Health and school performance of teenagers born before 29 weeks gestation.

OBJECTIVE: To ascertain the health and school performance of teenagers born before 29 weeks gestation (extremely low gestational age (ELGA)) and to compare those in mainstream school with classroom controls. METHODS: Three geographically defined cohorts of babies born in 1983 and 1984 were traced at the age of 15-16 years. Their health, abilities, and educational performance were ascertained using postal questionnaires to the teenagers themselves, their parents, their general practitioners, and the teachers of those in mainstream school. Identical questionnaires were sent to classroom controls. RESULTS: Of the 218 teenagers surviving to the age of 16 years, information was obtained on 179. Of these, 29 were in special schools and 150 in mainstream school, 10 of whom had severe motor or sensory impairment. Using the Child Health Questionnaire, parents of teenagers in mainstream school reported a higher incidence of problems than controls in physical functioning (difference in mean scores 9.0 (95% confidence interval (CI) 4.9 to 13.1)) and family life (difference in mean scores for family cohesion 7.0 (95% CI 1.6 to 12.4)). In all areas of learning, teachers rated the ability of the ELGA teenagers in mainstream school lower than the control group. Parents of teenagers in special schools reported a higher rate of problems in most areas. CONCLUSIONS: One in six ELGA survivors at age 16 years have severe disabilities and are in special schools. Most ELGA survivors are in mainstream school and are coping well as they enter adult life, although some will continue to need additional health, educational, and social services.

Chemotherapy and marrow transplantation for congenital leukaemia.

The optimum approach to congenital leukaemia is unclear. Results of treatment are generally discouraging and palliation is offered to many. The successful treatment of an infant with congenital leukaemia is reported.

Six years' experience of prophylactic oral vitamin K.

AIMS: The ability of oral vitamin K to eliminate all risk of vitamin K deficiency bleeding during the first three months of life was studied. METHODS: Babies (n=182,000) in the north of England judged well enough to be offered milk within 12 hours of birth were given 1 mg of phytomenadione (vitamin K(1)) suspended in a medium chain triglyceride oil by mouth at delivery between 1993 and 1998. The parents of those who were breastfed were given a further three doses to give to the baby once every two weeks after discharge. RESULTS: Four breastfed babies developed late vitamin K deficiency bleeding. In two, staff failed to follow policy guidelines, and in two there was undiagnosed alpha(1) antitrypsin deficiency. Audit suggested that 93% of breastfed babies had all four doses, as advised. CONCLUSIONS: An oral product that parents can administer themselves would be popular if licensed, but the total dose offered may need to be more than in this study if babies with undiagnosed liver disease are to be protected.

Mortality from early onset group B streptococcal infection in the United Kingdom.

AIMS: To assess the assumption that group B streptococcal infection is less common in the United Kingdom than it is in the United States. METHODS: All stillbirth and neonatal death records in the former Northern Health Region were scrutinised to determine how many babies had died of infection in 1981-96, and what had been the cause. RESULTS: Fifty one of 630 206 live born babies had died of confirmed group B streptococcal infection after becoming symptomatic within 48 hours of birth (0.8 neonatal deaths per 10,000 live births). There were a further 27 deaths from infection without a confirmed microbiological diagnosis, and 17 stillbirths from confirmed group B streptococcal infection. CONCLUSIONS: The incidence of death from early onset infection was marginally higher than the officially estimated rate for the United States before widespread prophylaxis was attempted. Strategies for perinatal prevention deserve greater attention in the United Kingdom.

Outcome of very preterm birth: children reviewed with ease at 2 years differ from those followed up with difficulty.

AIM: To determine whether those most easily reviewed in a population prevalence study differ from those followed up only with difficulty. METHODS: All babies born before 32 weeks of gestation in the North of England in 1983, 1990, and 1991 were traced, and all the survivors assessed at two years by one of two independent clinicians. RESULTS: 818 of the 1138 live born babies survived to discharge. There was some non-significant, excess disability in the 5% of long term survivors who were difficult to trace because of social mobility, but eight times as much severe disability in the 1% (9/796) in care and in the 5% (38/796) whose parents initially failed to keep a series of home or hospital appointments for interview, and five times as much emergent disability in the 2.7% (22/818) who died after discharge but before their second birthday. Had the babies who were seen without difficulty been considered representative of all the babies surviving to discharge, the reported disability rate would have been two thirds what it really was (6.9% instead of 11.0%). CONCLUSIONS: Population prevalence studies that ignore those who seem reluctant to cooperate risk serious ascertainment bias.

Selection biases invalidate current low birthweight weight-for-gestation standards. The Northern Neonatal Network.

OBJECTIVE: To obtain unbiased estimates of the variation of birthweight with gestation in infants born before 32 weeks of gestation. SETTING: The former Northern Regional Health Authority. DESIGN: Information on birthweight was collected during a collaborative study of every registered and unregistered birth at 22 to 31 weeks of gestation in the region in 1983 and 1990 to 1991. These birthweights were then related to computer-generated Tyneside norms for all registered births at 28 to 42 weeks of gestation between 1984 and 1991. Some local information was also collected on fetal weight after termination of pregnancy on social grounds at 16 to 21 weeks of gestation. RESULTS: Weight centiles constructed after excluding infants with a gross, externally visible, malformation and those dying before the onset of labour suggest that previously published European standards have overestimated birthweight in infants < 28 weeks of gestation, some low centiles being 30% in error. Female and first-born infants weighed 4% less than their male and later-born counterparts at all gestations studied. A single correction factor can therefore be used to correct for sex and parity, eliminating the need for separate centile graphs. Twin pregnancy was associated with a 10% reduction in mean birthweight in pregnancies lasting < 37 weeks, and this difference increased progressively in pregnancies lasting longer than this. CONCLUSION: The small number of low birthweight infants in previous datasets and the selective exclusion of all nonregistered births have made previous second trimester weight-for-gestation norms unreliable.

Changing prognosis for babies of less than 28 weeks' gestation in the north of England between 1983 and 1994. Northern Neonatal Network.

OBJECTIVE: To investigate the changing prognosis for babies of less than 28 weeks' gestation. DESIGN: A prospective, collaborative, population based survey. SETTING: The former Northern Regional Health Authority. SUBJECTS: All the births between 1983 and 1994 at 22 to 27 completed weeks' gestation to women normally resident in the region. MAIN OUTCOME MEASURES: Miscarriage, stillbirth, death in the first year of life, and disability in survivors. RESULTS: There were 479070 registered births in the study period. No baby of 22 weeks' gestation survived; only eight (4%) of the 197 babies of 23 weeks who were alive at the onset of labour survived for a year-a proportion that did not change during the study period. Survival among other babies of less than 28 weeks improved progressively between 1983-6 and 1991-4, but administration of artificial surfactant to babies requiring ventilation from mid-1990 was associated with further improvement in survival only in those over 25 weeks' gestation. Babies of 24 weeks required three times as much high dependency care per survivor as babies of 27 weeks (76 v 26 days). The rate of severe disability in the one year survivors of less than 26 weeks' gestation (30/123; 24%) was similar to that seen in the sampled survivors of 26 and 27 weeks (29/108; 27%); the proportion disabled did not change significantly during the study period. All the children born in 1983, 1987, and 1991 were later reassessed in greater detail: 10% (13/136) seemed destined for a continuing life of total dependency. CONCLUSIONS: Gestation, if accurately assessed, can give a woman facing very preterm delivery a clear indication of the prognosis for her baby and help her judge the appropriateness of accepting obstetric intervention and sustained perinatal support.

Gestational assessment assessed.

AIMS: To review the accuracy with which obstetric information on gestation is recorded in the neonatal records; and the reliability of the methods used for assessing gestational age after birth. METHODS: Service information on all babies born in 1989, and research information on all babies of < 32 weeks gestation born in the Northern Region in 1990-91, were reviewed to determine the accuracy with which antenatally collected information had been recorded in the neonatal records after birth. A prospective study was also mounted to assess how reliably paediatric staff could assess the gestational age of babies born to mothers with certain obstetric dates under service conditions. Paediatric residents looked at 347 babies of > 32 weeks gestation, and senior staff looked at 105 babies of < 30 weeks gestation. RESULTS: The best techniques for estimating gestation immediately after birth were only half as accurate (95% CI +/- 17 days) as estimates based on antenatal ultrasound at 15-19 weeks gestation. Assessments that relied on the tone, posture, and appearance of the baby at birth in those of < 32 weeks gestation were less reliable than assessments based on a retrospective review of when various reflex responses first appeared. They also tended to overestimate true gestation. Antenatal information of high quality was ignored, and arithmetic and transcription errors were introduced during the transfer of antenatal information into over 10% of postnatal records. CONCLUSIONS: Current ultrasound techniques for "dating" pregnancy antenatally are better than any of the methods of postnatal assessment. Given the reliability of the antenatal information now available, it is regrettable that so many inaccuracies have been allowed to creep into the routine computation and recording of gestation at birth.

Neonatal hypoglycaemia: changing attitudes in the Northern Region.

There has been a recent resurgence of interest in the significance of moderate hypoglycaemia in neonates; although old assumptions have been questioned, there are insufficient data for new and authoritative guidelines to be published. This longitudinal study was designed to test the hypothesis that there have been changes in attitudes among those caring for newborn babies in the 18 maternity units in one health Region. The data were collected by questionnaire in 1986 and 1991, and responses were complete. The results showed a significant shift to higher values in the definition of hypoglycaemia over the five years, in association with a tendency to feed babies earlier--although some units had not altered their policies.

Sonographic and pathological features of callosal hypoplasia in non-ketotic hyperglycinaemia.

A boy was born at 36 weeks' gestation weighing 2450 g. Though his Apgar score was 9 at birth, by the age of 48 hours he required artificial ventilation. He was deeply unconscious with complete lack of muscle tone, and non-ketotic hyperglycinaemia associated with secondary hypoplasia of the corpus callosum was confirmed by biochemical tests. The cranial ultrasound scan features correlated well with the neuropathological findings and may be helpful in the early detection of this incurable condition.

Pregnancy outcome at 24-31 weeks' gestation: mortality.

A study of all the mothers in the Northern region in 1983 whose pregnancies ended at between 24 and 31 weeks' gestation was undertaken. These pregnancies accounted for 1.3% of all the births and 44% of all the fetal and neonatal deaths in pregnancies that lasted more than 23 weeks. Most of the 389 singleton deliveries without malformations between 24 and 31 weeks were caused by spontaneous premature labour (n = 119, 31%), placental abruption (n = 79, 20%), pre-eclampsia (n = 56, 14%), and premature rupture of membranes (n = 48, 12%). The percentages of babies alive at the onset of delivery who survived the neonatal period were 66, 84, 78, and 73, respectively and the percentages of neonatal survivors with severe disabilities were 19, 13, 3, and 6, respectively. A further 65 (17%) of these babies died before the onset of labour for no obvious reason. The mode of delivery did not correlate with the outcome once the period of gestation at delivery was taken into account. The results highlight the inadequacy of the perinatal mortality index currently used in the United Kingdom, which identified 10.7 deaths/1000 registered births in 1983; 20% of the babies delivered at 24-31 weeks were excluded by this index because the birth went unregistered, as were 21% of all the babies born alive who died before discharge. An index that accounted for all babies weighing 500 g or more at birth irrespective of the period of gestation, and all neonatal (0-27 days) deaths, would be more appropriate and would bring reporting more into line with recommended international practice.

Pregnancy outcome at 24-31 weeks' gestation: neonatal survivors.

All surviving babies of less than 32 weeks' gestation born to mothers resident in the Northern region in 1983 were assessed. No baby was lost to follow up, and 230 long term survivors were assessed when 2 years old, by a single observer. Among 248 neonatal survivors, severe disability was present in 10 of the 37 at 24-27 weeks' gestation (27%) and in 18 of the 211 at 28-31 weeks' gestation (9%). On average the surviving babies required 27 days and seven days of intensive care nursing respectively. Babies who were ventilated for more than two weeks and babies who had neonatal fits had a poor prognosis. Because of postneonatal deaths only 20 of the 230 long term survivors of less than 32 weeks' gestation were severely disabled (9%). Comparable data were obtained for all babies weighing 1500 g or less at birth, irrespective of their gestational age. Severe disability was seen in eight of the 49 neonatal survivors (16%) who had weighed 500-999 g at birth, and in 17 of the 171 survivors (10%) who had weighed 1000-1499 g. The 10 neonatal survivors who had weighed exactly 1500 g at birth were all well. Only 18 of the 212 long term survivors (8%) who had weighed 1500 g or less at birth were severely disabled. Because the period of gestation is the only variable known to the obstetrician before delivery, and disability correlates better with gestation than birth weight, future studies should concentrate on relating morbidity, mortality, and the cost of neonatal care to gestation rather than weight at birth.