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.

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.

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.

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.