) and the percentage of female infants born LGA increased from 9.1% to 11.0% (21.0% increase). The mean birth weight increased significantly during the study period by 23 g among boys and 25 g for girls (P < 0.001). Also, during the study, the percentage of women who smoked during pregnancy decreased from 22.0% to 13.8%, the percentage of women with gestational diabetes increased from 1.1% to 4.6%, and the mean maternal age at delivery increased from 28.4 to 30.4 years. However, only some of the birth weight increase was accounted by the changing trends in smoking, diabetes, or maternal age. These findings indicate that the birth weight of babies born at term is increasing in NSW. Because only a portion of the increase in birth weight can be attributed to decreased smoking, increasing gestational diabetes and increasing maternal age, the determination of other factors responsible for the increase require further investigation.

Perinatal outcomes of hypoglycemic women during 75 g oral glucose tolerance test

Objective To analyze the perinatal outcomes of those women experienced hypoglycemia during 75 g oral glucose tolerance test(OGTT).Methods A retrospective study was conducted in 774.pregnant women who underwent OGTT and delivered in our institution from January 2005 to January 2006.The distribution of glucose levels of the fasting,1 h,2 h and 3 h of the OGTT was analyzed.Plasma glucose level below the 5th percentile and above the 1h percentile was defined as hypoglycemia and those below the 1th percentile as exceeding hypoglycemia.Perinatal outcomes including birth weight,birth height,obstetric complications,the incidence of small for gestational age (SGA)were compared between women with hypoglycemia or exceeding hypoglycemia. Results The birth weight in exceeding hypoglycemia group of fasting glucose was significantly lower than that of the others [(2817±764)g vs(3439±487)g,t=3.344,P＜0.01]and the incidence of SGA in this group was also higher(3/7 vs 3.4%,x2=22.78,P＜0.01);the proportion of babies with birth weight＜3000 g in the same group was higher than the others(5/7 vs 14.73%,P＜0.01).The newhorns height was significantly shorter in the hypoglycemia group at 2 h than the normal glycemic group [(49.03±1.68)cm vs(49.48±1.65)cm,P＜0.05].Conclusions The plasma glucose 1evel is associated with the newborns'birth weight and height.Women with hypoglycemia during OGTT are more likely to have babies with lower birth weight and height. Key words: Pregnancy complications; hypoglycemia; Glucose tolerance test; Blood glucose; Pregnancy outcome

Late reproduction behaviour in Sardinia: spatial analysis suggests local aptitude towards reproductive longevity

Evolution in human life-history traits is influenced by environmental factors and, when genetic components underlie the relations, by micro-evolutionary forces. Age at reproduction is largely influenced by the familial cultural context and socioeconomic level, besides the maternal well-being and genetic background. The Sardinian population is characterized by historico-geographical isolation and differentiates from Italian mainland and other European populations in bio-demographic and cultural characteristics, among which the tendency to delay maternity persisting through generations. In our study, we investigated whether, in Sardinia, areas of “reproductive longevity” exist, where a higher-than-average incidence of late maternities combines with a lower-than-average cost in terms of perinatal death. Data from the Italian Central Institute of Statistics regard all 1980–1996 Sardinian births. Using spatial analysis of late maternity (proportion of babies born to mothers aged ≥35 years) and associated perinatal mortality (proportion of babies stillborn and dead within 0–6 days born to mothers aged ≥35 years), we aimed at singling out areas where the indicators run high and low, respectively. The perinatal mortality cost associated with the advanced maternal age [odds ratios (95% CI)] was evaluated through multiple logistic regression models. We identified central inland excess areas qualified by higher incidence of late maternities (27% vs. 22% in nonexcess area) and lower cost in perinatal mortality [OR=1.38 (1.04–1.84) vs. OR=1.74 (1.55–1.96) in nonexcess area]. In these “reproductive longevity” areas, the inbreeding coefficient was 3.7-fold higher than in the nonexcess areas, suggesting possible population homozygosity in genetic factors affecting the trait. Further and deeper investigations on biological and environmental determinants could focus on these target areas.

Cerebral palsy and restricted growth status at birth: population‐based case–control study

To evaluate the association between growth status at birth and subsequent development of cerebral palsy in preterm and term infants. Population-based case-controlled study. Cerebral palsy register in Western Sweden. Subjects Cohort of 334 singletons born between 1983 and 1990, with cerebral palsy diagnosed from age 4, and 668 singletons matched for gestation, gender and delivery unit. Growth status at birth was determined using small for gestational age (SGA) categories, with customised birthweight percentiles (SGAcust) based on the Swedish population. Proportion of babies that were SGAcust, comparing cases and controls in three gestational age categories: early preterm (24-33 weeks), late preterm (34-36 weeks) and term (37+ weeks). Of the 334 children with cerebral palsy, 87 (26.6%) were born early preterm, 27 (8.1%) late preterm and 218 (66%) at term. Children who had been born at term were more likely to have been SGA <1st customised percentile (SGAcust1) than their matched controls (OR 6.6, 95% CI 2.3-18.6). In contrast, children with cerebral palsy born preterm were not more likely to have been SGAcust1 (OR 0.9, 95% CI 0.4-1.9), and this applied to early preterm as well as late preterm births. For less severely small babies (SGA between 1st and 5th customised percentiles), the association with cerebral palsy remained significant for term births (OR 5.2, 95% CI 2.7-10.1) but was again not significant for preterm births. Term singletons with severely SGA birthweights had a five- to seven-fold risk of developing cerebral palsy compared with gestational age-matched infants with birthweights within normal limits. For children born preterm, SGA was not more likely to be present in cases than in controls. These findings support the concept of cerebral palsy as a multifactorial condition and highlight the importance of antenatal surveillance of fetal growth.

PREMATURE CERVICAL CHANGE AND THE USE OF CERVICAL CERCLAGE

Preterm birth and its subsequent consequences continue to be a major challenge worldwide. In the United States in 2004, 12.5% of infants were born preterm, making the annual societal economic burden associated with preterm birth in excess of $26.2 billion (and this is a modest estimate). Spontaneous preterm birth accounts for about 75% of all preterm births; however, at earlier gestations iatrogenic preterm birth accounts for a greater proportion of all preterm births; at 27–28 weeks 50% are iatrogenic. The proportion of babies transferred to the neonatal unit is more than 90% for those born before 33 completed weeks of gestation compared with 31% at 36 weeks; delivery between 33 completed weeks and 36 completed weeks has a relatively low morbidity and mortality. Nonetheless, 1 in 3 children born preterm but beyond 32 weeks have educational and behavioural problems at the age of 7, with 1 in 4 children born between 32 and 35 weeks requiring support from non-teaching assistants at school. Although more than 40% of babies at 35 completed weeks show signs of maturity, some still need ventilation at 38 completed weeks. Almost one-fifth of all infants born at less than 32 weeks gestation do not survive the first year of life.

Polymorphisms in the Angiotensin Converting Enzyme Gene and Growth in the First Year of Life

Abnormal patterns of fetal and infant growth have been associated with an increased risk of cardiovascular disease in adulthood. Catch-up growth during the first year of life has been associated with a higher prevalence of type 2 diabetes mellitus, whereas a lack of catch-up growth tracks with a risk of hypertension. The role of genetic factors influencing both growth and blood pressure have not been explored. We genotyped cord blood samples from 530 singleton, Caucasian, uncomplicated pregnancies, drawn from a larger cohort of 1650 pregnancies, and related polymorphism in the angiotensin converting enzyme (ACE) gene (alleles insertion (I) or deletion (D)) with measures of size at birth and at age of 1 year. ACE genotype did not significantly influence size at birth, although there was a greater proportion of individuals with the D/D genotype born with a birth weight less than the 10th centile (P=0.004). The ACE I/I genotype was significantly associated with higher weight (p=0.001), body mass index (p=0.001) and mid arm circumference (p=0.001) at 1 year of age compared to the ACE D/D and I/D genotypes. Individuals with the I/I genotype displayed catch-up (gain from birth size of >or=0.6 Standard Deviation Score) in weight (p=0.04), body mass index (p=0.03) and mid arm circumference (p=0.03) compared to the D/D group, the majority of which showed no change or catch-down. The I/D genotype was distributed equally across the catch up/catch down/no change categories. The effect was more marked in males, but ACE genotype and sex of the infant contributed independently to mid arm circumference measurements and there was no interaction between the two. There was no effect of maternal or paternal ACE genotype on birth size. In a multiple linear regression model ACE genotype, socioeconomic status and sex of the infant explained 10.9% of the variance in body mass index SDS at 1 year of age. We conclude that the ACE I/I genotype is associated with a higher weight and body mass index SDS at 1 year of age, along with catch-up in terms of these measures from birth to 1 year. The D/D genotype is associated with a greater proportion of babies, born at term, that at small for gestational age. These results suggest that due consideration should be given to the underlying genotype of an individual when evaluating the association of early human growth with the development of risk factors for cardiovascular disease. The observation of independent effects of genotype, sex of the individual and socioeconomic status on postnatal growth suggests the need to develop methodologies for the integration of genetic and environmental factors in causality modelling.

Abstracts for the British Congenital Cardiac Association Annual Meeting: The Barbican, London, 24–25 November 2005: Oral Presentations: Twenty year trends in recognition of life-threatening neonatal cardiac malformations

Background: Babies with cardiovascular malformations are usually asymptomatic at birth. Earlier diagnosis is likely to lead to a better outcome. This study examines trends in the timing of diagnosis of potentially life-threatening cardiovascular malformations. Methods: Ascertainment of all cardiovascular malformations diagnosed in infancy in the resident population of one English health region in 1985–2004. Babies considered to have a life-threatening cardiovascular malformation included all those with hypoplastic left heart, pulmonary atresia with intact ventricular septum, transposition of the great arteries, or interruption of the aorta; and babies dying or undergoing operation in the first 28 days with coarctation of the aorta, aortic stenosis, pulmonary stenosis, tetralogy of Fallot, pulmonary atresia with ventricular septal defect, or total anomalous pulmonary venous connection. Results: Of 688,167 live born babies in the 20 years of the study, 4444 had cardiovascular malformations diagnosed in infancy (6.5 per 1000). Cardiovascular malformations were potentially life-threatening in 685 (15%). Over the time of the study, 8% were recognised prenatally, 58% postnatally before discharge from hospital, 31% in life after discharge and 3% after death. Malformations most likely to remain undiagnosed at discharge were coarctation of the aorta (63%), interruption of the aortic arch (50%), and total anomalous pulmonary venous connection (47%). Over the 20 years of the study, the proportion of babies diagnosed antenatally increased from around 1% to 20% and no case was first diagnosed after death in the last 10 years. However, the recent proportion going home without a diagnosis remains around 25%. Conclusions: Overall one third of babies with potentially life-threatening cardiovascular malformations leave hospital undiagnosed. In recent years better antenatal diagnosis has reduced this proportion to one quarter. Better early recognition of such babies is unlikely to be achieved by clinical examination and is more likely to come from further improvements in antenatal diagnosis and more widespread adoption of routine pulse oximetry.

The development and implementation of a multidisciplinary neonatal resuscitation team in a Canadian perinatal centre

Purpose: To describe the implementation of a multidisciplinary neonatal resuscitation team (NRT) at a Canadian tertiary perinatal centre. Methods: In February 2002, the primary role of neonatal resuscitation was transferred from attending physicians (on-call off-site) to a NRT (consisting of a neonatal intensive care nurse, a respiratory therapist, and, when available, a resident, clinical associate (supervised licensed physician), or nurse practitioner). The NRT attended moderate- and high-risk deliveries (in the latter case, accompanied by a neonatologist). Normal, low-risk deliveries remained the responsibility of caseroom (delivery room) staff, assisted by the NRT when concerns arose. A prospective assessment was performed of resuscitation requirements and outcomes. Results: Over 24 months, the NRT attended 2944 (64.5%) out of 4565 deliveries. The NRT attended 2497 moderate-risk deliveries, providing positive pressure ventilation (in 15.7% of cases), chest compressions (0.1%), and epinephrine (adrenaline) (0.08%). There were no neonatal deaths or morbidities related to resuscitation in this cohort. A small, but significant, proportion of babies with no identifiable risk factors required resuscitation by caseroom staff (in most cases with brief periods of positive pressure ventilation). Conclusion: Assignment of level of risk provides a safe means of delivering neonatal resuscitation services, facilitating NRT attendance at the majority of deliveries that required resuscitation. A NRT can perform safely and effectively in a tertiary perinatal centre with off-site support from experienced neonatal staff at high-risk deliveries only. Caseroom (delivery room) staff should continue to be trained in neonatal resuscitation.

Anthropometry of Malawian live births between 35 and 41 weeks of gestation

The aim of this analysis was to construct cross-sectional gestational age specific percentile curves for birthweight, length, head and mid-arm circumference for Malawian babies, and to compare these percentiles with reference values for babies born to women with normal pregnancies, from a developed country. A cross-sectional study which enrolled pregnant women attending two study hospitals between March 1993 and July 1994 was undertaken. Data on maternal socio-economic status, newborn anthropometry, previous obstetric history and current pregnancy were collected. Smoothed percentile values were derived using the LMS method. Malawian reference percentiles were constructed for fetal growth from 35 weeks' gestation for singleton births. Mean birthweight, length and head circumference were lower at all gestational ages for Malawian compared with Swedish newborns. Fetal growth per completed gestational week was higher by 60 g in weight, 0.5 cm in length and 0.2 cm in head circumference in Swedish compared with Malawian babies. Growth restriction was present from 35 to 41 weeks' gestation. The pattern for the 10th percentile suggested that this was occurring from well before 35 weeks' gestation in a proportion of babies.

Urinary tract infection: The urological perspective

Urinary tract infection in babies often presents with non specific symptoms and signs. It must be considered in the differential diagnosis of a febrile sick baby or any baby with failure to thrive. In a significant proportion of babies with recurrent urinary tract infection, urological abnormality is demonstrable. The diagnosis of urinary tract infection is confirmed by the presence of pus cells and growth of microorganism in a fresh urine specimen. The voidoing history and detailed ultrasound examination in the baby including a post void evaluation of the upper and lower urinary tract can lead to the possible diagnosis in the majority. Antibiotic therapy for urinary tract infection should be followed by consideration about the need for urinary drainage at the appropriate level, particularly in cases where resolution is delayed despite antibiotics. There is a role for prophylactic antibiotics after the resolution of acute infection, at least until detailed evaluation several weeks after the acute episode, has excluded any abnormality. Micturating cytourethrogram is usually done under antibiotic cover and better done in centres with facility for fluoroscopic examination. Isotope studies have to be evaluated in the light of inherent limitations. Transient urodynamic abnormality of the urinary bladder in infancy is being increasingly recognized and should be the subject of evaluation in specific circumstances. A multidisciplinary team improves the quality of investigations, subsequent interpretation and long term care of these children. A large majority of urological abnormality in infancy and early childhood can be effectively managed by endocopic procedures. Temporary urinary diversion may be required in a small proportion. Urological reconstruction should be approached with caution, after a detailed analysis of the evolving urological tract in a baby. An aggressive approach to early diagnosis and appropriate treatment of urinary tract infection and any underlying abnormality, has been shown to significantly reduce the incidence of chronic renal failure in long term longitudinal studies in children.

Estratégias que educadoras de creche afirmam utilizar para lidar com o choro dos bebês

O objetivo desse estudo é o de verificar a visão das educadoras de creche a respeito de como agem quando os bebês choram, se identificam a causa do choro e quais os motivos subjacentes que as levam a agir ou não. Vinte e uma educadoras de creche foram entrevistadas a respeito de cada um dos 90 bebês de 4 a 24 meses de idade, sob seus cuidados, segundo um roteiro semi-estruturado. Os resultados mostram que, com o aumento da idade, maior a proporção de bebês que chora pouco. O choro por necessidades primárias, na percepção das educadoras, tende a decrescer com o aumento da idade e, ao contrário, o choro por necessidades diversas tende a aumentar. As educadoras, na maioria das vezes, procuram eliminar a necessidade que causa o choro, priorizando o bem estar dos bebês. Discutem-se as práticas educativas das educadoras com os dados encontrados na literatura. Palavras-chave: creche; práticas educativas; educadoras.

Evaluation of surfactant function at birth determined by the stable microbubble test in term and near term infants with respiratory distress.

Surfactant function using the stable microbubble test (SMT) was investigated in term or near term infants with respiratory distress. Newborn infants > or = 34 weeks gestation with an initial clinical hypothesis of transient tachypnoea of the newborn (TTN) needing supplemental oxygen and controls were included. Gastric aspirates were collected immediately after birth for SMT. The first chest X-ray films were examined by three independent radiologists and according to their interpretation the babies were divided into a TTN, a respiratory distress syndrome of the newborn (RDS), or a poorly-defined X-ray group. A total of 32 infants with respiratory distress and 32 controls with similar gestational age and birth weight were studied. The median and interquartile range (IQR) of the stable microbubble (SMB) count was significantly lower (P < 0.001) for the respiratory distress group than for the control group (17; range 6-33 versus 120; range 79-275). The proportion of babies with less than 35 stable microbubbles/mm2 (SMB/mm2) was significantly different for the whole respiratory distress group (24/32-75%) and for the TTN (9/13-69%), the RDS (5/5-100%), and the poorly-defined (10/12-83%) groups as compared with the controls (2/32-6%; P < 0.05). A total of 24/26 babies (92%) who needed oxygen for > or = 24 h but only 1/6 (17%) of them who needed < 24 h had a bubble count of less than 35 SMB/mm2 (P < 0.05). the results suggest that deficiency or dysfunction of the surfactant system is involved in the majority of cases of respiratory distress in near term and possibly term babies. The stable microbubble test can enable clinicians to take an earlier decision to give surfactant to term or near term infants with more severe and progressive respiratory distress.

Infantile skeletal skew: the use of ultrasound in management.

The term 'infantile skeletal skew' recognizes the prenatal or postnatal moulding of a small proportion of babies who develop characteristic changes including plagiocephaly, wry neck, scoliosis, pelvic obliquity and postural foot deformities. Pelvic obliquity may cause an abduction contracture of the hip on one side and an adduction contracture on the other, and radiographs may suggest a 'dysplasia' of the acetabulum on the adducted side, giving rise to concern that the hip is unstable. In these cases we have found that early ultrasound assessment of the adducted side will reassure the clinician that the hip is 'in joint' and the condition should be allowed to resolve itself over several months without any treatment. Eighteen infants with features of moulding in whom there was concern over the development of the hip on the adducted side, have been prospectively studied with the use of ultrasound until the age of 18 months when a final radiograph confirmed normal development of the hips.

Effect of prolongation of pregnancy on perinatal mortality

Objectives: (1) To determine the distribution of singleton and twin births according to gestational age in a Nigerian obstetric population; and (2) to compare their perinatal outcomes according to gestational age. Methods: A 10-year retrospective comparative study of twin and singleton births at a tertiary care center in Enugu, Nigeria. The variables analyzed were: the proportion of deliveries occurring at each gestational age, the gestational age-specific rates for stillbirths, cesarean section, babies with 1-min Apgar scores less than 4 and those whose birthweights were below the 10th percentile for gestational age. The trends in these rates were determined by finding the best fitting polynomial regression curve for each variable. Tests of statistical significance for trends in proportions were carried out by means of the χ 2-test at the 95% confidence level. Results: Of the 496 twin births, 3.6% compared with 17.3% of the 496 singleton births went beyond 40 weeks’ gestation while 1.2% of the twin and 4.4% of the singleton deliveries occurred at 42 weeks’ gestation or beyond. For twins as well as singletons, there was a consistent and significant decline in the stillbirth rate and the proportion of babies with 1-min Apgar scores less than 4 up to 42 weeks ( P=0.0000). Among the twins, the proportion of babies with birthweights below the 10th percentile (i.e. those with impaired growth) significantly rose from 28 weeks and above ( P=0.0000) while among the singletons, a declining trend with gestational age was observed ( P=0.0003). However, among the twins with impaired growth, the stillbirth rate neither differed between the first and second twins at each gestational age nor did it increase with gestational age in both the first and second twins. While the cesarean section rate for singletons remained almost stable at approximately 13%, there was a significant rise in the cesarean section rate with gestational age among the twin births. Conclusions: There were 1.2% of twin deliveries compared with 4.4% of singleton deliveries which occurred at 42 weeks’ gestation or beyond. In the Nigerian population studied, the perinatal outcomes in twins did not differ from those of singletons up to 42 weeks’ gestation suggesting that the 42-week cut-off for prolonged pregnancy applies equally well to twins as to singletons.

Transmission of HIV in the dental clinic and elsewhere.

This review focuses on the risk of transmission of HIV in dental practice in developed and developing countries; and as a result of oral sex, perinatal transmission and breast feeding. Postexposure prophylaxis (PEP) and practical measures to control cross-infection with TB are also discussed. There are few data from resource-poor countries where prevalence of HIV and risk of infection are higher--issues that deserve priority. Available information indicates that the risk of HIV transmission in the dental office is very low. Transmission of HIV from three healthcare workers to patients has been confirmed, including a dentist who infected six patients. There are >300 reports (102 confirmed) of occupational transmission to healthcare workers, including nine dental workers (unconfirmed). Exposure to HIV has been reported by 0.5% dentists/year. The risk of HIV infection after percutaneous exposure (0.3%) can be reduced by 81% with zidovudine PEP. However, risk assessment is required to assess the need and appropriate regimen. The risk of HIV transmission associated with orogenital sex exists, but is considered extremely low: barrier protection is recommended. Conversely, the proportion of babies who acquire HIV from untreated HIV-seropositive mothers is 15-25% in developed countries and 25-45% in developing countries. The frequency of HIV transmission attributable to breastfeeding is 16%. Airborne transmission of TB can be avoided by the prompt referral of known/suspected cases of active TB for chemotherapy, deferral of elective procedures until patients are not infectious, and the use of appropriate standard/isolation precautions including adequate ventilation of treatment areas.

Glutamine supplementation for preventing morbidity in preterm infants.

The amino acid glutamine is the preferred respiratory fuel for rapidly proliferating cells under normal conditions. Recent research has suggested a number of roles for glutamine during critical illness. This research has been largely performed in experimental animals and in adults in a variety of disease settings. There is little information on the role of glutamine in children and infants, or whether glutamine supplementation is beneficial in preterm babies. To determine the effects of glutamine supplementation on morbidity and weight gain in preterm babies. Searches were made using Medline and Embase electronic databases and specific handsearching in the English language. The search strategy followed the guidelines of the Neonatal Cochrane Review Group. Randomised controlled trials comparing glutamine supplementation to no glutamine supplementation in preterm babies at any time from birth to discharge from hospital. Data regarding clinical outcomes including duration of parenteral nutrition, time to full enteral nutrition, rate of weight gain, rate of positive blood cultures and duration of hospital stay were extracted by both reviewers. Analysis was performed by the primary reviewer (TRJT) in accordance with the standards of the Cochrane Neonatal Review Group. Three trials met the selection criteria. Data on proportion of babies having one or more of positive blood cultures were available from all three studies. Meta-analysis showed no significant difference between glutamine-supplemented and non-supplemented babies; RR = 0.73 (95% CI 0.44, 1.23), RD = -8.8% (95% CI -23.2, 5.5). Data for other outcome variables were pooled from two studies. There were no significant differences between glutamine-supplemented and non-supplemented babies for days to full enteral nutrition (WMD 0.42, 95% CI -3.0, 3.8), rate of weight gain (WMD 0.6 g/kg/d, 95% CI -1.6, 2.8) or days of hospital stay (WMD -2.4, 95% CI -14.9, 10.2). There is no evidence to support the routine use of parenteral or enteral glutamine supplementation in preterm babies. A large randomised controlled trial should be performed to determine whether or not glutamine supplementation enhances gut integrity and reduces sepsis rate.

Reducing risk by improving standards of intrapartum fetal care.

Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward--guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH < 7.2. These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical risk management.