Australia's persistently high rate of early-term prelabour Caesarean delivery.

Objective To compare the incidence of prelabour Caesarean delivery (PCD) at early term (37 weeks and 0 days (370) to 38 weeks and 6 days (386) of gestation) between Australian states and hospital sectors over time and to compare these rates with those of England and the United States of America (USA). Method A population-based descriptive study of 556040 singleton PCDs at term (370-406 weeks) in all public and private hospitals in Australian states, 2005-16, was performed. The primary outcome was the early-term PCD rate, defined as early-term PCDs as a percentage of all term PCDs. Results Across Australian states, the early-term PCD rate fell from 56.4% in 2005 to 52.0% in 2016. Over a similar period, England's rate fell from 48.2% in 2006-07 to 35.2% in 2016-17, while the USA's rate fell from 47.4% in 2006 to 34.2% in 2016. Australian public hospitals reduced their rate from 54.2% in 2005 to 44.7% in 2016, but the rate increased in private hospitals from 59.1% in 2005 to 62.5% in 2016. There was considerable variation between states and hospital sectors. Conclusions The early-term PCD rate increased in Australian private hospitals from 2005 to 2016. The public hospital rate fell by nearly 10% over the period but remained ~10% above the English and USA national rates. What is known about the topic? Babies born at early term (370-386 weeks) are at greater risk of morbidity than babies born at full term (390-406 weeks). Australia has a persistently high rate of early-term prelabour Caesarean delivery (PCD). What does this paper add? This paper reveals concerning differences in the early-term PCD rate between Australian states and hospital sectors. Further, the paper highlights that both Australian hospital sectors (public and private) have not reduced their rates to levels achieved in England and the USA. What are the implications for practitioners? These results should inform efforts to reduce Australia's early-term PCD rate to prevent harm to babies.

Classification of causes and associated conditions for stillbirths and neonatal deaths.

Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases - Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process.

Public-private differences in short-term neonatal outcomes following birth by prelabour caesarean section at early and full term.

BACKGROUND: Prelabour caesarean section (CS) at early term (370 -386  weeks) is associated with higher rates of adverse short-term neonatal outcomes and higher costs than those performed at full term (390 -406  weeks). Prelabour CS is more common in private than in public hospitals in Australia, particularly at early term. AIMS: To evaluate the impact of hospital sector (public or private) and timing of delivery on short-term neonatal outcomes following prelabour CS at term. MATERIALS AND METHODS: A retrospective cohort study of 22 954 viable singleton prelabour CS births at term (370 -406  weeks) at a single centre encompassing co-located public and private hospitals during 1998-2013 was undertaken. Propensity score analysis was used to adjust for confounding differences between sectors. The primary outcome was Neonatal Critical Care Unit (NCCU) admission with serious morbidity. Secondary outcomes included respiratory distress, vigorous resuscitation and jaundice. RESULTS: The private hospital performed prelabour CS at over double the rate of the public hospital (33.7% of all private births vs 14.7% public) and more private than public prelabour CSs occurred at early term (66.8% vs 47.9%). Public babies were more than twice as likely as private babies to require admission to NCCU with serious morbidity (adjusted odds ratio (AOR) 2.54, 95% CI 1.77-3.65) but were less likely to need vigorous resuscitation (AOR 0.53, 95% CI 0.45-0.62). Disparities in outcomes between public and private cohorts were accentuated at full term. CONCLUSION: Despite early-term prelabour CSs occurring more often in the private hospital, public babies had more adverse outcomes and treatment escalations.

eRegistries: indicators for the WHO Essential Interventions for reproductive, maternal, newborn and child health.

BACKGROUND: Electronic health registries - eRegistries - can systematically collect relevant information at the point of care for reproductive, maternal, newborn and child health (RMNCH). However, a suite of process and outcome indicators is needed for RMNCH to monitor care and to ensure comparability between settings. Here we report on the assessment of current global indicators and the development of a suite of indicators for the WHO Essential Interventions for use at various levels of health care systems nationally and globally. METHODS: Currently available indicators from both household and facility surveys were collated through publicly available global databases and respective survey instruments. We then developed a suite of potential indicators and associated data points for the 45 WHO Essential Interventions spanning preconception to newborn care. Four types of performance indicators were identified (where applicable): process (i.e. coverage) and outcome (i.e. impact) indicators for both screening and treatment/prevention. Indicators were evaluated by an international expert panel against the eRegistries indicator evaluation criteria and further refined based on feedback by the eRegistries technical team. RESULTS: Of the 45 WHO Essential Interventions, only 16 were addressed in any of the household survey data available. A set of 216 potential indicators was developed. These indicators were generally evaluated favourably by the panel, but difficulties in data ascertainment, including for outcome measures of cause-specific morbidity and mortality, were frequently reported as barriers to the feasibility of indicators. Indicators were refined based on feedback, culminating in the final list of 193 total unique indicators: 93 for preconception and antenatal care; 53 for childbirth and postpartum care; and 47 for newborn and small and ill baby care. CONCLUSIONS: Large gaps exist in the availability of information currently collected to support the implementation of the WHO Essential Interventions. The development of this suite of indicators can be used to support the implementation of eRegistries and other data platforms, to ensure that data are utilised to support evidence-based practice, facilitate measurement and accountability, and improve maternal and child health outcomes.

Newborn hearing screening in Queensland 2009-2011: Comparison of hearing screening and diagnostic audiological assessment between term and preterm infants.

AIM: This study compares rates and timing of newborn hearing screening outcomes, audiological assessment and hearing loss diagnosis between infants of different gestational age groups. Early identification and management of sensorineural hearing loss (SNHL), ideally by 3-6 months of age, facilitates speech and language optimisation. Literature stratifying hearing screening and diagnostic audiology assessment by gestational age groups is lacking. METHODS: Subjects were infants with recorded gestational ages receiving newborn hearing screening in Queensland between 2009 and 2011. Data were provided through the Queensland Healthy Hearing database. Infants were analysed in <34 weeks, 34-36+6 weeks, 37-38+6 weeks and ≥39 weeks gestational age groups. RESULTS: Infants (175 911) were eligible for analysis, 7.9% being preterm. Per 1000 infants analysed, bilateral SNHL of >40 dB occurred in 2.4 for <34, 1.4 for 34-36+6 , 0.7 for 37-38+6 and 0.7 for ≥39 weeks gestation. Diagnoses attributable to newborn hearing screening direct referral were 93.1% for bilateral >40 dB SNHL and 88.2% for other hearing loss. Relative to term, preterm infants had a higher incidence of direct and targeted surveillance referrals, audiology assessment and hearing loss diagnosis. Preterm infants were screened later after birth. CONCLUSIONS: Specific hearing screening and diagnosis characteristics differed between preterm infants <34 and 34-36+6 weeks gestation, and term infants. Consideration of unique gestational age strata characteristics supports care individualisation. Preterm infants represent a diagnostic challenge, with higher rates of bilateral >40 dB SNHL than term but correspondingly higher false positive results on screening, justifying vigilant monitoring. Focused research into specific risk factors in preterm infants is warranted.

The timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37-41 weeks' gestation.

BACKGROUND: Births by elective caesarean section (CS) are rising, particularly before 39 weeks' gestation, which may be associated with unacceptably high risk of adverse neonatal outcomes. The optimal timing of these deliveries needs to be determined with recent recommendations to delay births by elective CS until 39 weeks. AIMS: To evaluate the association between gestational age (GA) at delivery and neonatal outcomes after elective CS between 37 and 41 weeks. MATERIALS AND METHODS: Retrospective cohort study of viable singleton neonates delivered by elective CS at Mater Mothers' Hospitals (1998-2009). Neonates were stratified into two GA groups with early term (ET, 37-38 weeks) compared with the reference group of full and late term (FLT, 39-41 weeks). The primary outcome examined was serious respiratory morbidity; secondary outcomes included depression at birth, nursery admission and assisted ventilation. RESULTS: Fourteen thousand and four hundred and forty-seven mother-baby pairs were included (59.9% delivered before 39 weeks). There was a significantly decreasing risk of adverse neonatal outcomes with increasing GA. Compared to FLT, delivery at ET almost tripled the risk of the primary outcome (AOR 2.74; 95% CI 1.79-4.21). Rates of most secondary outcomes were at least doubled. CONCLUSION: Elective CS performed at 37-38 weeks is associated with poorer neonatal outcomes compared to those delivered at 39-41 weeks. This study supports recent recommendations to delay delivery by elective CS until week 39 if possible.

Risk determinants in early intervention use during the first postnatal year in children born very preterm.

BACKGROUND: Early interventions (EI) are recognised for their potential risk-reduction capacity. Although developmental delay is common in children born very preterm reports continue to suggest poor uptake of EI services. This study examined the risk determinants of EI in Australian children born less than 32 weeks gestation during the first year of life. METHODS: As part of a multi-centre-randomised-trial, 195 children were prospectively studied during their first year of life and EI use, type of follow-up, perinatal, social and parental psychosocial risk factors were collected using questionnaires. Child neurodevelopmental disability-status was assessed at 12-months (cerebral palsy, blind, deaf, developmental quotient 1 standard deviation (SD) below mean). The associations between EI and variables were examined using Pearson's chi-squared test (χ2) and regression techniques. RESULTS: A total of 55% of children received EI, 51% attended post discharge neonatal intensive care unit (NICU) and the remainder attended exclusive primary health care. Risk factors included, 50% perinatal, 19% social and 34% psychosocial and at 12-months 23% were categorised as disabled. Low social risk and NICU follow-up attendance were significantly associated with EI use but only perinatal risk (OR 3.1, 95% CI 1.7, 5.6, p = <0.01) and disability (OR 2.2, 95% CI 1.1, 4.7, p = 0.04) independently predicted EI use. CONCLUSIONS: It is reassuring that children with perinatal risk receive EI, opportunity remains to improve EI uptake in families with social and parental psychosocial risk during the first year of life.

Human milk and the nutritional needs of preterm infants.

Key principles underpinning feeding guidelines for preterm infants include support for developmental care, breastfeeding, milk expression, and creating feeding plans. Early trophic feeding with colostrum and transitional milk improves immune protection and promotes gut maturation. Studies of preterm infants demonstrate that feeding mother's milk (MM) decreases the incidence of infection and necrotizing enterocolitis and improves neurodevelopmental outcome but may decrease ponderal and linear growth. Standard practice in neonatal units is to promote mother's own milk as the feed of choice for all infants. However, it is not feasible or prudent to do so for all preterm infants. Mothers of preterm infants have lower rates of successful breastfeeding compared with those of term infants. MM can contain harmful bacterial or viral pathogens. Although preterm human milk (HM) contains higher concentrations of protein, sodium, zinc, and calcium than mature HM, it falls short of supplying adequate quantities of nutrients required by preterm infants. Therefore, HM supplemented with nutrients is recommended for all infants born before 32 weeks gestation and for certain infants born at 32-36 weeks of gestation. HM is the preferred feed, but preterm formula is an appropriate option when there is an inadequate supply of MM.

Nutritional needs of the micropreterm infant.

We have used an expansive definition of a micropreterm infant as <30 weeks' gestation to provide a global perspective to a "high risk" group of preterm infants for which there are little published data to guide nutritional management. Consensus nutritional guidelines for preterm infants have been developed for infants >1000 g birth weight and >28 weeks' gestational age. Micropreterm infants have greater nutritional deficits at birth than more mature preterm infants and accumulate greater postnatal deficits. Nutritional guidelines based on the needs of preterm infants born >28 weeks' gestation are unlikely, on a theoretical basis, to meet nutritional requirements of micropreterm infants. Unfortunately, very few good quality studies have addressed the nutritional requirements of this group specifically; this makes it difficult to formulate solid, evidence-based nutritional recommendations for these neonates. Nutritional management of micropreterm infants is based on recommendations established for preterm infants, which are adjusted after considering an infant's gestational age, birth weight, and clinical status. Minimal enteral feeding should commence on the first or second day of life, with incremental advancement and fortification of human milk when 100 mL/kg is tolerated. Early use of parenteral nutrition is recommended, ideally initiated within the first hours of life and enteral feeds are being established; this will help prevent the accumulation of nutritional deficits and incidence of growth failure. Fortified human milk should be given in order to meet nutritional requirements. When human milk is not available in sufficient quantity, a preterm formula should be given.

Nutritional requirements and feeding recommendations for small for gestational age infants.

We define the small for gestational age (SGA) infant as an infant born ≥ 35 weeks' gestation and <10th percentile on the Fenton Growth Chart. Policy statements from many organizations recommend mother's own milk for SGA infants because it meets most of their nutritional requirements and provides short- and long-term benefits. Several distinct patterns of intrauterine growth restriction are identified among the heterogeneous grouping of SGA infants; each varies with regard to neonatal morbidities, requirements for neonatal management, postnatal growth velocities, neurodevelopmental progress, and adult health outcomes. There is much we do not know about nutritional management of the SGA infant. We need to identify and define: infants who have "true" growth restriction and are at high risk for adverse metabolic outcomes in later life; optimal growth velocity and "catch-up" growth rates that are conducive with life-long health and well being; global approaches to management of hypoglycemia; and an optimal model for postdischarge care. Large, rigorously conducted trials are required to determine whether aggressive feeding of SGA infants results in improved nutritional rehabilitation, growth, and neurodevelopmental outcomes. Before birth, maternal supplementation with specific nutrients reduces the rate and severity of growth restriction and may prevent nutrient deficiency states if infants are born SGA. After birth, the generally accepted goal is to provide enough nutrients to achieve postnatal growth similar to that of a normal fetus. In addition, we recommend SGA infants be allowed to "room in" with their mothers to promote breastfeeding, mother-infant attachment, and skin-to-skin contact to assist with thermoregulation.

Australasian neonatal intensive care enteral nutrition survey: implications for practice.

AIM: This survey investigated standardised feeding guidelines and nutrition policy in Australasian neonatal intensive care units and compared these with previously published surveys and international consensus nutrition recommendations. METHODS: An electronic survey on enteral nutrition comprising a wide range of questions about clinical practice was e-mailed to all 25 Australasian neonatal intensive care unit directors of tertiary perinatal centres. RESULTS: Twenty-five surveys were distributed; 24 (96%) were completed. All respondents preferred breast milk as the first feed. For infants <1000 g, 58% started feeds at 1 mL every 4 hours and 83% started enteral feeds on day 0-2 in the absence of contraindications. The identification of bile-stained gastric aspirates significant enough to withhold feeds varied. Multicomponent breast milk fortifiers were added by 58% when enteral feeds reached 150 mL/kg day, while 21% added these earlier at 120 mL/kg day or less. Iron supplementation was started at 4 weeks by 63% and at 6 weeks by 27%. Only 42% of units had a neonatal dietitian. Of the 24 units who responded, 58% had no written enteral feeding guidelines. CONCLUSION: Enteral nutrition was initiated earlier than in the past. Great variation remains in clinical practices. Nutritional implications are discussed. Standardisation of feeding guidelines and enteral nutrition policy based on current evidence and international consensus nutrition recommendations may be beneficial and should be encouraged.

Twelve-year review of neonatal deaths in the delivery room in a perinatal tertiary centre.

AIM: To describe decisions made for babies who died in the delivery room as a result of clinical practice of non-resuscitation or unsuccessful resuscitation. METHODS: A retrospective study was conducted of neonatal deaths (NNDs) ≥ 400 g and/or ≥20 weeks' gestation born at Mater Mothers' Hospitals 1998-2009 who were not admitted to a neonatal nursery. Deaths were divided into not resuscitated and unsuccessful resuscitation and subdivided by cause of death as extremely preterm, congenital abnormality or 'other'. RESULTS: Of all 539 NNDs, 217 (40.3%) were not admitted to a neonatal nursery, comprising 174 (80.2%) not resuscitated and 41 (18.9%) unsuccessful resuscitation, while in a further two newborn infants resuscitation was not required. Only 13 of 123 (10.6%) extremely preterm infants who died in the delivery room had resuscitation attempted. Of 77 infants who died from congenital abnormalities in the delivery room 18 (23.3%) had resuscitation attempted. Fifteen babies with other diagnoses died in the delivery room; five with severe intrapartum asphyxia without resuscitation and a further 10 (8 preterm) with Apgar scores of 0-1 at 1 min and ≤3 at 5 min who did not respond to extensive resuscitation. CONCLUSIONS: A large proportion of NNDs occurred outside the neonatal nurseries involving end-of-life decision-making. Review of the circumstances of these NNDs in the subcategories of extreme prematurity, congenital abnormalities and 'other' raises different management dilemmas with the potential for clinical practice improvement in compassionate care and transparency in decision-making.

Growth monitoring of low birthweight infants: what references to use?

Growth charts are the mainstay of monitoring growth in babies who were born small or preterm. A variety of different charts are available, each with specific limitations. Most birthweight centile charts underestimate growth restriction in preterm babies and there are few good charts for monitoring longitudinal growth in preterm babies; it is important to be aware of the limitations of using cross-sectional data for monitoring longitudinal growth. Customised centile charts of fetal growth are used increasingly for antenatal monitoring for small-for-gestational age fetuses despite a lack of robust evidence. It is also unclear whether customised centile charts should be used for assessing birthweight, particularly in babies born at term. Faltering post-natal growth in preterm babies is very common but need not be universal with close attention to nutrition. Monitoring of growth trajectories through infancy following either fetal growth restriction or post-natal faltering growth is important to ensure proportional growth, particularly during periods of accelerated growth. This review will discuss these issues in the context of current practice in Australia and New Zealand.

Infant formulas for preterm infants: in-hospital and post-discharge.

The availability and composition of preterm and post-discharge formulas (PDFs) have undergone considerable changes over the last decade. Human milk, supplemented with multi-component fortifier, is the preferred feed for very preterm infants as it has beneficial effects for both short- and long-term outcomes compared with formula. If supply of mother's milk or donor milk is inadequate, a breast milk substitute specifically designed for premature infants is the next option. Preterm formula is intended to provide nutrient intakes to match intrauterine growth and nutrient accretion rates and is enriched with energy, macronutrients, minerals, vitamins, and trace elements compared with term infant formulas. Post-natal longitudinal growth failure has been reported almost universally in extremely preterm infants. Since 2009, a nutritionally enriched PDF specifically designed for preterm infants post hospital discharge with faltering growth has been available in Australia and New Zealand. This formula is an intermediary between preterm and term formulas and contains more energy (73 kcal/100 mL), protein (1.9 g/100 mL), minerals, vitamins, and trace elements than term formulas. Although the use of a PDF is based on sound nutritional knowledge, the 2012 Cochrane Systematic Review of 10 trials comparing feeding preterm infants with PDF and term formula did not demonstrate any short- or long-term benefits. Health professionals need to make individual decisions on whether and how to use PDF.

The use of recombinant tissue plasminogen activator in the management of infective intracardiac thrombi in pre-term infants with thrombocytopaenia.

Bacterial endocarditis complicated by the development of intra-cardiac thrombus presents a difficult management dilemma in the pre-term infant. Here we present our experience with three infants who had this condition, all of whom were successfully managed using therapy with recombinant tissue plasminogen activator (r-TPA). Therapy in one of the infants was particularly instructive, as the condition was further complicated by severe thrombocytopaenia, making the decision to treat using r-TPA difficult.

Decreased use of postnatal corticosteroids in extremely preterm infants without increasing chronic lung disease.

BACKGROUND: Postnatal corticosteroids are effective in preventing chronic lung disease in preterm infant. There are concerns that corticosteroid use may be associated with an increased risk of impaired neurodevelopment. OBJECTIVE: To examine the effect of change in practice with the use of postnatal corticosteroids over an 8-year period in extremely preterm babies on the incidence of chronic lung disease (CLD) and cerebral palsy at 1 year of age. METHODS: Babies of birth weight <1,000 g or gestational age <28 weeks admitted from 1997 to 2004 were included in this retrospective analysis. The study period was divided into two eras: group 1: 1997-2000, group 2: 2001-2004. Data were collected from the neonatal database, individual records and from the Growth and Development Unit. The outcome measure of CLD was defined as oxygen dependency at 36 weeks postmenstrual age. Data for postnatal corticosteroid usage were collected for the number of babies per year, and total dose. RESULTS: 389 group 1 babies were compared to 368 group 2 babies. There was a significant decrease in the use of dexamethasone from 27% in group 1 to 13% in group 2 (p = 0.0001), and total dose - mg/kg (4.5 +/- 2.9 vs. 2.6 +/- 1.6, p = 0.0001). The incidence of CLD and need for home oxygen was similar between groups. The incidence of cerebral palsy reduced from 10.4% in group 1 to 6.6% in group 2, though this was not statistically significant (OR 0.63; 95% CI 0.3, 1.2.). CONCLUSION: Decreased postnatal corticosteroid use had no impact on the incidence of CLD or need for home oxygen therapy. The trend towards a reduced rate of cerebral palsy requires further investigation.

Measuring sensorineural disability in preterm children using a public health screening strategy: a randomised controlled trial.

AIM: To assess the efficacy of a preterm-targeted screening programme against the routine Australian National Health Medical Research Council (NHMRC) universal child health screening programme to detect disability in a general practice setting in children born < or =31 weeks gestation at 12-months of age. METHODS: Multi-centred trial involving 202 preterm children randomised to receive the preterm-targeted or NHMRC programme. Primary outcome, correct identification of neurosensory disability by general practitioners assessed against gold standard paediatric assessments. Sensitivity analysis estimated interrater agreement and screening accuracy. Secondary outcomes, post natal depression (PND), parental stress, health service use, screening programme helpfulness and correct identification of levels of disability severity. RESULTS: Of the 195 infants with data on the primary outcome in the preterm-targeted group, their general practitioners correctly identified the disability status of 61/93 (65.6%) children, as compared with 69/102 (67.6%) in the NHMRC group (odds ratios (OR) 0.91 95% confidence interval (CI) 0.50, 1.65). Responses where general practitioners were unsure of a child's disability status were coded as incorrect and not paired for sensitivity analysis. Sensitivity analysis for 180 diagnostic pairs showed fair interrater agreement for both groups (preterm-targeted k = 0.30 vs. NHMRC k = 0.29) with screening test results favouring the preterm-targeted group with greater sensitivity (73% vs. 33%) but lower specificity (70% vs. 92%) resulting in more over referrals (30% vs. 8%); however, these had a significantly lower mean Developmental Quotient (DQ) score compared with non-disabled children. PND scores were higher in preterm-targeted group (OR 1.33 95% CI 0.01, 2.66). CONCLUSION: The preterm-targeted programme used by general practitioners: (i) did not improve overall identification of disability status compared to the NHMRC universal programme (Australian New Zealand Clinical Trails Registry number, ACTRN 12606000472572); however (ii) it did demonstrate greater efficacy as a screening tool in accurately identifying disabled children.