Changes in infant mortality among extremely preterm infants: US vital statistics data 1990 vs 2000 vs 2010.

OBJECTIVE: Infant mortality among extremely preterm infants (22 to 28 weeks gestation) varies considerably by gestational age. The reduction in mortality over a 20-year period, when examined in gestational age week increments, may give a more precise estimate of progress or lack thereof in caring for these infants and provide information to better inform practitioners and parents of the risk of mortality among these small infants. The objective of this analysis is to examine infant mortality (birth to 365 days) by week of gestation for infants 22 to 28 weeks gestation comparing mortality rates, adjusting for maternal and infant birth characteristics, among US births for the years 1990, 2000 and 2010. STUDY DESIGN: US vital statistics period-linked birth and infant death certificate files for the years 1990, 2000 and 2010 were used. Maternal and infant characteristics for births at 22 to 28 weeks were abstracted from the files. A trimming procedure was used to remove records that had birth weights that exceeded the interquartile range of birth weights for a given week of gestational age. Infant mortality rates were calculated, and adjusted odds ratios for mortality were generated using logistic regression models. RESULT: A total of 15,593 live births, 22 to 28 weeks gestation were available for the year 1990; 17,095 for the year 2000; and 14,721 for the year 2010. Infant mortality rates ranged from 904 per 1000 live births at 22 weeks gestation in 1990, to 835 in 2000, to 866 in 2010. Across all gestational age groups there was an adjusted reduction in the odds ratio for mortality of ~50% from 1990 to the year 2000. However, between 2000 and 2010 there was no significant reduction in infant mortality except at 25 weeks gestation (adjusted odds ratio=0.81, 95% confidence interval=0.70, 0.93). CONCLUSION: Despite a significant reduction in infant mortality among extremely preterm infants between the years 1990 and 2000, there has been little progress in reducing mortality between the years 2000 and 2010.

Chorioamnionitis: epidemiology of newborn management and outcome United States 2008.

OBJECTIVE: Current American Academy of Pediatric recommendations call for the empirical use of antibiotics for all well-appearing term newborn infants born to women given a diagnosis of chorioamnionitis. The objective of this analysis was to determine among term infants (37-42 weeks gestation) the prevalence of exposure to clinical chorioamnionitis, intrapartum antibiotics, infant antibiotic use and neonatal intensive care unit (NICU) admission and the relationship of these risk factors to neonatal mortality. STUDY DESIGN: United States-linked infant birth and death certificate files for the year 2008 were used. Maternal demographic variables, labor and delivery risk factors and infant characteristics were analyzed for associations with a reported diagnosis of chorioamnionitis and neonatal death, NICU admission and antibiotic usage. RESULT: There were 2,281,386 births available with information on the diagnosis of chorioamnionitis. The prevalence of chorioamnionitis in this population was 9.7 per 1000 live births (LB) and the neonatal mortality rate for exposed infants was 1.40/1000 LB vs 0.81/1000 LB for infants without chorioamnionitis, odds ratio (OR)=1.72, 95% confidence interval 1.20-2.45. The OR for neonatal death for infants with chorioamnionitis exposure who received antibiotics vs those who did not was 0.69 (95% confidence interval=0.21-2.26). CONCLUSION: Exposure to chorioamnionitis is associated with an increased risk of neonatal mortality. Guidelines for treatment of infants exposed to chorioamnionitis with antibiotics are followed in only a small proportion of such cases.

Prematurity and sudden infant death syndrome: United States 2005-2007.

OBJECTIVE: In 1987, the sudden infant death syndrome (SIDS) rate in the United States was 1.2 per 1000 live births. By the year 2005, the SIDS rate had dropped more than half to approximately 0.5 per 1000 live births. In 1987, the risk of SIDS was 2.32 times greater for extremely premature infants compared with term infants. The objective of this analysis was to determine if with the falling SIDS rate there has been a change in the risk for SIDS among preterm infants. STUDY DESIGN: Data were obtained from the United States Linked Infant Birth and Death Certificate Public User Period files for the years 2005 to 2007. The adjusted odds ratios (ORs) for postneonatal out-of-hospital death by gestational age were determined by logistic regression modeling. RESULT: Over the 3-year period, there were 5203 postneonatal out-of-hospital deaths attributable to SIDS; 2010 attributable to other sudden deaths; 1270 attributable to suffocation in bed; and 3681 attributable to other causes. The adjusted OR for SIDS among the most preterm infants (24 to 28 weeks gestation) was significantly increased compared with term infants, OR(adj)=2.57 (95% confidence interval=2.08, 3.17), as were the adjusted ORs for the other causes of sudden infant death. CONCLUSION: Despite the marked drop in the incidence of SIDS since 1987, the risk for SIDS among preterm infants remains elevated. Other causes of sudden infant death for which SIDS is often mistaken reflect similar levels of increased risk among preterm infants.

Antenatal steroid use and neonatal outcome: United States 2007.

OBJECTIVE: Antenatal steroid use has been associated with reduction in the risk of neonatal mortality in meta-analyses of clinical trials. In 2007, a revised US birth certificate offered information on antenatal steroid use in 22 states. The aim of this study was to review the association between antenatal steroid use and neonatal mortality by gestational age categories for preterm infants (<37 weeks) for the United States for the year 2007. STUDY DESIGN: Data were obtained from the United States Linked Infant Birth and Death Certificate Public Use Period file for the year 2007. Associations between antenatal steroid use and neonatal death were determined by logistic regression adjusting for potentially confounding variables. RESULT: There were 245 453 preterm births and 4220 neonatal deaths available for analysis with complete data on antenatal steroid use. The highest prevalence for antenatal steroid use among neonatal intensive care unit admissions (NICU) was 22% in the 26 to 28 week gestational age category, whereas the lowest prevalence was in the 34- to 36-week group at 7%. Following adjustment for potentially confounding variables by logistic regression, the adjusted odds ratios (95% confidence interval) for neonatal mortality (antenatal steroid use versus non-use) ranged from 0.56 (0.46 to 0.67) at 22 to 25 weeks; 0.66 (0.53 to 0.83) at 26 to 28 weeks; 0.69 (0.55 to 0.85) at 29 to 33 weeks and 0.69 (0.47 to 1.01) at 34 to 36 weeks. CONCLUSION: These data are in accordance with meta-analytical data of randomized clinical trials and network reports on reduction of neonatal mortality with the use of antenatal steroids, and provide support for the use of antenatal steroids for late preterm births.

Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004.

OBJECTIVE: Home births attended by certified nurse midwives (CNMs) make up an extremely small proportion of births in the United States (<1.0%) and are not supported by the American College of Obstetrics and Gynecology (ACOG). The primary objective of this analysis was to examine the safety of certified nurse midwife attended home deliveries compared with certified nurse midwife in-hospital deliveries in the United States as measured by the risk of adverse infant outcomes among women with term, singleton, vaginal deliveries. STUDY DESIGN: United States linked birth and infant death files for the years 2000 to 2004 were used for the analysis. Adverse neonatal outcomes including death were determined by place of birth and attendant type for in-hospital certified nurse midwife, in-hospital 'other' midwife, home certified nurse midwife, home 'other' midwife, and free-standing birth center certified nurse midwife deliveries. RESULT: For the 5-year period there were 1 237 129 in-hospital certified nurse midwife attended births; 17 389 in-hospital 'other' midwife attended births; 13 529 home certified nurse midwife attended births; 42 375 home 'other' midwife attended births; and 25 319 birthing center certified nurse midwife attended births. The neonatal mortality rate per 1000 live births for each of these categories was, respectively, 0.5 (deaths=614), 0.4 (deaths=7), 1.0 (deaths=14), 1.8 (deaths=75), and 0.6 (deaths=16). The adjusted odds ratio (95% confidence interval) for neonatal mortality for home certified nurse midwife attended deliveries vs in-hospital certified nurse midwife attended deliveries was 2.02 (1.18, 3.45). CONCLUSION: Deliveries at home attended by CNMs and 'other midwives' were associated with higher risks for mortality than deliveries in-hospital by CNMs.

Improved growth and decreased morbidities in <1000 g neonates after early management changes.

OBJECTIVE: To test the hypothesis that three changes in the early management of extremely low birth weight (ELBW) neonates would decrease the incidence of extra-uterine growth restriction (EUGR) by 25%. The three early management practice changes (EMPC) included surfactant at delivery followed by immediate extubation to nasal continuous positive airway pressure (CPAP), decreased oxygen exposure and early parenteral amino acids. STUDY DESIGN: Historical cohort study of preterm infants

Respiratory distress syndrome mortality in the United States, 1987 to 1995.

OBJECTIVE: To review respiratory distress syndrome (RDS) mortality since the introduction of surfactant. DESIGN: Population-based historical cohort study. METHODS: United States vital statistic data were used for the years 1987 to 1995. Linked birth and infant death file data were available for the years 1987 to 1991 and for 1995. US natality and mortality files were used for the years 1992 to 1994. RESULTS: Whereas overall infant mortality decreased 25% over the-9 year period from a rate of 979 deaths/100,000 live births (LB) to a rate of 736, mortality attributed to RDS decreased 56% from a rate of 84 to 37. The crude black:white relative risk for RDS-related mortality increased from 2.02 in 1987 to 2.76 in 1995. The largest and most consistent drop in RDS-related mortality occurred in the 2000 to 2499 gm birth weight and 33- to 36-week gestation groups; average annual decline = 20%. There was a change in the distribution of the underlying causes of death over the 9-year period with an increase in the proportion of mortality attributed to prematurity. CONCLUSION: Since the advent of surfactant there has been a marked reduction in mortality attributed to RDS. Of concern is the increasing disparity between black and white RDS-related mortality.

Birth weight- and gestational age-specific sudden infant death syndrome mortality: United States, 1991 versus 1995.

OBJECTIVE: To estimate the changes in birth weight- and gestational age-specific sudden infant death syndrome (SIDS) mortality rates since the publication of the sleep-positioning recommendations by the American Academy of Pediatrics Task Force on Infant Positioning and SIDS. METHODS: This is a historical cohort study using US vital statistic linked birth and infant death certificate files for the years 1991 and 1995. SIDS deaths were identified as any death attributed to International Classification of Diseases, Ninth Revision code 7980, occurring between the 28th and 365th days of life. RESULTS: There were 4871 deaths attributed to SIDS in 1991 for a postneonatal mortality rate of 1.2/1000 postneonatal survivors compared with 3114 deaths in 1995 for a rate of.8/1000. This represents a 33% drop in the postneonatal SIDS mortality from 1991 to 1995. Between 1991 and 1995, SIDS rates declined 38%, 38%, 35%, and 32% for birth weight groupings of 500 to 999 g, 1000 to 1499 g, 1500 to 2499 g, and >/=2500 g, respectively. There were no SIDS deaths attributed to infants weighing <500 g. The SIDS rates declined 27%, 21%, 40%, and 23% for gestational age groups of <29 weeks, 29 to 32 weeks, 33 to 36 weeks, and >/=37 weeks. The rate of decline did not differ significantly across birth weight- or gestational age-specific categories. There was a significant increase in the black:non-black postneonatal SIDS mortality ratio from 2.00 to 2.28, reflecting a smaller decline in birth weight- and gestational age-specific mortality for blacks than observed for the non-black population. CONCLUSION: Postneonatal SIDS mortality decreased significantly across all broad birth weight and gestational age categories. If the decline in the prevalence of prone positioning that has been reported since 1992 has occurred across all birth weight and gestational age, these data support the hypothesis that supine or side sleep positioning is effective in preterm/low birth weight infants as well as term infants.

Sudden infant death syndrome among twins.

BACKGROUND: Sudden infant death syndrome (SIDS) is a major contributor to infant mortality. Previous studies have suggested that infants born of twin pregnancies are at greater risk for SIDS and that a twin who survives after a co-twin dies is at increased risk for SIDS. OBJECTIVE: To attempt to confirm the increased risk of SIDS among and within twin pairs through the use of US vital statistics data. METHODS: We analyzed data from the US-linked birth and infant death certificate tapes for the years 1987 through 1991 to determine the risk of SIDS in twin births compared with singleton births and to describe the characteristics of twin pairs in whom SIDS occurred. The analysis was limited to live births with weights of 500 g or more and gestational ages of 24 weeks or more. We used an algorithm to match co-twins (infants within a twin pair) to measure sex and birth weight concordancy, to identify twin pairs, in which one or both twins died of SIDS; and to examine, when both twins died, whether they died on the same day. RESULTS: There were 23464 singleton SIDS deaths and 1056 twin SIDS deaths during the 5-year period. The crude relative risk for SIDS among twins compared with singleton births was 2.06 (95% confidence interval, 1.94-2.19). The adjusted relative risk independent of birth weight and sociodemographic variables was 1.13 (95% confidence interval, 0.97-1.31). We successfully matched the co-twins of 172029 twin pregnancies. Of these, 767 were twin pregnancies in which one or both twins died of SIDS. Among the 767 twin pregnancies in which one or both twins experienced SIDS, there were only 7 in which both twins died of SIDS (rate ratio, 4.0 per 100000 twin pregnancies). In only 1 of these 7 did both twins die on the same day (rate ratio, 0.58 per 100000 twin pregnancies). The relative risk for a second twin dying of SIDS was 8.17 (90% confidence interval, 1.18-56.67). CONCLUSIONS: Independent of birth weight, twins do not appear to be at greater risk for SIDS compared with singleton births. In addition, the occurrence of both twins dying of SIDS is uncommon, and the occurrence of both twins dying on the same day is extremely uncommon.

Risk of previous very low birth weight and very preterm infants among women delivering a very low birth weight and very preterm infant.

OBJECTIVE: To examine the relationship of the birth of a very low birth weight (VLBW, < 1500 gm) and very preterm (VPT, < or = 32 week) infant to previous occurrences of VLBW-VPT infants among women who had two to five pregnancies. STUDY DESIGN: This was a case-control study using data from the 1988 National Maternal and Infant Health Survey (NMIHS). A case was defined as a singleton live birth weighing 500 to 1499 gm with a gestational age of < or = 32 weeks. Control infants were defined as singleton births weighing > 2500 gm with gestational ages of > or = 38 weeks. RESULTS: There were 128 non-black cases and 864 non-black controls, and 241 black cases and 1205 black controls available for analysis. Logistic regression was used to adjust for a history of previous stillbirth, mother's birth weight, pre-pregnancy weight, pregnancy interval, and sociodemographic risk factors. The adjusted odds ratio for the occurrence of a previous VLBW-VPT birth for non-black cases versus controls was 21.24 (6.87, 65.7) and for black cases versus controls, 6.87 (3.82, 12.34). CONCLUSION: These results confirm the substantial risk of previous VLBW-VPT infants among women giving birth to such an infant, independent of sociodemographic factors and other prior pregnancy outcomes.

Increased survival in low birth weight neonates given prophylactic surfactant.

OBJECTIVE: To compare the effectiveness of a prophylactic surfactant treatment strategy (PRO) to the effectiveness of a rescue (RESC) surfactant treatment strategy in patients at high risk for developing hyaline membrane disease (HMD). STUDY DESIGN: We analyzed data from a retrospective cohort consisting of all patients admitted to the neonatal intensive care units at the centers participating in the recently completed Infasurf-Survanta Comparative Trial. To be in the cohort, a patient had to be admitted during the trial, be <48 hours of age on admission, have a gestational age of <30 weeks, have a birth weight of 501 to 1250 gm, and be free of congenital anomalies. Twelve centers participated in this study. They contributed 1097 patients of whom 381 were treated with a PRO strategy. RESULTS: Survival was significantly higher in the PRO-strategy patients (84% vs 72%, p < 0.05) as was survival without oxygen requirement at a postconceptional age of 36 weeks (60% vs 46%, p < 0.05). In addition, the patients with PRO had a lower prevalence of grade III and IV intraventricular hemorrhage (IVH, 9% vs 14%, p < 0.05). All analyses were controlled for birth weight and type of study center. CONCLUSION: These data support the conclusion that using a PRO treatment strategy results in improved survival in patients at risk for developing HMD. A PRO treatment strategy may also decrease the likelihood of developing a severe IVH.

The relationship between preceptor expectations and student performance on 2 pediatric objective structured clinical examination stations.

BACKGROUND: We designed 2 pediatric objective structured clinical examination stations, 1 anemia case associated with lead exposure and 1 failure-to-gain-weight case associated with extended breast-feeding, to evaluate third-year medical students who had studied in pediatric community preceptors' offices as part of a 12-week multidisciplinary ambulatory clerkship rotation. OBJECTIVE: To examine the relationship between preceptor expectations and student performance on these 2 objective structured clinical examination stations. METHODS: To elicit community preceptors' expectations of student performance, we constructed a 46-item survey replicating checklists filled out by simulated patients evaluating student performance on the objective structured clinical examination stations. The percentage agreement among preceptors for each checklist item as well as the percentage agreement between preceptor responses and student responses on each checklist item were calculated. A summary score of preceptor responses across all checklist items and a summary score for student responses across all checklist items on each station were calculated. The correlation coefficients between preceptor and student summary scores were then examined. RESULTS: Fifty-nine preceptor surveys were mailed and 38 were returned (64% response rate). Data were usable from 37 surveys. Eighty-nine percent (33 of 37)of the preceptors agreed that a third-year clerkship student should have the knowledge to care for the patient with anemia and 92% (34 of 37)of the preceptors agreed similarly for the growth-delay case. Agreement among preceptors on individual checklist items varied widely for both cases. Fifty-seven students studied at the anemia station and 34 students studied at the growth-delay station. The mean+/-SD agreement across the 26 items on the anemia case between preceptor responses and student responses was 62%+/-23% and, for the 21 items on the growth-delay case, 60%+/-17%. The mean+/-SD preceptor summary score for the anemia case was 17.4+/-3.8 (maximum, 26) and 16.0+/-3.6 (maximum, 21) for the growth-delay case. The mean student score on the anemia case was 15.5+/-3.7 (maximum, 26) and, for the growth-delay case, 10.0+/-4.5 (maximum, 21). The Pearson correlation coefficient between the preceptor and student scores on the anemia case was 0.19 (P=.15), and for the growth-delay case,-0.41 (P=.06). CONCLUSIONS: These data suggest community preceptors agree on topic areas in which students should be clinically competent. There was, however, considerable variation in agreement among preceptors about what preceptors believe students should be able to do and how the students actually perform. The overall percentage agreement between preceptor expectations and student performance appears to be no better than chance.

Impact of transfusion guidelines on neonatal transfusions.

BACKGROUND: Preterm infants with birth weights (BW) <1250 gm are given multiple blood transfusions either for replacement of blood loss or for correction of symptomatic anemia of prematurity. OBJECTIVE: To assess the effectiveness of transfusion guidelines in reducing the number of transfusions given to infants with BW <1250 gm. METHODS: This cohort study was conducted at the regional teaching medical center with level III obstetric and neonatal services. Preterm infants with BW <1250 gm and gestational age <32 weeks were admitted to the neonatal intensive care unit during a period of 6 months before and after implementation of transfusion guidelines. The final sample size constituted 39 infants before guidelines (BG) and 41 infants after guidelines (AG). The primary outcome measure was the total number and volume of transfusions given per infant in the first 2 weeks of life and before discharge from the nursery. RESULTS: We observed a significant reduction in the mean number (4.7 to 2.7, p = 0.003) and volume (52 ml to 30 ml, p = 0.0005) of transfusions given per infant in the first 2 weeks of life, as well as a definite trend toward reduction in the total number (10.5 to 8.0, p = 0.08) and volume (156 ml to 119 ml, p = 0.07) of transfusions given before discharge in the BG versus AG, respectively. When all the transfusions given to the 41 infants in the AG group were analyzed for compliance with guidelines, 96% (313 of 328) were observed to be in compliance. CONCLUSION: This study shows that transfusion guidelines are effective in decreasing the number of transfusion given to infants with BW <1250 gm. An indirect benefit of guidelines contributing to a reduced number of transfusions may be a heightened awareness to decrease blood losses.

A comparison of performance between third-year students completing a pediatric ambulatory rotation on campus vs in the community.

OBJECTIVE: To compare the performance of third-year medical students who completed the ambulatory component of their pediatric rotation in a community setting with the performance of third-year medical students who had their ambulatory experience on campus. METHODS: As part of a pilot project to implement a third-year Multidisciplinary Ambulatory Clerkship, 61 third-year medical students spent 12 weeks rotating through the primary care disciplines of family medicine, internal medicine, and pediatric practitioners' offices at sites distant from the university campus while 127 students remained on campus for their ambulatory experiences in these disciplines. The components of the overall pediatric grade consisted of a clinical performance evaluation in the ambulatory setting (4 weeks), a clinical performance evaluation on a 4-week inpatient rotation, and a grade from a multiple-choice final examination. RESULTS: The overall mean+/-SD final pediatric grade of students receiving their ambulatory pediatrics experience in the Multidisciplinary Ambulatory Clerkship was 86.5+/-3.4 compared with 88.0+/-3.4 for students receiving their ambulatory experience on campus (P<.007). This difference was accounted for by performance on the written final examination. Multidisciplinary Ambulatory Clerkship students had a mean+/-SD score of 78.9+/-8.3 and a failure rate of 18% compared with a mean score of 83.7+/-8.1 and failure rate of 3.9% for students who remained on campus for their ambulatory experience (P<.001 for both comparisons). No differences were noted between the 2 groups on their clinical performance evaluations for their ambulatory or inpatient experiences. CONCLUSIONS: These data suggest a difference in the learning experience between students receiving their pediatric ambulatory experience in the community vs on campus. Differences in exposure to structured learning experiences that occurred more frequently on campus might account for some of the difference in final examination results. Development of a standardized, structured learning experience across community sites would seem to be an appropriate means of enhancing learning in the community setting.

Does breast-feeding influence intelligence quotients at 9 and 10 years of age?

The effect of breast-feeding on intellectual development remains controversial. We explored this relationship in a high socioeconomic population in which breast-feeding was supplemented with soy containing formulas at some time during the first year of life. As part of the 1988 National Institute of Child Health and Human Development school-based survey of two metropolitan Washington, D.C. counties to identify children in the 1978 to 1979 birth cohort who had been exposed to the chloride deficient formulas Neo-Mull-Soy and Cho-Free during infancy, information on breast-feeding was also obtained on children exposed to the chloride-deficient formulas and a group of control children exposed to other soy formulas. Because no differences in intellectual development were observed between the two groups, they were combined and the effect of breast-feeding on intellectual development at 9 and 10 years was assessed. There were 176 infants that received no breast-feeding and 342 who were breast-fed. The median duration of breast-feeding was 124 days (interquartile range, 42-248 days). There were no differences in birth weight, gender or race between the infants who were breast-fed and those who were not. The mean Weschler Intelligence Scale-Revised Full Scale IQ was 122 among those breast-fed compared to 118 among those that were not (P = 0.0008). However, following adjustment by linear regression for maternal education, paternal education and annual income the adjusted mean full scale IQ was 111 among the breast-fed and 110 among the non-breast-fed (P = 0.23). Further analyses limited to those exclusively breast-fed for the first 60 days failed to demonstrate any significant relationship between breast-feeding and IQ.

Systemic hypertension in very low-birth weight infants with bronchopulmonary dysplasia: incidence and risk factors.

The purpose of our study was to determine if systemic hypertension (HTN) occurred among infants with birth weight less than 1250 g (very low-birth-weight [VLBW] infants) in association with Bronchopulmonary dysplasia (BPD). We designed a historical cohort study to review the clinical course and the occurrence of systemic HTN in infants born during the year 1992 with birth weights between 600-1250 g. The overall incidence of HTN was 6.8% (5 of 73) and the incidence in infants with BPD was 12% (5 of 41). The mean age of onset of HTN was 105 days (range 90 to 133 days), and at the time of discharge 3 of 5 (60%) infants remained hypertensive and 3 of 5 (60%) were on supplemental oxygen. All the five hypertension infants (100%) were on supplemental oxygen at 36 weeks of postceptional age compared to 18 of 36 (50%) of nonhypertensive BPD infants. The association between HTN and severe BPD was further denoted by longer hospital stay (145 +/- 37 vs. 94 +/- 28 days, p = 0.004), longer duration of O2 therapy (108 +/- 36 vs. 67 +/- 34 days, p = 0.01), and prolonged use of aminophylline (104 +/- 44 vs. 61 +/- 23 days, p = 0.03), in the hypertensive BPD infants versus nonhypertensive BPD infants, respectively. This study substantiates an increased risk of developing systemic HTN, among VLBW infants with severe BPD.

Comparison of Infasurf (calf lung surfactant extract) to Survanta (Beractant) in the treatment and prevention of respiratory distress syndrome.

OBJECTIVE: To compare the relative safety and efficacy of Infasurf (calf lung surfactant extract; ONY, Inc, Amherst, NY, IND #27169) versus Survanta (Beractant, Ross Laboratories, Columbus, OH) in reducing the acute severity of respiratory distress syndrome (RDS) when given at birth and to infants with established RDS. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Thirteen neonatal intensive care units participated in the treatment arm: seven of these concurrently participated in the prevention arm. PATIENTS: The treatment arm enrolled infants of

Home apnea monitoring and sudden infant death syndrome.

OBJECTIVE: To estimate the U.S. national prevalence of apnea monitor use by birth weight classification and to examine the relationship between the use of apnea monitors and the occurrence of Sudden Infant Death Syndrome (SIDS). DESIGN AND SETTING: Data obtained from the 1988 National Maternal and Infant Health Survey (NMIHS) were used. Prevalence estimates of apnea monitor use were obtained by weighting survey data, and the relationship between monitor use and SIDS was accomplished by a case-control analysis using SIDS deaths and live controls obtained from the NMIHS. OUTCOME MEASURE: Weighted estimates of the prevalence of apnea monitor use and odds ratios for the odds of use of an apnea monitor among SIDS victims compared with the odds of use of an apnea monitor among living controls. RESULTS: The national prevalence estimates for home apnea monitor use among birth weight strata of 500 to 1,499 g, 1,500 to 2,499 g, and 2,500 g or more for blacks were 19.9, 2.6, and 1.1% compared with 44.0, 8.8, and 1.2% for non-blacks. The only significant association between the use of apnea monitors and SIDS was for black 500- to 1,499-g infants. The adjusted odds ratio for SIDS among monitored black 500- to 1,499-g infants vs unmonitored infants was 3.93 (1.09, 14.17). CONCLUSIONS: This analysis suggests a marked difference in reported monitor use between U.S. black and non-black infants. In addition, black very low birth weight infants at highest risk for SIDS appear to be preferentially selected for monitoring. The protective effect of home apnea monitoring in this survey population is unclear.

Colonization and infection associated with Malassezia and Candida species in a neonatal unit.

The objectives of this study were to determine, in neonates of < 1250 g birthweight (N = 57), the initial time of skin colonization by Malassezia furfur, rate of colonization by Candida spp., and whether skin colonization by these yeasts was predictive of central line colonization or fungaemia. By age two weeks, 51% of neonates were culture-positive for M. furfur on umbilical or groin skin. During hospitalization, positive skin cultures for M. furfur or Candida spp. were obtained in 70% and 37% of neonates, respectively. Risk factors associated with positive skin cultures were mechanical ventilation and three or more episodes of suspected sepsis. Eight of the 52 infants with central venous catheters, had positive blood cultures withdrawn from the lines; five (62%) of these had positive skin surveillance cultures. Although positive skin cultures for M. furfur, Candida spp., or both were commonly observed in this population, they were not predictive of positive central line cultures or systemic illness.