Increased mortality of preterm infants transferred between tertiary perinatal centres.

Over 18 months almost one quarter of infants born before 30 weeks'' gestation in a tertiary perinatal centre who required intensive care had to be transferred to other tertiary centres because intensive care facilities were fully occupied. When infants with lethal congenital malformations were excluded half of the 34 infants who were transferred died; this was twice the mortality (24%) in the 111 infants remaining. The difference between the groups was significant (relative odds = 3.1) and remained so after adjustment for any discrepancies in gestational age (relative odds = 4.0). After adjustment for potential confounding variables by logistic function regression the risk of dying for those transferred remained significantly higher than that for infants who remained (relative odds = 4.6, 95% confidence interval 1.8 to 12.1). As the requirement for neonatal intensive care is episodic and unpredictable more flexibility has to be built into the perinatal health care system to enable preterm infants delivered in tertiary perinatal centres to be cared for where they are born.     

Referral of mothers and infants for intensive care.

During 1975-7, 96 mothers were referred to University College Hospital for delivery from 39 other hospitals because their pregnancies were considered to be at very high risk. One hundred of the 111 infants born to the 96 mothers weighed 2500 g or less and 60 weighed 1500 g or less. A high proportion of the infants developed serious illnesses necessitating intensive care. The birth-weight-specific neonatal mortality rates of the infants were much lower than those of infants born in England and Wales as a whole and were also lower than those of the 370 infants transported to this hospital for intensive care after delivery elsewhere. Whenever possible mothers with very high-risk pregnancies should be referred for delivery to centres with full facilities for the intensive care of the mother, fetus, and newborn infant.     

Effectiveness of neonatal transport.

The condition of 259 infants transferred to the neonatal intensive care unit (NICU) of the Montreal Children''s Hospital from Oct. 1, 1974 to Mar. 31, 1975 was evaluated. Their transport was provided by personnel and equipment from the Montreal Children''s Hospital. When the transport team arrived at the referring hospital hypothermia (temperature of less than 36 degrees C) was present in 25.2% of the 163 infants for whom complete temperature measurements were available. Most (77.3%) of the infants were warmed during transport and only 3.1% arrived at the NICU with a temperature of less than 35 degrees C. The mortality was significantly higher in babies of all birth weight groups whose core temperature had been below the optimal temperature for survival (36 to 37 degrees C). It appears that the use of appropriate equipment and trained personnel can reduce the incidence of hypothermia and therefore the mortality in infants requiring transfer.     

Treatment of the terminal stages of breast cancer.

To assess the intensity of and changes in diagnostic investigations and treatment in the terminal stages of breast cancer 555 patients in the area of Tampere University Central Hospital in whom breast cancer had been diagnosed from 1977 to 1980 were followed up for five years. The case notes for the last visit of 519 patients were analysed. The amount of diagnostic activity was similar for those who died and for the survivors. A higher proportion of women who died than of women who survived received treatment at the last follow up visit, and 2.6 times as many of those dying within one week of the last visit were given chemotherapy as were survivors with recurrent disease. Resources devoted to diagnostic investigations and treatment of cancer in terminally ill patients could be better used for care of the patients. This would be more likely to improve the patients'' quality of life and conserve resources.     

Body fat of British and Dutch infants.

The fatty acids in the body fat of 41 British and 37 Dutch infants between birth and 1 year were determined. At birth linoleic acid contributed 1-3% of the total fatty acids of the body fat in infants in both countries. By one month its proportion in the fat of the Dutch infants was about 25% and by four months 32-37%; in the fat of the British infants it was never more than 3%. In the Dutch infants this large increase in the linoleic acid percentage was accompanied by a fall in the percentage contribution of others, particularly the saturated acids myristic, palmitic, and stearic. Infants born preterm showed changes in their fat after birth similar to those in fullterm infants. The difference between the composition of the fat of the infants in the two countries is attributed to the nature of the fat in the milk they received. Until recently most British infants who are not breast-fed have been given milks based on cow''s milk with only minor modifications. For the past 10 years many Dutch infants have been given a milk in which all the cow''s milk fat has been replaced by maize oil. Dutch infants also had a lower concentration of cholesterol in their serum than British infants, which was not unexpected. The results show that the triglycerides in the adipose tissue are profoundly influenced by the nature of the fat in the diet.     

Congenital heart disease and prenatal exposure to exogenous sex hormones.

One-hundred and four infants with congenital heart disease were identified from their birth certificates and matched with normal controls. Their gestational histories were examined to see whether they had been exposed to exogenous sex hormones. Exposure was 8-5 times more common among the infants with malformations than among controls. A history of hormone exposure was more common among those patients with multiple malformations, and the exposed infants were also more likely to have died (and to have died earlier) than those who had not been exposed, which suggests that hormone exposure causes severe types of malformations. The commonest type of exposure was to hormone pregnancy tests, which was needless exposure. Only two of the mothers of malformed infants had inadvertently used oral contraceptives in the first trimester.     

Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life.

OBJECTIVE--To assess the relations between early introduction of solid food and infant weight, gastrointestinal illness, and allergic illnesses during the first two years of life. DESIGN--Prospective observational study of infants followed up for 24 months after birth. SETTING--Community setting in Dundee. PATIENTS--671 newborn infants, of whom 455 were still available for study at 2 years of age. MAIN OUTCOME MEASURES--Infants'' diet, weight, and incidence of gastrointestinal illness, respiratory illness, napkin dermatitis, and eczema at 2 weeks and 2, 3, 4, 6, 9, 12, 15, 18, 21, and 24 months of age. RESULTS--The infants given solid food at an early age (at < 8 weeks or 8-12 weeks) were heavier than those introduced to solids later (after 12 weeks) at 4, 8, 13, and 26 weeks of age (p < 0.01) but not at 52 and 104 weeks. At their first solid feed those given solids early were heavier than infants of similar age who had not yet received solids. The incidence of gastrointestinal illness, wheeze, and nappy dermatitis was not related to early introduction of solids. There was a significant but less than twofold increase in respiratory illness at 14-26 weeks of age and persistent cough at 14-26 and 27-39 weeks of age among the infants given solids early. The incidence of eczema was increased in the infants who received solids at 8-12 weeks of age. CONCLUSION--Early introduction of solid food to infants is less harmful than was previously reported. Longer follow up is needed, but, meanwhile, a more relaxed approach to early feeding with solids should be considered.     

Air transport of infants in Newfoundland and Labrador.

Air transportation of 33 infants in small unpressurized aircraft over long distances is described. Twenty-six of the infants were transported more than 320 km in environmental temperatures varying from -35 to +21 degrees C. A commercially available incubator was used. Although more than half the infants had a rectal temperature within the normal range at the time of arrival at hospital, 12 infants had rectal temperatures above 37.5 degrees C as a result of efforts to diminish heat loss. Adequate oxygenation of infants at 3000 m in unpressurized aircraft can be difficult. Cold and vibration can affect equipment, and at high altitudes the readings from oxygen analysers may not be true. The use of an expanded transport team, which includes experienced nonmedical personnel, is particularly important in these cases.     

Prenatal risk assessment and obstetric care in a small rural hospital: comparison with guidelines.

An assessment was made of the potential usefulness in a small rural hospital of the guidelines for prenatal risk assessment and management of the Newfoundland and Labrador Prenatal Record, a form similar to that in use in other provinces. A retrospective chart review was done for 266 pregnancies followed at the Baie Verte Peninsula Health Centre prior to the introduction of the guidelines. The pattern of practice was to request consultation and to transfer patients for delivery less often than was suggested by the guidelines; only 32% of patients at risk were assessed by an obstetrician. By the time of delivery only 39% of the patients were at no predictable risk according to the guidelines. Nevertheless, neonatal morbidity was present in this group (4% of the infants had an Apgar score of 6 or less at 1 or 5 minutes), though less often than in those at risk (18% of the infants had a low Apgar score). However, the group at no predictable risk required nonelective intervention in 40% of cases, approximately the same rate as that for the group at risk. It is necessary for some small hospitals to have the facilities and the trained staff to handle the problems that occur even in low-risk patients. To maintain the delivery rate necessary to retain skills, the guidelines may help family practitioners and consulting obstetricians to select some patients at risk who can be managed in small hospitals.     

Nutritional services during pregnancy and birthweight: a retrospective matched pair analysis.

Since 1963, unselected prenatal patients at the Royal Victoria Hospital, Montreal, have been given nutritional counselling and, if it was judged necessary, dietary supplementation by the Montreal Diet Dispensary. From uniform data collected for all obstetric patients in 1963--74, 1213 recipients of the dispensary services (89.7% of those available and eligible for matching) were paired with controls matched for date of delivery (within 12 months), religious affiliation, parity, trimester of pregnancy during which prenatal care was begun and weight at the time of conception. The proportion of infants of low birthweight (less than 2500 g) was 5.7% for the recipients and 6.8% for the controls; the difference was not significant, but the recipients'' infants were heavier at birth than the controls'' infants, by an average of 40 g (P less than 0.05). The difference in birthweight was greatest for the infants of women in their first pregnancy (average 61 g) and least for the infants of women with three or more past deliveries (average 9 g). Increased birthweight (by an average of 53 g, P less than 0.02) among the recipients'' infants was limited to those born to women weighing less than 140 lb (63 kg) at the time of conception; among the heavier women the controls had infants who were heavier, but not significantly so. Differences between the groups in duration of gestation and maternal weight gain accounted for only a small part of these differences in birthweight. This study provides evidence that the Montreal Diet Dispensary program significantly increased birthweight. Further efforts must now be directed towards judging the long-term benefit of these changes.     

Thermal environment and sudden infant death syndrome: case-control study.

OBJECTIVE--To compare the thermal environment of infants who died of the sudden infant death syndrome with that of age matched control infants. DESIGN--Case-control study. Infants who died were matched with two controls, one for age and one for age and birth weight. Thermal measurements were conducted at the death scene for cases and at the scene of last sleep for control infants, who were visited unexpectedly within four weeks of the index infant''s death on a day of similar climatic conditions. A follow up questionnaire was administered to parents of cases and controls. SETTING--The geographical area served by the professional Tasmanian state ambulance service, which includes 94% of the Tasmanian population. SUBJECTS--41 infants died of the sudden infant death syndrome at home; thermal observations at death scene were available for 28 (68%), parental questionnaire data were available for 40 (96%). 38 controls matched for age and 41 matched for age and birth weight. RESULTS--Cases had more excess thermal insulation for their given room temperature (2.3 togs) than matched controls (0.6 togs) (p = 0.009). For every excess thermal insulation unit (tog) the relative risk of the sudden infant death syndrome was 1.26 (95% confidence interval 1.05 to 1.52). The average thermal bedding value calculated from parental recall was similar to that observed by attendant ambulance officers (mean difference = 0.4 tog, p = 0.39). Cases were more likely to have been found prone (odds ratio 4.58; 1.48 to 14.11). Prone sleeping position was not a confounder or effect modifier of the relation between excess thermal insulation and the syndrome. CONCLUSIONS--Overheating and the prone sleeping position are independently associated with an increased risk of the sudden infant death syndrome. Further work on infant thermal balance and sudden infant death is required and guidelines for appropriate infant thermal care need to be developed.     

What Happens to Patients on Antiretroviral Therapy Who Transfer Out to Another Facility?

Background

Long term retention of patients on antiretroviral therapy (ART) in Africa''s rapidly expanding programmes is said to be 60% at 2 years. Many reports from African ART programmes make little mention of patients who are transferred out to another facility, yet Malawi''s national figures show a transfer out of 9%. There is no published information about what happens to patients who transfer-out, but this is important because if they transfer-in and stay alive in these other facilities then national retention figures will be better than previously reported.

Methodology/Principal Findings

Of all patients started on ART over a three year period in Mzuzu Central Hospital, North Region, Malawi, those who transferred out were identified from the ART register and master cards. Clinic staff attempted to trace these patients to determine whether they had transferred in to a new ART facility and their outcome status. There were 805 patients (19% of the total cohort) who transferred out, of whom 737 (92%) were traced as having transferred in to a new ART facility, with a median time of 1.3 months between transferring-out and transferring-in. Survival probability was superior and deaths were lower in the transfer-out patients compared with those who did not transfer.

Conclusion/Significance

In Mzuzu Central Hospital, patients who transfer-out constitute a large proportion of patients not retained on ART at their original clinic of registration. Good documentation of transfer-outs and transfer-ins are needed to keep track of national outcomes. Furthermore, the current practice of regarding transfer-outs as being double counted in national cohorts and subtracting this number from the total national registrations to get the number of new patients started on ART is correct.     

Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study.

OBJECTIVE--To determine the relation between sleeping position and quantity of bedding and the risk of sudden unexpected infant death. DESIGN--A study of all infants dying suddenly and unexpectedly and of two controls matched for age and date with each index case. The parents of control infants were interviewed within 72 hours of the index infant''s death. Information was collected on bedding, sleeping position, heating, and recent signs of illness for index and control infants. SETTING--A defined geographical area comprising most of the county of Avon and part of Somerset. SUBJECTS--72 Infants who had died suddenly and unexpectedly (of whom 67 had died from the sudden infant death syndrome) and 144 control infants. RESULTS--Compared with the control infants the infants who had died from the sudden infant death syndrome were more likely to have been sleeping prone (relative risk 8.8; 95% confidence interval 7.0 to 11.0; p less than 0.001), to have been more heavily wrapped (relative risk 1.14 per tog above 8 tog; 1.03 to 1.28; p less than 0.05), and to have had the heating on all night (relative risk 2.7; 1.4 to 5.2; p less than 0.01). These differences were less pronounced in the younger infants (less than 70 days) than the older ones. The risk of sudden unexpected death among infants older than 70 days, nursed prone, and with clothing and bedding of total thermal resistance greater than 10 tog was increased by factors of 15.1 (2.6 to 89.6) and 25.2 (3.7 to 169.0) respectively compared with the risk in infants of the same age nursed supine or on their side and under less than 6 tog of bedding. CONCLUSIONS--Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days. Educating parents about appropriate thermal care and sleeping position of infants may help to reduce the incidence of the sudden infant death syndrome.     

Can Marmoset Mothers Count to Three? Effect of Litter Size on Mother–Infant Interactions

Harper (Parental Care in Mammals, Plenum Press, New York, 1981, p. 158) proposed that ‘there may be lower and upper limits for frequency or intensity of offspring stimulation that, on average, serve as reliable boundaries, below or above which it would be uneconomical to invest at all or at current levels.‘ This proposition was tested in captive common marmosets by comparing the responses of marmoset mothers exposed to differing number of infants. Fifteen common marmoset (Callithrix jacchus) litters (seven twin and eight triplet litters) from 11 different dams were observed for 6–12, 30‐min sessions over days 1–4 following birth. Mothers nursed smaller infants less frequently (F = 4.208, df = 1, 22; p = 0.052) regardless of litter size. The percent time mothers spent transporting (nursing and carrying) each infant was less for triplets than twins (F = 11.785, df = 1, 12; p = 0.005). Average transport bout length was significantly shorter for smaller infants (F = 7.566, df = 1, 22; p = 0.012) and was half as long for triplet infants as for twins (F = 10.733, df = 1, 7; p = 0.013). Twice as many transport bouts for triplets included maternal harassment of infants, than for twins (F = 42.742, df = 1, 24; p = 0.0001). Infant‐initiated transfers to the mother were more common for triplets than for twins (Mann–Whitney U = 79.50, p = 0.006). The overall maternal carrying score (% carry × number of infants carried) was lower for triplet litters than for twin litters (F = 15.38, df = 1, 3; p = 0.029); i.e. mothers of triplets did not, overall, invest in more carrying and nursing than did mothers of twins but instead invested less. These findings suggest that, as opposed to the strong attraction to infants that is common for many primates, the marmoset mother's tolerance for carrying infants does not increase with increasing infant stimuli present; rather, marmoset mothers will only tolerate a limited amount of time transporting and nursing infants, regardless of litter size. This limited tolerance may be due to the species’ small body size and anti‐predator strategies (e.g. concealment) that make infant care incompatible with other essential activities, such as foraging.     

Attitudes to viability of preterm infants and their effect on figures for perinatal mortality.

OBJECTIVE--To examine how local attitudes to management of extreme preterm labour can influence data on perinatal mortality. DESIGN--One year prospective study in a geographically defined population. SETTING--The 17 perinatal units of Trent region. PATIENTS--All preterm infants of less than or equal to 32 weeks'' gestation in the Trent region. INTERVENTIONS--Infants who had been considered viable at birth were referred for intensive care; those who had been considered non-viable received terminal care. MAIN OUTCOME MEASURES--Whether each infant was born alive, dead, or alive but considered non-viable. RESULTS--Large differences were observed among units in the rates of delivery of infants of less than or equal to 27 weeks'' gestation (rates varied from 7.2 to 0 per 1000 births). These differences were not present in the data relating to infants of between 28 and 32 weeks'' gestation. The variation seemed to result from different approaches to the management of extreme preterm labour--that is, whether management took place in a labour ward or a gynaecology ward. CONCLUSIONS--Place of delivery of premature babies (less than or equal to 27 weeks'' gestation) may influence classification and hence figures for perinatal mortality. In addition, the fact that the onus of judgment regarding viability and classification is often placed on relatively junior staff might also affect the figures for perinatal mortality. The introduction of a standard recording system for all infants greater than 500 g would be advantageous.     

Thermal characteristics of wild and captive Micronesian kingfisher nesting habitats

To provide information for managing the captive population of endangered Guam Micronesian kingfishers (Halcyon cinnamomina cinnamomina), four biologically relevant thermal metrics were compared among captive facilities on the United States mainland and habitats used by wild Micronesian kingfishers on the island of Pohnpei (H. c. reichenbachii), Federated States of Micronesia. Additionally, aviaries where kingfishers laid eggs were compared to those in which birds did not attempt to breed. Compared to aviaries, habitats used by wild Pohnpei kingfishers had 3.2°C higher daily maximum and minimum temperatures and the proportion of time when temperatures were in the birds' thermoneutral zone was 45% greater. No differences were found in the magnitude of temperature fluctuation in captive and wild environments. In captive environments in which birds bred, daily maximum temperatures were 2.1°C higher and temperatures were within the thermoneutral zone 25% more often than in the aviaries where the kingfishers did not breed. No differences were found in the magnitude of temperature fluctuation or the daily minimum temperature. Results suggest that the thermal environment has the potential to influence reproduction, and that consideration should be given to increasing temperatures in captive breeding facilities to improve propagation of the endangered Micronesian kingfisher. Zoo Biol 23:301–308, 2004. Published 2004 Wiley‐Liss, Inc.     

Hospital care for the elderly in the final year of life: a population based study.

OBJECTIVES--To determine whether among people aged 65 and over those who died at advanced old age spent more of their last year of life in hospital than those who died younger, and whether the increase in longevity in the elderly between 1976 and 1985 was accompanied by increased time spent in hospital in the last year of life. DESIGN--Linkage of death records to abstracts of records of hospital inpatient care in the preceding year of patients'' lives. SETTING--Six health districts in England covered by the Oxford record linkage study. RESULTS--People who died at advanced ages (85 and over) were less likely than people who died at younger ages (65-84) to have been admitted to hospital in the last year of life. Once admitted the very old tended to spend longer in hospital than others. The mean total time spent in hospital by the elderly in the year before death (based on all deaths including those among people not admitted at all) showed no appreciable change over time. The median time in hospital based on all deaths increased by about three days between 1976 and 1985. During that time there was a gain in life expectancy in the population of about one year from the age of 65. CONCLUSION--The gain in life expectancy in this population was not at the expense of any substantial increase in time spent in hospital in the final year of life.     

Spontaneous preterm labour and delivery at under 34 weeks' gestation.

The management and outcome of 242 infants delivered between 26 and 34 weeks'' gestation in an obstetrical and neonatal regional referral centre as a result of spontaneous preterm labour were recorded prospectively. Results of the survey show that the decision to intervene and delay delivery will depend on the availability of neonatal intensive care facilities. Infants likely to require intensive neonatal care should be transferred in utero to a centre with these facilities. The use of steroids reduces the mortality of preterm infants. The maximum effect occurs between 30 and 32 weeks'' gestation, and there is no benefit after 34 weeks. If the weight is over 1500 g the mode of delivery of the preterm infant presenting by the breech does not influence outcome; if under 1500 g a caesarean section improves survival over those infants born by vaginal breech delivery.     

Maternal fatness and viability of preterm infants

To investigate the effect of maternal fatness on the mortality of infants born preterm up to the corrected age of 18 months 795 mother-infant pairs were studied. Maternal fatness was defined by Quetelet''s index (weight/(height²)) and all infants weighed less than 1850 g at birth. In 771 mother-infant pairs maternal age, complications of pregnancy, mode of delivery, parity, social class, and the baby''s sex and gestation were analysed by a logistic regression model for associations with infant mortality (but deaths from severe congenital abnormalities and those occurring during the first 48 hours after birth were excluded). In a subgroup of 284 mother-infant pairs all infant deaths except those from severe congenital abnormalities were analysed in association with the infant''s birth weight and gestation and the mother''s height and weight; this second analysis included another 24 infants who had died within 48 hours after birth. In the first analysis mortality overall was 7% (55/771), rising from 4% (71/173) in thin mothers (Quetelet''s index <20) to 15% (6/40) in mothers with grades II and III obesity (Quetelet''s index >30). After adjusting for major demographic and antenatal factors, including serious complications of pregnancy, maternal fatness was second in importance only to length of gestation in predicting death of infants born preterm. In the second analysis mortality overall was 15% (44/284), rising from 9% (5/53) in thin mothers to 47% (8/17) in mothers with grades II and III obesity. In both analyses the relative risk of death by 18 months post-term was nearly four times greater in infants born to obese mothers than in those born to thin mothers. In addition, maternal fatness was associated with reduced birth weight, whereas it is associated with macrosomia in term infants.These data differ fundamentally from those reported in full term babies of obese mothers. It is speculated that the altered metabolic milieu in obesity may reduce the ability of the fetus to adapt to extrauterine life if it is born preterm.     

Provision of facilities for secondary transport of seriously ill patients in the United Kingdom

A survey by questionnaire of 280 hospitals with general intensive care units was carried out to find out what facilities were provided for secondary transport of seriously ill patients in the United Kingdom. Replies were received from 181 units. Extrapolating from the survey data showed that about 10 000 patients were transported each year, although many units transferred only a few patients. An appreciable minority of units reported that facilities for secondary transport were inadequate and many were obliged to send inexperienced medical staff with patients. Almost half of the respondents thought that arrangements for transfer were unsatisfactory, but only a tenth said that they delayed or refused transfer for this reason. This undoubtedly reflects a policy of “making do” despite inadequate resources.We believe that these results support the concept of regional transport services, where each major unit would be adequately equipped and staffed and unnecessary duplication of resources avoided.