Alternatives to low birthweight as a population-level indicator of infant and child health.

BACKGROUND: Low birthweight (<2500 g) is often used as a population-level indicator of maternal-child health, as it is easy to measure and correlates with poorer infant health outcomes. However, it conflates preterm birth and intrauterine growth restriction, which have different causal pathways and require different approaches to prevention. Small for gestational age (SGA) (a proxy for growth restriction) and preterm birth may be more informative measures. We evaluated low birthweight as a population-level indicator. METHODS: We conducted a population-based cohort study of singleton live births in New South Wales (NSW), Australia, using linked data from 1994-2006 birth, hospital, death and educational records, with follow-up until 2014. Outcomes of babies born of low birthweight, preterm and SGA were compared with well-grown term infants (i.e. not low birthweight or SGA). Overlap between groups and temporal trends were also examined. RESULTS: Of 1 093 765 singleton live births, 47 946 (4.4%) infants were low birthweight and had poorer outcomes than well-grown term infants (2.7% vs. 0.1% infant mortality; 13% vs. 6% below national minimum numeracy standard). SGA and preterm infants also had poorer outcomes (0.5%, 2.3% infant mortality respectively; 10%, 11% below numeracy standard) but 80% of SGA and 47% of preterm infants were not low birthweight. For all outcomes, low birthweight identified a smaller proportion of infants with poor outcomes than preterm birth and than either SGA or low birthweight at term. The proportion of low-birthweight births remained constant over time, while the proportion of births that were preterm increased and proportion of SGA decreased. CONCLUSIONS: Low birthweight, SGA and preterm infants are all at higher risk of poorer outcomes but low birthweight inadequately captures, and masks trends in, both preterm births and births that are SGA. Reporting preterm births and an indicator of growth restriction at term will identify vulnerable groups better than using the measure of low birthweight.

Gestational age, morbidity and mortality among twin births in New South Wales, Australia 2003-2014: A cohort study.

BACKGROUND: Evidence suggests that the trend toward early planned births observed among singletons may be evident among twin pregnancies. AIMS: To describe trends in gestational age at birth, pregnancy characteristics, neonatal morbidity and mortality among twin pregnancies. MATERIALS AND METHODS: Population-based data linkage study of twin births of ≥30 weeks of gestation without a major congenital anomaly born in 2003-2014 in New South Wales (NSW), Australia. Linked pregnancy and birth, hospital and mortality data were used. Generalised linear regression was used to assess linear trends. Risk difference (RD) and 95% confidence intervals were estimated. RESULTS: Among 28 076 eligible twin births (14 038 pregnancies), 49% of births occurred prior to 37 weeks and 69% of births were planned (pre-labour caesarean or induction of labour). There were increases over time in the proportion of twin births at preterm gestations (30-34 weeks (RD 2.1, 95% CI 0.1, 4.0), 35-36 weeks (RD 7.5, 95% CI 5.4, 9.7)) and in the rates of planned births (pre-labour caesarean (RD 6.4, 95% CI 4.0, 8.8), induction (RD 4.6, 95% CI 2.6, 6.6)). There was no significant change in stillbirth or neonatal death rates, but there was an increase in neonatal morbidity over the study period. Concurrently, there were increases in the prevalence of gestational diabetes; and decreases in pregnancy hypertension, assisted reproductive technology use, small-for-gestational age and birthweight discordance. CONCLUSIONS: Gestational age at birth among twin births is decreasing and birth intervention is increasing. There are increasing rates of neonatal morbidity, but no overall change in perinatal mortality.

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study.

AIM: Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions. METHODS: Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated. RESULTS: Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group. CONCLUSION: Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

Childhood health and education outcomes following early term induction for large-for-gestational age: A population-based record linkage study.

INTRODUCTION: There is debate about optimal management of pregnancies with a large-for-gestational age baby. A recent randomized controlled trial reported that early term induction of labor reduced cesarean section rates and infant morbidity. However, long term childhood outcomes have not been assessed. The aim of this study was to assess maternal, neonatal and child health and education outcomes for large-for-gestational age babies induced at 37-38 weeks' gestation. MATERIAL AND METHODS: Population-based record linkage study of term (37+ weeks), cephalic-presenting singleton pregnancies with a large-for-gestational age baby in New South Wales, Australia, 2002-2006. Linked birth, hospital, mortality and education data were used with at least 9 years follow up from birth. Exposure was induction of labor at 37-38 weeks, compared to expectant management (spontaneous birth at ≥37 weeks and planned births at ≥39 weeks). Relative risks and 95% confidence intervals were estimated using Modified Poisson regression with robust variance. RESULTS: Among 10 174 eligible pregnancies, 412 (4.0%) had an induction at 37-38 weeks. Women in the induction group were less likely to have a cesarean section (RR: 0.65, 95% CI: 0.51-0.82). Infants had higher rates of: low Apgar scores, birth trauma, neonatal jaundice and phototherapy use, and admission to special care nursery or neonatal intensive care than their expectantly managed counterparts. As children, they had higher rates of hospital admission (RR: 1.16, 95% CI: 1.04-1.30) and special needs (RR: 1.98, 95% CI: 1.12-3.50). However, by age 8 there was no difference in overall literacy and numeracy achievement. CONCLUSIONS: Although women who had an early term labor induction with large-for-gestational age were less likely to have a cesarean section, the increased risk of neonatal morbidities and additional healthcare utilization suggests the need for caution in early induction of large-for-gestational age babies before 39 weeks' gestation.

Pediatric admissions that include intensive care: a population-based study.

BACKGROUND: Pediatric admissions to intensive care outside children's hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population. METHODS: We undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010-2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU). RESULTS: Of 498,466 pediatric hospitalizations, 7525 (1.5%) included time in an intensive care unit - 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die. CONCLUSIONS: A substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.

Comparison of neonatal red cell transfusion reporting in neonatal intensive care units with blood product issue data: a validation study.

BACKGROUND: Infants in Neonatal Intensive Care Units represent a heavily transfused population, and are the focus of much research interest. Such research commonly relies on custom research databases or routinely collected data. Knowledge of the accuracy of transfusion recording in these databases is important. This study aims to assess the reporting of red blood cell transfusion neonatal intensive care unit data compared with routinely collected hospital blood bank ("Blood Watch") data. METHODS: Blood Watch data was linked with the NICUS Data Collection, and with routinely collected birth and hospital data for births between 2007 and 2010. The sensitivity, specificity, and positive and negative predictive values for transfusion were calculated, compared to the Blood Watch data. The agreement between the NICUS and Blood Watch datasets on quantity transfused was also assessed. RESULTS: Data was available on 3934 infants, of which 16.2% were transfused. Transfusion was reported in the NICUS Data Collection with high specificity (98.3%, 95% confidence interval (97.8%,98.7%)), but with some under-enumeration (sensitivity 89.2% (95% CI 86.5%,91.5%)). There was excellent agreement between the NICUS and Blood Watch datasets on quantity transfused (Kappa 0.90, 95% CI (0.88,0.92)). Transfusion reporting in the hospital data for these infants was also reliably reported (Sensitivity 83.7% (95% CI 80.6%,86.5%), specificity 99.1% (95% CI 98.7%,99.4%)). CONCLUSIONS: Transfusion is reliably reported in the neonatal intensive care unit data, with some under-reporting, and quantity transfused is well recorded. The NICUS Data Collection provides useful information on blood transfusions, including quantity of blood transfused in a high risk population.

Educational outcomes for children with cerebral palsy: a linked data cohort study.

AIM: To identify a cohort of children with cerebral palsy (CP) from hospital data; determine the proportion that participated in standardized educational testing and attained a score within the normal range; and describe the relationship between test results and motor symptoms. METHOD: This population-based retrospective cohort study used data from New South Wales, Australia. We linked hospital data for children younger than 16 years of age admitted between 1st July 2000 and 31st March 2014 to education data from 2009 to 2014. Hospital diagnosis codes were used to identify a cohort of children with CP (n=3944) and describe their motor symptoms. Educational outcomes in the CP cohort were compared with those among children without CP. RESULTS: Of those with educational data (n=1770), 46% were exempt from reading assessment because of intellectual or functional disability, 7% were absent or withdrawn from testing and 47% participated in testing. About 30% of all children with educational data had test scores in the normal range. The proportion was greatest among those with hemiplegia (>40%) and lowest among those with tetraplegia (<10%). INTERPRETATION: One-third of children with CP participated in standardized testing and achieved a result in the normal range. The proportions were lower in children with more severe motor symptoms. WHAT THIS PAPER ADDS: From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school. The rate of disability-related exemption from standardized educational testing was almost 50%. Thirty per cent of children with CP achieved educational scores in the normal range.

Long-term outcomes for large for gestational age infants born at term.

AIM: Large for gestational age (LGA) babies have increased risks for short-term outcomes such as shoulder dystocia, neonatal hypoglycaemia and longer hospital stay. Little is known of long-term health, development and educational outcomes of LGA babies. The aim of this study was to determine the long-term health, mortality, development and educational outcomes for infants born LGA at term. METHODS: A population-based record linkage study of live singletons born at term (37-41 weeks of gestation) in New South Wales, Australia, from 2001 to 2006. RESULTS: This study compared 49 439 LGA (>90th percentile for birthweight, gestational age and sex) and 400 418 appropriate size for gestational age (AGA; 10th-90th percentile) infants. LGA infants had increased risk of birth and neonatal outcomes and hospitalisations, for brachial plexus injury after the neonatal period, and for all causes from 1 to 5 years of age. There were no differences in mortality up to 5 years of age or hospitalisations for type 1 diabetes in childhood. LGA infants had lower rates of developmental vulnerability (in kindergarten) and showed a significant trend (χ2 for trend <0.0001) to fewer low scores and more high scores in reading and numeracy (in Year 3) compared with AGA. After adjusting for potential confounders, only the relative risk for higher reading scores was statistically significant. CONCLUSIONS: LGA infants show positive long-term health, development and educational outcomes. Concerns for LGA infants still remain in the perinatal period as a result of birth trauma; however, these complications usually do not persist in postnatal and early childhood.

Neonatal exchange transfusions in tertiary and non-tertiary hospital settings, New South Wales, 2001-2012.

AIM: To describe neonatal exchange transfusions in New South Wales (NSW) before and after release in January 2007 of a NSW Health guideline regarding exchange transfusions in tertiary and non-tertiary hospitals. METHODS: The study population included neonates receiving exchange transfusion in NSW hospitals, 2001-2012. Linked birth and hospital data for mothers and babies were used to describe birth characteristics and maternal and neonatal conditions. Exchange transfusions were identified in hospital data and compared for 2001-2006 and 2007-2012. Maternal and neonatal characteristics were compared with χ2 and Wilcoxon signed-rank tests. RESULTS: Between 2001 and 2012, there were 286 exchange transfusions performed for 281 neonates in NSW hospitals. The number of exchange transfusions decreased from 187 in 184 neonates for 2001-2006 to 99 in 97 neonates 2007-2012 (P < 0.001). The percentage of exchange transfusions performed at tertiary hospitals increased from 85% in 2001-2006 to 91% in 2007-2012, although this was not statistically significant (P = 0.16). Most neonates requiring exchange transfusion were born in tertiary hospitals: 62% for 2001-2006 and 69% for 2007-2012. Among those born in a non-tertiary hospital, the percentage transferred or admitted to a tertiary hospital for exchange transfusion was 63% in 2001-2006 and 77% in 2007-2012. CONCLUSION: Between 2001 and 2012, there was a decrease in neonatal exchange transfusions in NSW. After the 2007 guideline there was a non-significant increase in the proportion of exchange transfusions performed at tertiary hospitals. Although rare, exchange transfusions are still expected to occur occasionally in non-tertiary hospitals, requiring continuing support for this procedure in these settings.

Association of Gestational Age and Severe Neonatal Morbidity with Mortality in Early Childhood.

BACKGROUND: Although infant and child mortality rates have decreased substantially worldwide over the past two decades, efforts continue in many nations to further these declines. The identification of pertinent perinatal factors that are associated with early childhood mortality would help with these efforts. We investigated the association of two crucial perinatal factors, gestational age and severe neonatal morbidity at birth, with mortality during infancy (29-364 days) and early childhood (1-5 years). METHODS: The study population included all singleton livebirths, ≥32 weeks' gestation in New South Wales, Australia in 2001-11. Birth data were linked to hospitalisation morbidity data and deaths data (linked birth cohort n = 871 916), and multivariable Cox regression models were used to assess mortality. RESULTS: The median follow-up time per child was 4.95 years (range 0.00-5.92 years; 3 614 738 total person-years), with 984 deaths observed. Gestational age was associated with increased mortality, and specifically from deaths attributable to infections, respiratory conditions, and injuries during infancy, but not during early childhood. Severe neonatal morbidity strongly mediated the effects of gestational age during infancy, but not during early childhood, and was associated with increased mortality from circulatory, nervous, and respiratory system causes. CONCLUSIONS: The direct effects of gestational age on mortality extended up to 1 year of age, whereas severe neonatal morbidity remained associated with heightened mortality into early childhood. Efforts to maximise the health and well-being of vulnerable infants, with emphasis on preventing infections and injuries, may help further reduce early childhood mortality.

Survival, Hospitalization, and Acute-Care Costs of Very and Moderate Preterm Infants in the First 6 Years of Life: A Population-Based Study.

OBJECTIVES: To investigate survival, hospitalization, and acute-care costs of very (28-31 weeks' gestation) and moderate preterm (32-33 weeks' gestation) infants in the first 6 years of life and compare outcomes with the more widely studied extremely preterm infants (24-27 weeks' gestation) and to full term (low risk) infants (39-40 weeks' gestation). STUDY DESIGN: Birth data from all women residing in New South Wales, Australia, with gestational ages between 24-33 and 39-40 weeks in 2001-2011 were linked probabilistically to hospitalization and mortality data. Study outcomes were evaluated with the use of descriptive and multivariable analyses at birth (N = 559,532), discharge (N = 540,240), and at 1 (N = 487,447) and 6 years of age (N = 230,498). RESULTS: Mortality was greatest among extremely preterm infants (eg, 31.2% within 6 years) and decreased with increasing gestational age. Likewise, hospitalization within the first year of life increased with decreasing gestational age (aOR 5.5 [95% CI 4.7-6.4], 3.7 [3.4-4.0], and 2.6 [2.5-2.8] for birth at 24-27, 28-31, and 32-33 weeks' gestation, relative to 39-40 weeks' gestation). Hospitalization remained significantly increased with preterm birth at each year of age up to 6 years (aORs 1.3-1.6 at 6 years). Cumulative costs were significantly greater with preterm birth within the first year of life, and also between 1 and 6 years of age. CONCLUSIONS: The risks of adverse health outcomes were significantly greater in very and moderately preterm infants relative to full term infants but lower than extremely preterm infants. Crucially, preterm birth was associated with prolonged increased odds of hospitalization (up to age 6 years), contributing to greater resource use.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial.

BACKGROUND: Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS: The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS: Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION: In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING: Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Red cell and platelet transfusions in neonates: a population-based study.

OBJECTIVES: This study aimed to describe the use of red cells, platelets and exchange transfusions among all neonates in a population cohort, to examine trends in transfusion over time and to determine transfusion rates in at-risk neonates. DESIGN: Linked population-based birth and hospital data from New South Wales (NSW), Australia, were used to determine rates of blood product transfusion in the first 28 days of life. The study included all live births ≥23 weeks' gestation in NSW between 2001 and 2011. RESULTS: Between 2001 and 2011, 5326 of 989 491 live born neonates received a red cell, platelet or exchange transfusion (5.4/1000 births). Transfusion rates were 4.8 per 1000 for red cells, 1.3 per 1000 for platelets and 0.3 per 1000 for exchange transfusion. Overall transfusion rate remained constant from 2001 to 2011 (p=0.27). Among transfused neonates, 60% were <32 weeks' gestation (n=3210, 331/1000 births), 40% were ≥32 weeks' gestation (n= 2116, 2/1000 births) and 7% received transfusions in a hospital without a neonatal intensive care unit (NICU). Factors other than prematurity associated with higher transfusion rates were prior in utero transfusion (631/1000), congenital anomaly requiring surgery (440/1000) and haemolytic disorder (106/1000). CONCLUSIONS: In this population-based study, preterm neonates had a higher rate of transfusion than term neonates; however, 40% of those who received a transfusion were born ≥32 weeks' gestation and 7% were transfused in hospitals without an NICU. These findings need to be considered by transfusion services and personnel developing neonatal transfusion guidelines.

Hospitalisations from 1 to 6 years of age: effects of gestational age and severe neonatal morbidity.

BACKGROUND: To investigate whether the adverse infant health outcomes associated with early birth and severe neonatal morbidity (SNM) persist beyond the first year of life and impact on paediatric hospitalisations for children up to 6 years of age. METHODS: The study population included all singleton live births, >32 weeks gestation in New South Wales, Australia, in 2001-2005, with follow-up to 6 years of age. Birth data were probabilistically linked to hospitalisation data (n = 392 964). The odds of hospitalisation, mean hospital length of stay (LOS) and costs, and cumulative LOS were evaluated by gestational age and SNM using multivariable analyses. RESULTS: A total of 74 341 (18.9%) and 41 404 (10.5%) infants were hospitalised once and more than once, respectively. SNM was associated with increased odds of hospitalisation once (adjusted odds ratio [aOR] 1.16 [95% confidence interval 1.10, 1.22]) and more than once [aOR 1.51 (1.43, 1.61)]. Decreasing gestational age was associated with increasing odds of hospitalisation more than once from aOR 1.19 at 37-38 weeks to 1.49 at 33-34 weeks. Average LOS and costs per hospital admission were increased with SNM but not with decreasing gestational age. Cumulative LOS was significantly increased with SNM and decreasing gestational age. CONCLUSIONS: Adverse effects of SNM and early birth persist between 1 and 6 years of age. Strategies to prevent early birth and reduce SNM, and to increase health monitoring of vulnerable infants throughout childhood may help reduce paediatric hospitalisations.

Early discharge of infants and risk of readmission for jaundice.

OBJECTIVES: To examine the association between early discharge from hospital after birth and readmission to hospital for jaundice among term infants, and among infants discharged early, to investigate the perinatal risk factors for readmission for jaundice. METHODS: Birth data for 781,074 term live-born infants born in New South Wales, Australia from 2001 to 2010 were linked to hospital admission data. Logistic regression models were used to investigate the association between postnatal length of stay (LOS), gestational age (GA), and readmission for jaundice in the first 14 days of life. Other significant perinatal risk factors associated with readmission for jaundice were examined for infants discharged in the first 2 days after birth. RESULTS: Eight per 1000 term infants were readmitted for jaundice. Infants born at 37 weeks' GA with an LOS at birth of 0 to 2 days were over 9 times (adjusted odds ratio [aOR] 9.43; 95% CI, 8.34-10.67) and at 38 weeks' GA were 4 times (aOR 4.05; 95% CI, 3.62-4.54) more likely to be readmitted for jaundice compared with infants born at 39 weeks' GA with an LOS of 3 to 4 days. Other significant risk factors for readmission for jaundice for infants discharged 0 to 2 days after birth included vaginal birth, born to mothers from an Asian country, born to first-time mothers, or being breastfed at discharge. CONCLUSIONS: This study can inform guidelines or policy about identifying infants at risk for readmission for jaundice and ensure that appropriate post-discharge follow-up is received.

Association of prelabor cesarean delivery with reduced mortality in twins born near term.

OBJECTIVE: To examine short-term and longer-term outcomes for twins born at or near term, comparing prelabor cesarean delivery with birth after a trial of labor. METHODS: This study was conducted on a retrospective cohort of twin pregnancies delivered at 36 weeks of gestation or greater from 2000 to 2009. Pregnancies with an antenatal death, lethal anomaly, birth weight discordance 25% or more, or birth weight less than 2,000 g or more than 4,000 g were excluded. Outcomes included severe hypoxia, stillbirth and neonatal death, and hospital admissions or death during the first 5 years of life. RESULTS: Approximately 45% of 7,099 twin pregnancies were delivered by prelabor cesarean delivery. Compared with delivery after labor, prelabor cesarean delivery was associated with significantly reduced risks of adverse neonatal and child outcomes including severe birth hypoxia (0.08% compared with 0.75%, relative risk 0.10, 95% confidence interval [CI] 0.04-0.26), neonatal death (0.00% compared with 0.15%, relative risk 0.05, 95% CI 0.00-0.82), and death up to 5 years of age (0.16% compared with 0.40%, relative risk 0.41, 95% CI 0.20-0.85). Whereas total mortality for first twins was similar after labor (0.15%) compared with prelabor cesarean delivery (0.16%), total mortality was four times more common in second twins born after labor (0.64%) compared with second twins born after prelabor cesarean delivery (0.16%). CONCLUSION: Compared with prelabor cesarean delivery, twin pregnancies at and beyond 36 weeks of gestation delivered after labor have increased risks for birth outcomes associated with hypoxia, with second twins having significantly increased mortality up to 5 years of age. However, the absolute mortality rate for relatively uncomplicated twin pregnancies delivered at or near term is low and needs to be balanced against maternal morbidity. LEVEL OF EVIDENCE: II.

Long term follow up of high risk children: who, why and how?

BACKGROUND: Most babies are born healthy and grow and develop normally through childhood. There are, however, clearly identifiable high-risk groups of survivors, such as those born preterm or with ill-health, who are destined to have higher than expected rates of health or developmental problems, and for whom more structured and specialised follow-up programs are warranted. DISCUSSION: This paper presents the results of a two-day workshop held in Melbourne, Australia, to discuss neonatal populations in need of more structured follow-up and why, in addition to how, such a follow-up programme might be structured. Issues discussed included the ages of follow-up, and the personnel and assessment tools that might be required. Challenges for translating results into both clinical practice and research were identified. Further issues covered included information sharing, best practice for families and research gaps. SUMMARY: A substantial minority of high-risk children has long-term medical, developmental and psychological adverse outcomes and will consume extensive health and education services as they grow older. Early intervention to prevent adverse outcomes and the effective integration of services once problems are identified may reduce the prevalence and severity of certain outcomes, and will contribute to an efficient and effective use of health resources. The shared long-term goal for families and professionals is to work toward ensuring that high risk children maximise their potential and become productive and valued members of society.

Trends in New South Wales infant hospital readmission rates in the first year of life: a population-based study.

OBJECTIVE: To examine the trends in hospital readmissions in the first year of life and identify whether changes in maternal and infant risk factors explain any changes. DESIGN: Population-based study using de-identified linked health data. PARTICIPANTS: All 788 798 live-born infants delivered in New South Wales from 1 January 2001 to 31 December 2009 with a linked birth and hospital record. MAIN OUTCOME MEASURES: The number of infants readmitted to hospital at least once after discharge home from the birth admission to 1 year of age, per 100 live births each year, and changes in maternal and infant risk factors assessed by logistic regression. RESULTS: The number of infants readmitted to hospital up to age 1 year decreased by 10.5% (average annual reduction, 1.8%; 95% CI, - 1.7% to - 0.01%, P = 0.001), from 18.4 per 100 births in 2001 to 16.5 in 2009. Fifty-five per cent of this decrease could be explained by changes in factors that are associated with likelihood of hospitalisation; length of stay during the birth admission, maternal age and maternal smoking. The rate of readmissions for jaundice and feeding difficulties increased significantly over the study period, while readmissions for infections decreased. CONCLUSIONS: There has been a decrease in the rate of infants readmitted to hospital in the first year of life, which can be partly explained by increasing maternal age, decreasing maternal smoking and a shift to shorter length of hospital stay at birth. Improved maternal and neonatal care in hospital and increased postnatal support at home may have contributed to reduced risk of readmission.

Blood transfusion during pregnancy, birth, and the postnatal period.

OBJECTIVES: To identify risk factors for transfusion and trends in transfusion rates across pregnancy and the postnatal period. METHODS: Linked hospital and birth data on all births in hospitals in New South Wales, Australia, between 2001 and 2010 were used to identify blood transfusions for women during pregnancy, at birth, and in the 6 weeks postpartum. Poisson regression was used to identify risk factors for red cell transfusion in the birth admission. Separate models were fitted for cesarean and vaginal births. RESULTS: Between 2001 and 2010, there were 12,147 transfusions across 891,914 pregnancies, with a transfusion rate of 1.4%. The transfusion rate increased steadily from 1.2% in 2001 to 1.6% in 2010. The majority of transfusions (91%) occurred during the birth admission, and 81% of these transfusions were associated with a diagnosis of hemorrhage. Women with bleeding or platelet disorders (vaginal: number transfused 529, relative risk [RR] 7.8, 99% confidence interval [CI] 6.9-8.7, cesarean: n=592, RR 8.7, CI 7.7-9.7) and placenta previa: (vaginal n=73, RR 4.6, CI 3.4-6.3, cesarean: n=875, RR 5.7, CI 5.1-6.4) were at highest risk of transfusion. Among vaginal births, increased risk was evident for forceps (n=1,036, RR 2.8, CI 2.5-3.0) or vacuum births (n=1,073, RR 1.9, CI 1.7-2.0) compared with nonoperative births. CONCLUSIONS: Rates of obstetric blood product transfusion have increased by 33% since 2001, with the majority of this associated with hemorrhage. Women with bleeding or platelet disorders and placenta previa are at increased risk of transfusion and should be treated accordingly. LEVEL OF EVIDENCE: II.