Unni Wariyar

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. Key messages Children seen for review without difficulty in any study of community prevalence are seldom representative of those who are not assessed Failure to review those who prove difficult to trace introduces less bias than failure to review those who prove difficult to review once traced Studies where it is not possible to see some children for assessment might usefully include a calculation of what the total prevalence would be if there was a fivefold difference in the proportion with the condition in question among the children who were not seen Parental support for any such study can nearly always be obtained if an effort is made to make the family feel, from the outset, that they are partners in a collaborative exercise of genuine worth

Behavioral and Emotional Adjustment of Teenagers in Mainstream School Who Were Born Before 29 Weeks’ Gestation

Objectives. To investigate behavioral and emotional problems and positive adjustment of 15-to 16-year-olds who were born at extremely low gestational age (ELGA), from the perspective of parents, teachers, and teenagers. Methods. Prospective follow-up was conducted of birth cohorts, with classroom control subjects. All infants who were born before 29 weeks in 1983–1984 (mean gestational age: 27 weeks) to mothers who resided in 3 regions of the United Kingdom were studied. A total of 82% (179 of 218) of survivors were traced at age 15 to 16. The 150 in mainstream school were compared with age- and gender-matched classroom control subjects (n = 108). Behavioral and emotional problems, delinquency, peer relations, self-esteem, and hobbies, were assessed by standardized, well-validated instruments, including the Strengths and Difficulties Questionnaire, administered by mail to parents, teenagers, and teachers. Results. Parents were more likely to rate ELGA teenagers than control subjects as in the “abnormal” range for hyperactivity (8% vs 1%; difference: 7%; (95% confidence interval [CI]: 2–12), peer relationship problems (19% vs 5%; difference: 14%; 95% CI: 6-21), and emotional problems (18% vs 7%; difference: 11%; 95% CI: 3-19), but not conduct problems (10% vs 5%; difference: 5%; 95% CI: −1 to 12)). Teachers reported a similar pattern. In contrast, compared with control subjects, ELGA teenagers did not rate themselves as having more problems with peers, hyperactivity, conduct, depression, or low self-esteem. They reported more emotional problems but less delinquency, alcohol, cannabis, and other drug use. Conclusions. Compared with mainstream classmates, children who are born extremely early continue to have higher levels of parent- and teacher-reported emotional, attentional, and peer problems well into their teens. However, despite these problems, they do not show signs of more serious conduct disorders, delinquency, drug use, or depression.

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.

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. Key messages The best techniques for estimating gestation immediately after birth are only half as accurate (95% CI ± 17 days) as estimates based on antenatal ultrasound Such estimates are even less accurate than this in babies of less than 30 weeks gestation Documenting when various reflexes appear can provide a better retrospective estimate of gestation in the preterm baby than methods based on posture, tone and physical appearance The transfer of obstetric information relating to gestation into the neonatal record is frequently faulty; such records were in error by > one week in 15% of preterm babies entered into one recent multi-centre research study, and 92% of the errors involved an under recording of gestation More care should be taken over collecting obstetric information relating to gestation at birth, given its potential value

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 K1) 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 α1 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.

Preventing late bleeding in infants with vitamin K deficiency

Editor-The wisdom of using intramuscular vitamin K has become an issue for debate again. Oral and intramuscular prophylaxis both prevent early bleeding, but oral prophylaxis is poor at eliminating late bleeding (between 8 and 90 days after birth) unless treatment is repeated at intervals (1 2-a finding consistent with evidence that intestinal uptake is improved when babies are offered several small, rather than fewer large, oral doses of vitamin K.3 It is also consistent with the suggestion that intramuscular prophylaxis works not because it bypasses poor …