Two-thirds of adolescents who received active perinatal care after extremely preterm birth had mild or no disabilities.

AIM: Active perinatal care (APC) increases the survival of extremely preterm (EPT) infants, but may increase the rate of disabilities. We examined neurodevelopmental outcomes in adolescents aged 10-15 years who were born EPT and received APC in two Swedish tertiary care centres. METHODS: Cognitive function was assessed using the Wechsler Intelligence Scale for Children, and neurosensory impairments were assessed by reviewing the case records and a standard parent health questionnaire. The outcomes were compared to term-born controls. RESULTS: We assessed 132 EPT adolescents and 103 controls. The rates of cerebral palsy, moderate to severe visual impairment and moderate to severe hearing impairment were 9%, 4% and 6%, respectively, for the EPT children and zero for the controls. Serious cognitive impairment was present in 31% of the EPT adolescents and 5% of the controls. Combining impairments across domains showed that 34% of EPT adolescents had moderate and severe disabilities compared with 5% of the controls. Impairments were more common at 23-24 weeks of gestational age (43%) than at 25 weeks (28.4%). CONCLUSION: Two-thirds (66%) of adolescents born EPT who received APC had mild or no disabilities. Our results are relevant for healthcare providers and clinicians counselling families.

Executive Functioning and Learning Skills of Adolescent Children Born at Fewer than 26 Weeks of Gestation.

AIMS: To assess the cognitive and behavioral aspects of executive functioning (EF) and learning skills in extremely preterm (EPT) children compared with term control children aged 10 to 15 years. METHODS: A total of 132 of 134 (98% of all eligible survivors) EPT children born at the 2 Swedish regional tertiary care centers from 1992 to 1998 (mean age = 12 years, mean birth weight = 718 g, and mean gestational age = 24.4 weeks) and 103 matched term controls were assessed. General intelligence was assessed using the Wechsler Intelligence Scale for Children (WISC-III-R), and cognitive aspects of EF were analyzed using EF-sensitive subscales of the WISC-III-R and Tower test of the Delis-Kaplan Executive Function Scale (D-KEFS). Behaviors related to EF and learning skills were assessed using the Five to Fifteen questionnaire, which is a validated parent and teacher instrument. Academic performance in school was assessed by teachers' responses on Achenbach's Teachers Report Form. Analyses performed included multivariate analyses of covariance (ANCOVA and MANCOVA) and logistic regression analyses. RESULTS: The EPT children displayed significant deficits in cognitive aspects of EF compared with the controls, exhibiting decreases on the order of 0.9 SD to 1.2 SD for tasks of verbal conceptual reasoning, verbal and non-verbal working memory, processing speed and planning ability (P <0.001 for all). After excluding the children with major neurosensory impairment (NSI) or a Full Scale intelligence quotient (FSIQ) of < 70, significant differences were observed on all tests. Compared with controls, parents and teachers of EPT children reported significantly more EF-related behavioral problems. MANCOVA of teacher-reported learning skills in children with FSIQ >70 and without major NSI revealed no interactions, but significant main effects were observed for the behavioral composite executive function score, group status (EPT vs control) and FSIQ, for which all effect sizes were medium to large. The corresponding findings of MANCOVA of the parent-reported learning skills were very similar. According to the teachers' ratings, the EPT children were less well adjusted to the school environment. CONCLUSION: EPT children born in the 1990s who received active perinatal care are at an increased risk of executive dysfunction, even after excluding children with significant neurodevelopmental disabilities. Even mild to moderate executive dysfunctions has a significant impact on learning skills. These findings suggest the need for timely interventions that address specific cognitive vulnerabilities and executive dysfunctions.

Preterm appropriate for gestational age infants: size at birth explains subsequent growth.

AIM: The aim was to evaluate growth and breastfeeding up to 18 months corrected age (CA) among preterm appropriate for gestational age (AGA) infants whose mothers initiated breastfeeding during the infants' hospital stay. METHODS: One hundred and twenty-seven preterm AGA infants with a median birth weight of 2320 (769-3250) g and gestational age 34.29 (25.00-35.86) weeks were evaluated up to a CA of 18 months. A retrospective, descriptive and comparative design was used. Data were obtained by chart review of hospital medical records and a questionnaire completed by the mothers. RESULTS: The changes in standard deviation scores (SDS) during the infants' hospital stay were -0.9 for weight, -0.3 for length and -0.5 for head circumference (HC). Infants with higher SDS at birth showed more negative changes from birth to discharge. Median increments in SDS from discharge to a CA of 2 months were as high as, or higher than, the loss from birth to discharge. CONCLUSION: Preterm AGA infants with higher SDS for weight, length and HC at birth are at higher risk of inadequate growth during their hospital stay.

Milk for small infants.

UNLABELLED: This study investigated weight patterns of infants born SGA, in relation to two different feeding regimens during hospital stay. We compared 21 SGA infants prescribed 200 mL/kg milk on day 2, with 21 infants, prescribed 170 mL/kg on day 9. The infants fed according to the proactive nutrition policy tolerated large volumes of milk and showed lower weight loss. CONCLUSION: A proactive nutrition policy demonstrably reduces weight loss in SGA infants.

Growth and breastfeeding among low birth weight infants fed with or without protein enrichment of human milk.

The effect of protein enrichment of mother's milk on growth of low birthweight infants needs further exploration in order to optimize feeding strategies. The aim of this study was to describe feeding and growth of infants weighing <1,900 g at birth, up to a corrected age of 18 months, with or without protein-enriched breastmilk. A retrospective, descriptive, non-experimental design was used to describe the growth of 52 low birthweight infants. Data on their growth and feeding were collected from medical records at hospitals and child health care clinics. Despite more severe morbidity, the infants given protein-enriched milk showed similar growth as the other study infants. Standard deviation score for length at birth correlated positively with delta standard deviation score for length, from discharge to 12 and from discharge to 18 months corrected age. Duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. At discharge a smaller proportion of singletons fed with protein enriched milk were breastfed 'fully'. Infants who established breastfeeding at an early post-menstrual age were born with more optimal weight standard deviation score and had a better weight gain after discharge. We conclude that protein-enriched breast milk enables low birthweight infants requiring especially intensive care to attain growth at discharge comparable to that of healthier infants not given enriched milk. Low standard deviation score for length at birth may predict poor growth after discharge. However duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. Therefore it is important that mothers of LBW infants are given sufficient support of lactation and breastfeeding.

Extremely preterm cesarean delivery: a clinical study.

OBJECTIVES: To describe indications for cesarean section for extremely preterm delivery, peri- and postoperative complications and perinatal outcome. DESIGN: A case-referent study with clinical follow-up. SETTING: A tertiary perinatal center. POPULATION: All deliveries at gestational age <28 weeks at Umeå University Hospital in 1997-2003. For preterm cesarean section referents were women with elective first-time term cesarean section. METHODS: Indications for cesarean section delivery were assessed. Peri- and postoperative complications, asphyxia, and infant survival at discharge were described. RESULTS: The cesarean section rate was 75%, in one third the operation was considered as difficult. Indications for extremely preterm abdominal delivery were severe disease during pregnancy and delivery complications. Six out of ten cesarean sections were performed on fetal indication. Nonisthmic incision was performed in 20% of cases. No major postoperative complications and few minor postoperative complications were noted. Irrespective of mode of delivery, few of the infants had severe asphyxia. CONCLUSION: In balancing the risks of complications related to the surgical procedure against the purported benefits of the infant, this study adds support to the argument to deliver even extremely preterm infants by cesarean section.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish tertiary care centres. Part 2: infant survival.

AIM: To determine neonatal survival rates based on both foetal (stillborn) and neonatal deaths among infants delivered at 23-25 wk, and to identify maternal and neonatal factors associated with survival. METHODS: The medical records of 224 infants who were delivered in two tertiary care centres in 1992-1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Data were analysed by gestational age groups and considered in three time periods. Logistic regression models were used to identify factors associated with survival. RESULTS: The rate of foetal death was 5%. Of infants born alive, 63% survived to discharge. Survival rates including foetal deaths in the denominator at 23, 24 and 25 wk were 37%, 61% and 74%, respectively, and survival rates excluding foetal deaths were 43%, 63% and 77%, respectively. Of infants born with 1-min Apgar scores of 0-1, 43% survived. In the total cohort, survival rates including foetal deaths in the denominator increased from 52% in time period 1 to 61% in time period 2 and 74% in time period 3 (p < 0.02). On multivariate logistic regression analysis, higher birthweight (OR: 1.91 per 100 g increment; 95% CI: 1.45-2.52), female gender (OR: 3.33; 95% CI: 1.65-6.75), administration of antenatal steroids (OR: 2.95; 95% CI: 1.46-5.98) and intrauterine referral from a peripheral hospital (OR: 2.35; 95% CI: 1.18-4.68) were associated with survival. Apgar score < or = 3 at 1 min (OR: 0.46; 95% CI: 0.22-0.95) was associated with decreased survival. The use of antenatal steroids was protective at 23-24 wk (OR: 5.2; 95% CI: 2.0-13.7), but not at 25 wk. CONCLUSIONS: Active perinatal management that included universal initiation of neonatal intensive care virtually eliminated intrapartum stillbirths and delivery room deaths, and resulted in survival rates that compare favourably with those of recent studies. However, the policies of active care postponed death in non-survivors. Individual variations in outcome in relation to the infant's condition at birth as reflected by the Apgar scores preclude the making of treatment decisions in the delivery room.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish perinatal centres. Part 3: neonatal morbidity.

AIM: To determine major neonatal morbidity in surviving infants born at 23-25 weeks, and to identify maternal and infant factors associated with major morbidity. METHODS: The medical records of 224 infants who were delivered at two tertiary care centres in 1992-1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Of the 213 liveborn infants, 140 (66%) survived to discharge. Data were analysed by gestational age and considered in three time periods. Logistic regression models were used to identify factors associated with morbidity. RESULTS: Of the survivors, 6% had intraventricular haemorrhage grade > or = 3 (severe IVH) or periventricular leukomalacia (PVL), 15% retinopathy of prematurity > or = stage 3 (severe ROP) and 36% bronchopulmonary dysplasia (BPD). On logistic regression analysis, severe IVH or PVL was associated with duration of mechanical ventilation (odds ratio, OR: 1.53 per 1-wk increment in duration; 95% confidence interval, CI: 1.01-2.33). Severe ROP was associated with the presence of a patent ductus arteriosus (PDA) (OR: 3.31; 95% CI: 1.11-9.90) and birth in time period 3 versus time periods 1 and 2 combined (OR: 6.28; 95% CI: 2.10-18.74). BPD was associated with duration of mechanical ventilation (OR: 2.71 per 1-wk increment in duration; 95% CI: 1.76-4.18) and with the presence of any obstetric complication (OR: 2.67; 95% CI: 1.07-6.65). Gestational age and birthweight were not associated with major morbidity. Of all survivors, 81% were discharged home without severe IVH, PVL or severe ROP. CONCLUSIONS: Increased survival as a result of active perinatal and neonatal management was associated with favourable morbidity rates compared with those in recent studies. Among survivors born at 23-25 weeks, neither gestational age nor birthweight was a significant determinant of major morbidity.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish tertiary care centres. Part 1: maternal and obstetric factors.

AIMS: To provide descriptive data on women who delivered at 23-25 wk of gestation, and to relate foetal and neonatal outcomes to maternal factors, obstetric management and the principal reasons for preterm birth. METHODS: Medical records of all women who had delivered in two tertiary care centres in 1992-1998 were reviewed. At the two centres, policies of active perinatal and neonatal management were universally applied. Logistic regression models were used to identify prenatal factors associated with survival. RESULTS: Of 197 women who delivered at 23-25 wk, 65% had experienced a previous miscarriage, 15% a previous stillbirth and 12% a neonatal death. The current pregnancy was the result of artificial reproduction in 13% of the women. In 71%, the pregnancy was complicated either by pre-eclampsia, chorioamnionitis, placental abruption or premature rupture of membranes. Antenatal steroids were given in 63%. Delivery was by caesarean section in 47%. The reasons for preterm birth were idiopathic preterm labour in 36%, premature rupture of membranes in 41% and physician-indicated deliveries in 23% of the mothers. Demographic details, use of antenatal steroids, caesarean section delivery and birthweight differed between mothers depending on the reason for preterm delivery. Of 224 infants, 5% were stillbirths and 63% survived to discharge. On multivariate logistic regression analysis comprising prenatally known variables, reasons for preterm birth were not associated with survival. Advanced gestational duration (OR: 2.43 per wk; 95% CI: 1.59-3.74), administration of any antenatal steroids (OR: 2.21; 95% Cl: 1.14-4.28) and intrauterine referral from a peripheral hospital (OR: 2.93; 95% CI: 1.5-5.73) were associated with survival. CONCLUSIONS: Women who deliver at 23-25 wk comprise a risk group characterized by a high risk of reproductive failure and pregnancy complications. Survival rates were similar regardless of the reason for preterm birth. Policies of active perinatal management virtually eliminated intrapartum stillbirths.

Regional differences in stillbirth and neonatal death rate in Sweden with a cause-of-death specific analysis.

UNLABELLED: Regional differences in stillbirth and neonatal death rates in Sweden were studied and a cause-of-death analysis was done in the 4 counties (among 24) with an increased mortality. The study is based on a computerized evaluation of infant cause of death, using a slightly modified Wigglesworth classification and a hierarchical classification (NICE: Neonatal and Intrauterine death Classification according to Etiology). Differences between the identified counties with respect to specific causes of death were demonstrated. CONCLUSION: There are differences between Swedish counties with respect to the risk for stillbirth or neonatal death. The NICE cause-of-death classification can be used for the routine surveillance of stillbirths and neonatal deaths in a population and can help in pinpointing weak elements in antenatal, delivery and neonatal care.

Cause-specific stillbirth and neonatal death in Sweden: a catchment area-based analysis.

UNLABELLED: A register-based study of the impact of obstetric and neonatal care on stillbirth and neonatal death rate was performed on all births in Sweden in 1983-1995. Each birth was assigned to a primary delivery hospital where the mother with a term singleton pregnancy was most likely to have been delivered (not possible for 25% of the deliveries), and the catchment areas of each hospital were classified according to the level of care of that hospital. Only small differences in total mortality existed between the different levels of care of the primary hospital: areas served by primary hospitals with obstetric service and resources for neonatal intensive care including continuous positive airway pressure but without facilities for ventilator treatment for prolonged periods showed a 7% excess risk of stillbirth or neonatal death. CONCLUSION: In areas with the lowest level of care of the primary delivery hospitals (with no or only basic neonatal care) the total mortality was not increased, indicating that the referral system works well. When the analysis was repeated for specific causes of death, more marked differences were noted, especially for death due to obstetric complications where the death risk increased with decreasing level of care of the primary delivery hospital. Even though no marked differences in total mortality were seen, a further reduction can be obtained by increasing referral for some specific conditions.

Maternal risk factors for cause-specific stillbirth and neonatal death.

BACKGROUND: To study specific effects of four maternal risk factors: age, parity, educational level, smoking, for specific causes of stillbirth and neonatal death according to a previously described hierarchic classification. METHODS: The study is based on 9,785 stillbirths or neonatal deaths among infants born in Sweden, 1983-1995 (n=1,412,754) and identified with various Swedish health registers. Statistical analysis is performed using Mantel-Haenszel analysis. RESULTS: Some risk factors, known from the literature, were confirmed and could be quantified. In addition, high parity was shown to increase the risk for death associated with multiple births (OR=2.49, 95% CI 2.07-3.01) and low educational level seems to be protective for such death (OR=0.75, 95% CI 0.60-0.93). If the infant is SGA, the risk for death is higher at high than at low parity (1.70, 95% CI 1.19-2.43, and 1.0, 95% CI 1.06-1.15, respectively). Maternal smoking seems to aggravate the placental abruption because the death risk in the presence of abruption increases when the mother smoked (OR = 1.74, 95% CI 45-2.08). CONCLUSIONS: The study shows that the groups of the classification system used (NICE) differ in their association with known risk factors for stillbirth and neonatal deaths and an analysis based on specific causes of death can therefore unravel risk factors hidden when total mortality is used. The computerized method of classification and the cause-of-death classification developed by us is clearly useful for such analyses which requires large materials.

First week kangaroo care in sick very preterm infants.

The aim was to investigate whether kangaroo care (KC) with and without nasogastric tube feeding (NG) is tolerated by sick preterm infants during the first week of life. Seventeen infants with current or resolving illness received 1 h of KC. The study patients were originally recruited for a study on the response of intestinal peptides to feeding during KC. Median gestational age was 28 wk and median birthweight 1238 g. During KC, eight infants received NG. During KC, oxygen requirements were unchanged or decreased in 15 infants and increased in 2 infants. Changes in arterial blood gases, transcutaneous pO2/pCO2, heart rate and temperature were minimal. One episode of apnoea occurred. In conclusion, KC was well tolerated, as was NG, during KC.

Lack of precision in neonatal death classifications based on the underlying causes of death stated on death certificates.

Large-scale analyses of causes of neonatal deaths are usually based on death-certificate information. A new computer-based method has been introduced to define the cause of stillbirths and neonatal deaths in large amounts of material and to classify them according to two different models [Wigglesworth and Neonatal and Intrauterine death Classification according to (a)Etiology (NICE)]. The method is based on a combination of detailed information from health care registries and the death-certificate information. The present study aimed to compare these two classification models with a previously published method based solely on death certificate information [International Collaborative Effort (ICE)]. The study population comprised 2378 neonatal deaths in Sweden between 1987 and 1992. Cross-tabulation was made between the ICE classification and the other two classification models. In addition, case examples are presented in detail, exemplifying how classification errors arose. The ICE classification gives a rather low precision, notably for two important causes of death: asphyxia and immaturity. Among 328 infants dying from asphyxia according to computerized Wigglesworth classification, ICE classified 59% as asphyxia and 22% were labelled immaturity. When ICE classified the deaths as due to asphyxia, this was verified in only 50%. Among 792 infants dying from immaturity according to computerized Wigglesworth classification, 64% were classified as such by ICE. The findings cast doubts on the results of studies based exclusively on death-certificate information. Whenever possible in the analysis of neonatal deaths, death-certificate information should be supplemented with more detailed data. The computer-based method introduced here makes such analyses possible for large databases.

Survival and 2-year outcome with expectant management of second-trimester rupture of membranes.

OBJECTIVE: To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester. METHODS: Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age. RESULTS: Rupture of membranes occurred at 14-19 weeks (mean 17.4 weeks) in 10 women, at 20-25 weeks (mean 24.0 weeks) in 24, and at 26-28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. CONCLUSION: Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.

Plasma somatostatin and cholecystokinin levels in preterm infants during kangaroo care with and without nasogastric tube-feeding.

AIM OF THE STUDY: To analyze the influence of kangaroo care (KC) with and without nasogastric tube-feeding (NGTF) on plasma cholecystokinin (CCK) and somatostatin (SS) levels in preterm infants and in their parents. PATIENTS AND METHODS: Eighteen infants, median (range) gestational age 28 wks (24-34 wks) and birth weight 1230 g (766-2660 g) received KC for > or = 60 min at a median age of 3 days. In infants, blood samples were taken before KC and at 5, 30 and > or = 60 minutes of KC and from the parents (n = 15) before and at > or = 60 minutes of KC. Eight infants receiving KC and 67 infants not receiving KC were fed by nasogastric tube. Blood samples were taken before and 30 min after the end of feeding. All blood samples were analyzed by specific SS and CCK radioimmunoassays. RESULTS: In infants, the median plasma cholecystokinin level decreased from 10.3 to 9.0 pmol/l (p < 0.05) during KC without feeding. Plasma SS did not change. Plasma CCK levels increased from 10.1 to 22.3 pmol/l (p = 0.028) after NGTF during KC and were unchanged after NGTF without KC. Plasma somatostatin levels were unchanged after NGTF in both groups. In parents, plasma somatostatin levels and cholecystokinin levels did not change during KC. CONCLUSIONS: In infants, plasma cholecystokinin, but not somatostatin levels, decreased during KC. Plasma CCK levels increased after NGTF only in combination with KC. Plasma SS levels were unchanged. In parents, plasma somatostatin and cholecystokinin levels were not influenced by KC.

Neurosensory outcome and growth at three years in extremely low birthweight infants: follow-up results from the Swedish national prospective study.

A prospective national investigation comprising 633 extremely low birthweight (ELBW) infants born alive in the 2-y period 1990-1992 with a birthweight of < or = 1000 g and gestational age of > or = 23 completed weeks was conducted regarding neurosensory outcome and growth. Three-hundred and sixty-two (98%) surviving ELBW infants were assessed at a median age of 36 months, using a specially designed protocol. At follow-up, mean height, weight and head circumference in both boys and girls were significantly lower than the reference values. The incidence of cerebral palsy was 7% among all children and 14%, 10% and 3% in children born at 23-24, 25-26 and > or = 27 gestational weeks, respectively. At least one obvious handicap was present in 14%, 9% and 3% of these three groups of children, respectively. After adjustment for gestational age, a significantly increased risk of handicap was found in children with intraventricular haemorrhage grade > or = 3 and/or periventricular leucomalacia and in children with retinopathy of prematurity stage > or = 3. The results show that more than 90% of ELBW children born at > or = 25 completed gestational weeks were without neurosensory handicap at 36 months of corrected age. In infants born at 23-24 weeks of gestation, both survival and long-term outcome were less favourable.

Plasma somatostatin and cholecystokinin levels in response to feeding in preterm infants.

BACKGROUND: The functions of the gut are modulated by the autonomic nervous system and gut peptides, such as somatostatin and cholecystokinin, which have opposite functions. This study reports plasma somatostatin and cholecystokinin levels in response to feeding in preterm infants. METHODS: In 76 infants--gestational age 23 to 36 weeks, birth weight 460 to 2867 g--blood samples were taken on day 1 before the first meal in life, and 30 minutes after the end of the meal. Samples were again taken on days 3 and 4. The infants were fed human milk by nasogastric tube, by breast, or by bottle. In 10 additional infants, (gestational age 27-36 weeks) who were studied at a median postnatal age of 15 days, the response of the peptides to breast-feeding was compared with that of tube-feeding. Plasma somatostatin and cholecystokinin were analyzed by specific radioimmunoassays. RESULTS: On day 1, the median plasma somatostatin level increased after feeding in small-for-gestational-age infants but not in appropriate-for-gestational-age infants. On days 3 and 4, the somatostatin level decreased in infants with a gestational age of 32 weeks or more. On day 1, plasma cholecystokinin levels increased in infants with a gestational age of 32 weeks or more: The response was more pronounced in small-for-gestational-age infants. On days 3 and 4, plasma cholecystokinin levels increased only in breast-feeding infants. In the 10 infants fed by breast and by tube, plasma cholecystokinin levels increased after breast-feeding and tended to increase after tube-feeding. The plasma somatostatin levels were unaffected after feeding. CONCLUSIONS: Plasma somatostatin and cholecystokinin increased after feeding in small-for-gestational-age infants on day 1. On days 3 and 4, the responses to feeding seemed to be dependent on the infant's gestational age. Breast-feeding enhanced the release of cholecystokinin but not that of somatostatin.

NICE, a new cause of death classification for stillbirths and neonatal deaths. Neonatal and Intrauterine Death Classification according to Etiology.

BACKGROUND: Stillbirths and neonatal deaths are often the result of a complicated chain of events. For epidemiological purposes a classification into single cause of death groups is essential. For large-scale studies, a method is needed which enables such grouping based on available register data. METHODS: A cause of death classification system called NICE is presented. It is hierarchical and is aetiologically orientated. A computerized method is adapted which makes use of data in four central Swedish registries. A validation of the computer method has been made from the medical records on a 10% sample of all stillbirths and neonatally dead infants in Sweden from 1983 to 1990. RESULTS: The specificity of the computer method is high, sensitivity is less satisfactory for some subgroups. A time trend analysis illustrates the usefulness of the classification system and shows a decline with time for two groups: placental abruption and obstetric complications. CONCLUSIONS: The NICE classification system fulfils the criteria of an aetiologically orientated classification system which can be used in a computerized environment.