Economic and Clinical Impact of Using Human Milk-Derived Fortifier in Very Low Birth Weight Infants.

Background: Implementation of exclusive human milk (EHM) feeding defined as mother's own milk or donor human milk fortified with human milk-derived fortifiers can place an economic burden on institutions. Methods: Retrospective study of very low birth weight (VLBW) infants before and after the implementation of EHM feedings. Neonatal demographics and clinical outcomes including necrotizing enterocolitis, severe retinopathy of prematurity, bronchopulmonary dysplasia, late-onset sepsis, days on parenteral nutrition (PN), and length-of-stay were collected. The net cost to the institution was estimated using published data. Results: Sixty-four infants in the pre-EHM period and 57 infants in the post-EHM period were enrolled. Net product acquisition cost in 2020 and 2021 was $884,823. The EHM feeding guideline led to a reduction in the mean length of stay and mean days of PN use by 6.3 and 6.8 days per infant, respectively. This led to a cost saving of $1,813,444 ($31,815 per infant). No significant difference in incidence of short-term morbidities was observed. Combining the cost avoidance from clinical outcomes, the estimated financial impact over 2 years excluding insurance reimbursement was an estimated $ 913,840 ($16,032 per infant). Conclusion: Implementation of EHM-based feeding in VLBW infants is a cost-effective option for neonatal intensive care units that can result in reduced length of stay and days on PN without adversely impacting short-term morbidities.

Effect of Maternal Preeclampsia on Cardiac Structure and Function in Very Low Birth Weight Infants.

OBJECTIVE: We aimed to determine whether exposure to severe maternal preeclampsia (PE) in very low birth weight (VLBW) infants is associated with hypertrophic cardiac changes and altered hemodynamics. STUDY DESIGN: Case-control study of VLBW infants born at Los Angeles General Medical Center from May 2015 to August 2023, who had an echocardiogram within the first 7 days of life. Cases were infants exposed to maternal PE and controls were infants not exposed to maternal PE matched by birth weight (BW) 1:1. Laboratory, placental pathology results, hemodynamic data and clinical outcomes were collected and compared between cases and control infants. RESULTS: A total of 43 cases matched by BW with control infants were studied. There were no significant anatomical cardiac changes by echocardiography between cases and control infants. Cases had significantly higher blood pressure within the first 72 hours of life and lower ejection fraction (EF), fractional shortening, and peak systolic flow velocity through their patent ductus arteriosus (PDA) within the first week of life. Cases were more likely to be smaller despite being born at a later gestational age (GA), as well as small for GA with placental weight less than 10th percentile compared to control infants. CONCLUSION: Our findings indicate that infants born to mothers with PE have higher systemic vascular resistance as evidenced by elevated blood pressure, and lower EF and shortening fraction and higher pulmonary vascular resistance as evidenced by lower peak flow velocity through the PDA. We did not observe hypertrophic cardiac changes in exposed infants. These findings should be considered in clinical decision-making during management of these infants. KEY POINTS: · VLBW infants exposed to severe PE have higher rate of Small for gestational age and smaller placentas.. · VLBW infants exposed to severe PE have higher systemic vascular resistance during transitional period and lower EF and fractional shortening.. · VLBW infants exposed to severe PE have higher pulmonary vascular resistance..

Transient Hypoglycemia and Biochemical Differences in Infants Less Than 1,250 G at Birth Fed Human Milk with Human Milk-Derived Fortifier versus Cow Milk-Derived Fortifier.

OBJECTIVE: Fortification of human milk (HM) with either human milk-derived fortifier (HMDF) or cow milk-derived fortifier (CMDF) is important in preterm infants. The objective is to compare the incidence of hypoglycemia, and biochemical values in infants less than 1,250 g at birth fed HMDF versus CMDF. STUDY DESIGN: It is a retrospective cohort study on infants less than 1,250 g at birth who were fed with HMDF or CMDF. Hypoglycemia was defined as blood glucose (BG) level equal to or less than 60 mg/dL within 72 hours of full enteral feeds when off total parenteral nutrition and intravenous fluids. RESULTS: Ninety infants were enrolled (HMDF = 61, CMDF = 29). HMDF group had a higher rate of hypoglycemia (46 vs. 24%; p = 0.048) after achievement of full enteral feeding. The median minimum BG was lower (61 vs. 71; p ≤ 0.01), while blood urea nitrogen (12 vs. 6; p ≤ 0.01) and albumin (3.1 vs. 2.7; p ≤ 0.01) were higher in HMDF group compared with CMDF. CONCLUSION: At full enteral feedings in infants less than 1,250 g at birth, an HMDF diet may predispose to hypoglycemia needing intervention. Close monitoring of BG levels once off parenteral nutrition is recommended. KEY POINTS: · Exclusive human milk (EHM) feeding results in better nutritional indices.. · EHM feeding at higher calorie/ounce improves growth.. · Blood glucose needs to be monitored when off TPN during EHM feeding..

Outcomes of patent foramen ovale greater than 3 mm at birth in extremely low birthweight infants.

BACKGROUND: Foramen ovale (FO) is an obligate fetal shunt that typically resolves after birth, although patency throughout life is not uncommon. The natural history of patent FO (PFO) is known in term infants, but less is known about its course in extremely preterm infants. We describe the echocardiographic changes in FO size from birth to discharge in extremely low birth weight (ELBW) infants in this retrospective study. METHODS: Cohort was divided based on size of FO at birth. Size of FO at discharge was measured and evaluated relative to postnatal weight gain. Demographics and clinical outcomes were compared between the two groups. RESULTS: Of the 54 ELBW infants, 50 were born with FO less than 3 mm in diameter (small), and 4 were born with FO greater than 3 mm (large). Of small defects, the majority (44/50, 88%) did not increase in size with weight gain, and minority (6/50, 12%) increased in size, and three of these 6 patients, FO grew to be slightly larger than 3 mm. In contrast, all large defects (4 of 4, 100%) nearly doubled in size with postnatal growth. These 4 ELBW infants with enlargement of FO had a flap valve evident on echocardiogram obtained prior to discharge, and subsequently closed on outpatient follow-up echocardiograms, although time to resolution was variable (6 months - 3 years). One infant had presumptive resolution because of the presence of flap valve. CONCLUSION: No maternal or neonatal demographic characteristics were predictive of FO enlargement, although, demonstrable flap valve on discharge echocardiogram correlated with resolution of FO on outpatient follow-up echocardiogram. Therefore, based on our data, we recommend that ELBW infants born with large FO should have echocardiographic re-evaluation of the atrial septal opening prior to discharge, to specify the presence of a flap valve or lack thereof, which is an important detail that can help a neonatologist determine the need for outpatient cardiac follow-up.

Pulmonary hemorrhage in extremely low birth weight infants: Significance of the size of left to right shunting through a valve incompetent patent foramen ovale.

OBJECTIVE: Pulmonary hemorrhage is a rare but severe complication of extremely low birth weight (ELBW) infants. The association of hemodynamically significant patent ductus arteriosus (hsPDA) and the diameter of the foramen ovale (FO) with pulmonary hemorrhage has not been reported. STUDY DESIGN: Case control study of ELBW infants with and without pulmonary hemorrhage. Each ELBW infant with an echocardiogram within 48 h of pulmonary hemorrhage was analyzed. RESULT: 16 infants with pulmonary hemorrhage were matched with 32 controls by birth weight and gestational age. Echocardiogram showed hsPDA in all infants and those with pulmonary hemorrhage had significantly smaller patent FO [PFO] (1 vs 2.4 mm, p < 0.01) (OR 0.007; 95% CI 0.00007, 0.67 p = 0.03). Incidence of pulmonary hemorrhage was 8.9%. CONCLUSION: ELBW infants with hsPDA who experienced pulmonary hemorrhage had a significantly restricted or closed FO. Evaluation of FO should be considered with serial echocardiograms when evaluating for hsPDA.

Low maternal vitamin D is associated with increased risk of congenital and peri/postnatal transmission of Cytomegalovirus in women with HIV.

BACKGROUND: CMV infection of the fetus or neonate can lead to devastating disease, and there are no effective prevention strategies to date. Vitamin D is a potent immunomodulator, supports antiviral immune responses, and plays an important role in placental immunity. METHODS: Retrospective cohort study to evaluate the impact of low maternal vitamin D on congenital and early postnatal transmission of CMV among HIV-infected, non-breastfeeding women and their HIV exposed but negative infants from an urban HIV clinic. Vitamin D panel was performed on stored maternal plasma obtained near time of delivery. Infant CMV testing at 0-6 months included urine and oral cultures, and/or serum polymerase chain reaction testing. RESULTS: Cohort included 340 mother-infant pairs (births 1991-2014). Among 38 infants (11%) with a CMV+ test between 0-6 months, 4.7% (14/300) had congenital CMV transmission (CMV+ test 0-3 weeks), and 7.6% (24/315) had peri/postnatal CMV (CMV+ test >3 weeks-6 months). Women with lower calcitriol (1,25-dihydroxyvitamin D), the active form of vitamin D, were more likely to have an infant with congenital (OR 12.2 [95% CI 1.61-92.2] P = 0.02) and peri/postnatal (OR 9.84 [95% CI 2.63-36.8] P = 0.0007) infections in multivariate analyses, independent of maternal HIV viral load and CD4 count. CONCLUSION: This study demonstrates an association between inadequate maternal calcitriol during pregnancy and increased congenital and early postnatal acquisition of CMV among non-breastfeeding women with HIV and their HIV negative infants.

Neonatal hypoglycemia after initiation of late preterm antenatal corticosteroids.

OBJECTIVE: To compare the frequency and severity of neonatal hypoglycemia in pregnancies treated with and without late preterm antenatal corticosteroids. STUDY DESIGN: We conducted a retrospective cohort study of late preterm deliveries at LAC + USC (2015-2018). Neonatal outcomes were compared between pregnancies treated with and without corticosteroids. RESULTS: 93 pregnancies (39.9%) received corticosteroids and 140 (60.1%) did not. Neonates born to women given corticosteroids were more likely to be hypoglycemic (47.3 vs. 29.3%, ORadj 2.25, padj = 0.01). The mean initial glucose (45.6 mg/dL vs. 51.9 mg/dL, p = 0.01) and glucose nadir (39.1 mg/dL vs. 45.4 mg/dL, p < 0.001) were significantly lower if the neonates received corticosteroids. Neonates admitted to the NICU solely for hypoglycemia were more likely to be born to women treated with corticosteroids (ORadj 4.71, padj = 0.01). CONCLUSION: Administration of late preterm corticosteroids was associated with an increased incidence and severity of neonatal hypoglycemia.

Low Bioactive Vitamin D Is Associated with Pregnancy-Induced Hypertension in a Cohort of Pregnant HIV-Infected Women Sampled Over a 23-Year Period.

OBJECTIVE: To examine the association of vitamin D insufficiency and risk of pregnancy-induced hypertension (PIH) among human immunodeficiency virus (HIV)-infected pregnant women. STUDY DESIGN: This is a retrospective cohort study evaluating the impact of low maternal vitamin D levels on PIH and perinatal outcomes among HIV-infected pregnant women receiving care at an urban HIV center from 1991 to 2014. RESULTS: A total of 366 pregnant women were included, of which 11% developed PIH. Lower levels of 25-hydroxyvitamin D (25(OH)D) and bioactive 1,25-dihydroxyvitamin D (1,25(OH)2D) were associated with increased HIV disease activity. 25(OH)D levels were not significantly associated with the incidence of PIH. Higher 1,25(OH)2D levels were associated with reduced incidence of PIH in univariate (odds ratio, OR: 0.87 [95% confidence interval, CI: 0.79-0.95], p = 0.004) and multivariate (OR: 0.88 [95% CI: 0.80-0.97], p = 0.010) analyses. No association was found between 25(OH)D levels and other obstetric outcomes. Lower 1,25(OH)2D levels were associated with group B Streptococcus colonization (OR: 0.92 [95% CI: 0.86-0.99]) and low birth weight (LBW) (OR: 0.90 [95% CI: 0.83-0.98]) on multivariate analysis. Mean 1,25(OH)2D levels were significantly lower in women with preterm delivery and LBW infants. CONCLUSION: Lower bioactive vitamin D levels are related to PIH in HIV-infected women. This association may be related to the coexistence of abnormal placental vitamin D metabolism and abnormal placental implantation.

Early postnatal weight gain as a predictor for the development of retinopathy of prematurity.

OBJECTIVE: The objective of this study is to validate the reliability of early postnatal weight gain as an accurate predictor of type 1 retinopathy of prematurity (ROP) requiring treatment in a large predominantly Hispanic US cohort with the use of an online tool called WINROP (weight, neonatal retinopathy of prematurity (IGF-1), neonatal retinopathy of prematurity). STUDY DESIGN: Retrospective cohort study consisted of preterm infants <32 weeks gestation and birth weight <1500 g. Weekly weights to 36 weeks post-menstrual age or discharge if earlier were entered into the WINROP tool. This tool generated alarm and risk indicator for developing ROP. The infants with type 1 ROP requiring treatment as well as all stages of ROP were compared with the alarms and risks generated by WINROP tool. RESULTS: A total of 492 infants were entered into the WINROP tool. The infants who developed type 1 ROP requiring treatment, the WINROP tool detected 80/89 (90%) at less than 32 weeks gestation. Nine infants developed type 1 ROP were classified as low risk and did not alarm. CONCLUSIONS: Postnatal weight gain alone, in predominantly Hispanic US population, predicted type 1 ROP requiring treatment before 32 weeks of gestation in infants with a sensitivity of 90%. The tool appeared to identify majority of affected infants much earlier than the scheduled screening.

Initial hematocrit values after birth and peri/intraventricular hemorrhage in extremely low birth weight infants.

OBJECTIVE: Ischemia followed by reperfusion plays a significant role in the pathogenesis of peri/intraventricular hemorrhage (P/IVH). Delayed cord clamping promotes placental transfusion to newborn and is associated with decreased P/IVH. We hypothesized that extremely low birth weight (ELBW) infants with higher initial hematocrit (Hct) after birth are less likely to develop P/IVH. STUDY DESIGN: Pre- and postnatal data on inborn ELBW infants over 7 years were reviewed. We examined the relationship between P/IVH in the first week and initial Hct using logistic regression modeling. RESULTS: We studied 225 infants with a median gestational age (GA) 25.7 (22.4-31.7). Forty-one percent had grade I-IV P/IVH. In univariate analysis, cesarean section (CS) and higher GA, birth weight, 5-minute Apgar, and initial Hct were associated with decreased likelihood of P/IVH while higher maximum PCO2 in first 3 days and use of inotropes/vasopressors, postnatal steroid for hypotension, hypernatremia, transfusion, and use of insulin for hyperglycemia during the first week of life were associated with increased likelihood of P/IVH. In multiple regression analysis, only GA, CS, and initial Hct remained significantly associated with P/IVH. Adjusting for GA and CS, the odds of P/IVH was higher with Hct < 40% (OR 2.04, 95% CI [1.11, 3.76]) and Hct < 45% (2.38 [1.19, 4.76]). CONCLUSION: Higher initial Hct is associated with decreased P/IVH. Initial Hct < 45% was associated with a 2-fold increase in P/IVH. We speculate that lower initial Hct represents a lower intravascular volume status and promotes cerebral hypoperfusion preceding P/IVH.

Graves' hyperthyroidism in pregnancy: a clinical review.

BACKGROUND: Graves' hyperthyroidism affects 0.2% of pregnant women. Establishing the correct diagnosis and effectively managing Graves' hyperthyroidism in pregnancy remains a challenge for physicians. MAIN: The goal of this paper is to review the diagnosis and management of Graves' hyperthyroidism in pregnancy. The paper will discuss preconception counseling, etiologies of hyperthyroidism, thyroid function testing, pregnancy-related complications, maternal management, including thyroid storm, anti-thyroid drugs and the complications for mother and fetus, fetal and neonatal thyroid function, neonatal management, and maternal post-partum management. CONCLUSION: Establishing the diagnosis of Graves' hyperthyroidism early, maintaining euthyroidism, and achieving a serum total T4 in the upper limit of normal throughout pregnancy is key to reducing the risk of maternal, fetal, and newborn complications. The key to a successful pregnancy begins with preconception counseling.

Neonatal Outcomes by Mode of Delivery in Preterm Birth.

OBJECTIVE: We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of 652 infants born between 24 and 30 (6/7) weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables. RESULTS: Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.90), require intubation (OR, 1.80; 95% CI, 1.12-2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02). CONCLUSION: Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.

Urinary tract infections in a neonatal intensive care unit.

OBJECTIVE: Our aim was to describe laboratory findings and imaging results for neonatal patients diagnosed with urinary tract infection (UTI). STUDY DESIGN: Medical records were reviewed for infants diagnosed with UTI in a single neonatal intensive care unit (NICU) over a 13-year period. RESULTS: Of the 8,241 patients admitted to the NICU during the study period, 137 infants were diagnosed with UTI. Imaging was reviewed for 101 patients. Renal pelvis dilation was found in 34% of patients and vesicoureteral reflux was found in 21%. Renal pelvis dilation was not associated with reflux (OR: 0.53 [95% CI: 0.18-1.5]). The sensitivity of urinalysis to detect a positive culture was 76%, and the specificity was 41%. Tests of cure for bacterial infections were uniformly negative. CONCLUSION: Renal pelvis dilation was common but not associated with reflux among NICU patients diagnosed with UTI. Diagnostic criteria in this population are not well defined, and guidelines are needed for diagnosis and management of UTIs in NICU patients.

The C in TORCH: a cost-effective alternative to screening small-for-gestational-age infants.

BACKGROUND: Infants born with birth weights under the 10th percentile for their gestational age are classified as small for gestational age (SGA). TORCH infections are reported to be associated with SGA infants. With the low incidence of infections, screening is likely to be expensive and of low utility. OBJECTIVE: The objective of this study was to determine the utility and cost-effectiveness of screening SGA infants with TORCH serology titers, urine cytomegalovirus (CMV) cultures and cranial ultrasounds. METHODS: A retrospective review was conducted on all infants admitted to the neonatal intensive care unit (NICU) at Los Angeles County and University of Southern California (LAC+USC) Medical Center from January 2003 to December 2011 with a diagnosis of SGA or intrauterine growth restriction. Birth characteristics such as birth weight, length, head circumference and gestational age were recorded. TORCH titer results, urine CMV results and cranial ultrasound findings were collected. RESULTS: Between 2003 and 2011, 232 SGA infants were admitted to the NICU at LAC+USC Medical Center. Of these, 117 infants (50%) had TORCH titer testing performed; there was only 1 positive CMV IgM and 1 positive HSV IgM result. Repeat urine CMV testing was performed on 109 infants (47%), with a total of 296 urine CMV samples collected from these infants; 6 infants had positive results, of whom 3 had repeat positive urine CMV samples. Overall, 149 of the infants had a cranial ultrasound done, none of which were positive for calcifications. CONCLUSIONS: TORCH titer testing, urine CMV screening and cranial ultrasound screening are of low yield in screening clinically asymptomatic SGA infants for TORCH infections. Given the low number of positive results, a cost-effective alternative of selective TORCH testing may be limited to infants with additional clinical findings. This study serves as a reminder to periodically examine testing practices and patient population to maximize cost-effectiveness.

Decrease in incidence of bronchopulmonary dysplasia with erythropoietin administration in preterm infants: a retrospective study.

BACKGROUND: Despite advances in clinical care, the incidence of bronchopulmonary dysplasia (BPD) remains high in premature infants. Erythropoietin (EPO) is used for the treatment of anemia of prematurity (AOP) to decrease blood transfusion needs. EPO has been shown to mobilize circulating endothelial progenitor cells and to enhance lung repair in animal models. OBJECTIVE: To determine whether EPO treatment for AOP was associated with a reduced incidence of BPD in premature infants. METHODS: This retrospective study was performed on all live-born neonates with birth weights from 500 to 1,500 g and gestational age (GA) from 22 to 32 weeks admitted from 1994 to 2002. Infants who received EPO and those who did not receive EPO were compared for incidence of BPD and other morbidities. RESULTS: Of 478 patients, 297 received EPO before 36 weeks' postmenstrual age (group 1) and 181 did not receive EPO (group 2). Group 1 was of similar birth weight but lower GA than group 2. The incidence of BPD was lower in group 1 than group 2 (26 vs. 36%, p = 0.03); after adjusting for significant risk factors, the adjusted odds ratio for BPD was 0.50 (95% CI 0.32, 0.79), p = 0.0028. The BPD rate was much lower when EPO was initiated before 4 weeks of age (16%) as compared to later initiation (44%). CONCLUSIONS: This study shows an association between EPO treatment and reduced incidence of BPD in preterm infants, particularly when EPO treatment was initiated within the first 4 weeks of life.

Severe brachial plexus palsy in women without shoulder dystocia.

OBJECTIVE: Neonatal brachial plexus palsy frequently is described in conjunction with shoulder dystocia complicating a vaginal delivery. In this study, we present a series of cases of severe brachial plexus palsy that occurred without shoulder dystocia. METHODS: Cases were identified from deliveries at the Los Angeles County and University of Southern California Medical Center. Various maternal and neonatal characteristics were analyzed. RESULTS: Eight cases without shoulder dystocia but with severe brachial plexus palsy requiring neonatal intensive care unit admission were identified. None of the patients had maternal diabetes, previous shoulder dystocia, previous macrosomia, or labor induction. The mean second stage of labor was normal (2.15 ± 1.93), as was the mean birth weight (3,514 ± 1,043). One case required cesarean delivery. CONCLUSION: These results demonstrate that severe brachial plexus palsy occurs in women without shoulder dystocia and without identifiable risk factors.

The contribution of withholding or withdrawing care to newborn mortality.

OBJECTIVE: We sought to determine the contribution of withholding or withdrawing care to neonatal mortality in our hospital over a 10-year period from 1993 through 2002. BACKGROUND: Although not initiating or withholding intensive care for certain newborns has been practiced openly for the past 25 years, little information has been published concerning the results of these practices on neonatal mortality. DESIGN AND METHODS: All infants who were born in our hospital and remained in the hospital until their death were evaluated for the care they received at the time of birth and near the time of their death. The contribution of not initiating care or withdrawing care to the neonatal mortality rates in our hospital was determined. Information was obtained directly from the patients' charts as well as the neonatal database and monthly neonatal mortality and morbidity review. Other information, if needed, was obtained from the monthly ethics committee reviews of all nursery deaths. Information was collected relating to birth weight, gestational age, diagnosis, time of death, and year of death. Hospital and neonatal unit protocols were evaluated to determine how closely they were followed. RESULTS: During the 10-year period, 380 deaths (0.8%) of a total of 47820 live births occurred in our hospital. Care was not initiated or was withdrawn in close to 72% of those deaths; total care until death occurred in 28%. Total care for infants who died over the 10-year period decreased markedly as care not initiated or care withdrawn increased. Most of this increase in not initiating care and in withdrawal of care was in the smaller of the extremely low birth weight infants. CONCLUSIONS: The majority of nursery deaths of infants born in our hospital occurred as the result of selected noninitiating of care or as a result of withdrawing care in infants not responding or considered to have a futile outcome. Only slightly more than one quarter of the infants received total care until the time of death.

Causes of nursery death beyond the neonatal period.

OBJECTIVE: To investigate causes of death in infants who died after 28 days, beyond the neonatal period but before discharge from the nursery, to establish their clinical courses and causes of death and to attempt to find criteria for earlier identification of these infants. METHODS: We identified 30 such infants (12% of nursery deaths) from 1993 through 1998 and conducted a retrospective review of their records including placental pathology and autopsy reports when available. In all, 14 infants who weighed or = 880 g died of diverse congenital anomalies, including five with nonhemolytic hydrops and four with pulmonary hypoplasia. One infant without congenital anomaly weighed 3290 g. Support for this severely asphyxiated infant was withdrawn after 103 days because of progressive cortical atrophy. The remaining 14, the largest of which weighed 860 g, died of complications of prematurity, which we termed postponed neonatal deaths (PND). They followed a typical course of progressive multiple organ failure. All received assisted ventilation and postnatal steroids, developed chronic lung disease, and were on ventilation at the time of death. Renal insufficiency occurred late in the course. Acute infections and renal failure were the major proximal causes of death. When compared with surviving controls the PND were less likely to have received antenatal steroids and received more inotropic agents for cardiovascular support and more amphotericin for fungal infection; surgery for perforated bowel was confined to the PND. CONCLUSIONS: The incidence of postneonatal nursery deaths has not changed in more than 20 years remaining at 11 to 12% of nursery deaths. Congenital anomaly was a prominent cause of death (50%). When infants without congenital anomalies (PND) were compared to surviving controls, no differences were found, which could reliably identify PND early in their course. The only potentially preventable factor was lack of antenatal steroid exposure in the PND.