INTENSIVE CARE AND THE VERY-LOW-BIRTH-WEIGHT INFANT

254 INTENSIVE CARE AND THE VERY-LOW-BIRTH-WEIGHT INFANT SIR,-Dr Jones and her colleagues reportl that the survivalrate and long-term prognosis for infants of very low birthweight (<1500 g) born at Hammersmith Hospital did not improve between 1961 and 1975, despite the introduction of intensive-care methods. Jones et aLl and Dr Gordon (July 7, p. 36) cite data from University College Hospital (U.C.H.)2 in support of their view that intensive care is without demonstrable effect on the mortality or mobidity of very-low-birthweight infants. The publication from U.C.H. referred to dealt only with infants weighing 1000 g or less. Its purpose was to show that the frequency of major handicap (7%) in survivors of this extremely low birthweight admitted to our neonatal unit over the ten-year period 1966-75 was lower than in previous reports

(14-100%). Neither Jones et al.nor Gordon refer to our repeatedly published2-6 mortality data for infants weighing 1001-1500 g. These infants constitute about 70% of the very-low-birthweight ( 1500 g) population. Fig. 1 gives the mortality-rate for infants born at U.C.H. weighing 1001-1500 g and fig. 2 gives 1500 g. Data for England the rate for all infants weighing < and Wales are shown for comparison. Jones R K, Cummins M, Davies P A. Infants of very low birthweight: a 15-year analysis. Lancet 1979; 1: 1332-35. 2. Stewart A L, Turcan D M, Rawlings G, Reynolds E O R. Prognosis for infants weighing 1000 g or less at birth. Arch Dis Child 1977; 52: 97-104. 3. Rawlings G, Reynolds E O R, Stewart A, Strang L B. Changing prognosis for infants of very low birth weight. Lancet 1971; 1: 516-19. 4. Stewart A L, Reynolds E O R. Improved prognosis for infants of very low 1.

birthweight. Pediatrics 1974; 54: 724-35. 5. Blake A M, McIntosh N, Reynolds E O R, St Andrew D. Transport of newborn infants for intensive care. Br Med J 1975; iv: 13-19. 6. Reynolds E O R. Neonatal intensive care and the prevention of major handicap in Major mental handicap: methods and costs of prevention. (Ciba Found Symp 59). Amsterdam; Elsevier, 1978; 77-106.

Intensive-care methods were introduced at U.C.H. at the end of 1965. For example, from then on all infants weighing >1000 g (and many weighing less) were mechanically ventilated if severe respiratory failure developed-providing they did not also have lethal malformations. Fig. 2 shows that the mortality-rate for the whole group of very-low-birthwright infants born at U.C.H. has been below the national rate in every year since 1966. For the past 10 years the U.C.H. mortality rate for infants weighing 1001-1500 g has been approximately half the national rate (fig. 1). When intensive-care methods were introduced at U.C.H., we were worried in case we might salvage increasing numbers of handicapped children. An extensive follow-up study has shown this not to be SO.2-4,7 We do not believe that the experience of Jones et al. at Hammersmith Hospital should be taken as typical of all units providitig intensive care for infants of very low birthweight. Deptartment of Pædiatrics and Obstetrics, University College Hospital and Medical School, London WC1E 6HX

E. O. R. REYNOLDS ANN L. STEWART

SIR,-In their paper Dr Jones and her colleagues show that of 247 babies weighing 1001-1500 g born at Hammersmith Hospital over 15 years, 112 (45%) died within 28 days despite intensive treatment. Of 73 comparable babies born in Salisbury, U.K., in 1969-76 and handled conservatively,’ 27 (37%) died within 28 days. The corresponding figures for the past five years of each series were 42% and 28%, respectively. 17 Salisbury deaths were below 1250 g and 10 above this weight, compared with 76 and 36 respectively, at the Hammersmith. Of the smaller babies 2 were under 28 weeks gestation (26 and 25 weeks), 2 had lethal deformities, 6 prolonged apnoea at birth, and 3 had intracranial damage; there were 3 second twins. Of the heavier babies, 1 had renal agenesis, 2 (1 a quadruplet) had prolonged apnoea at birth, and 2 had tentorial tears; 1 was a first twin born by the breech after prolonged prolapse of the cord, and 1 had repeated apnoea; 2 were born at home without help and came in cold and moribund, and 1 died in his cot after discharge home. There is considerable room for improvement, but these results suggest that help before birth is likely to be more effective than a wider spread of intensive care, and that we should heed the Hammersmith workers’ call for further study. Central

Hospital, Honiara, Solomons Islands

Fig. I-Neonatal-mortality rates for infants born in U.C.H. weighing 1001-1500 g during 1963-78 (n=307), and for those born in England and Wales.

National 1963.

figures

for this

weight-group

were not

available before

SiR,-We were interested to read the 15-year analysis by Dr Jones and her colleagues (June 23, p. 1332) of the outcome of infants of very low birthweight (VLBW) born at the Hammersmith Hospital between 1960 and 1975. At the same time we were anxious lest those with less experience than these workers might draw conclusions not necessarily supported by the summarised and limited data provided. Our anxiety was warranted : in his letter of July 7 (p. 36) Dr Gordon concludes that "superintensive care ... does not improve survival in these infants". Then, having compared the incidence of cerebral palsy in his own "non-superintensive unit" with that for all forms of handicap at the Hammersmith, he argues against the provision of neonatal intensive care for these infants. We would like to explain why we disagree most strongly with this view. Most major units in the U.K. struggled, first to introduce special care for newborn infants during the 1960s, and then intensive care during the 1970s. The Hammersmith Hospital 7. Sewart

A, Turcan D, Rawlings G, Hart S, Gregory S. Outcome for infants

risk of mayor handicap. In: Major mental handicap: methods and of prevention Ciba Found Symp 59. Amsterdam; Elsevier, 1978: 151-64. 1. Hughes-Davies TH. Conservative care of the newborn baby. Arch Dis Child at

high

costs

for infants born in U.C.H. Fig. 2-Neonatal-mortality weighing 1500 g during 1960-78 (n=478), and for those born in England and Wales. rates

T. H. HUGHES-DAVIES

1979; 54: 59-61.

255 was an

exception. There, special care was put on a sound foot-

in the 1950s under the direction of Prof. Peter Tizard. Furthermore, when he and nearly all the senior members of his staff left the hospital in 1972, the establishment of intensive care must have received a setback. Thus, at the Hammersmith, a less striking improvement in outcome than usual might have been expected over the period 1960-75. Even more important, the technological advances of the early 1970s that permitted a dramatic improvement in survival of the larger infants that make up two-thirds of neonatal intensive care, only became

ing

to make a real impact on the VLBW infants after 1975.’ In our own unit the survival of VLBW infants rose to 78% in 1978, the greatest improvement being among infants having a gestational age of less than 30 weeks. This is important, for in the past a high proportion of surviving VLBW infants were small for gestational age and born after 30 weeks. Indeed, one of the main strategies of obstetrics in recent years has been the antenatal detection and premature delivery of such infants. Unfortunately, a proportion will already have received a handicapping insult by the time they are born. In the Hammersmith series 15 (74%) of the 19 handicapped VLBW children were born to women with significant antenatal or intrapartum complications, and at least 12 (63%) were small for gestational age (using Bristol standards, 84% were small for gestational age). In addition, 7 infants (37%) were asphyxiated at birth. Thus it seems likely that a high proportion of the handicaps were sustained before special or intensive care was started. Our conclusion would be that the Hammersmith data provide a powerful vindication for the provision of good newborn care. 5-3% of these very vulnerable infants were found to have major handicap. However, this group included a case of Turner’s syndrome, a Russell-Silver dwarf, and a case of congenital rubella. If these three children are excluded, then 9 (56%) of the remaining 16 children are apparently able to attend a normal school; only 1 is severely educationally subnormal. Over a fifteen-year period this is a remarkable achievement, especially when contrasted with the disappointing results of earlier years. 2,3

NEONATAL MORTALITY-RATES FOR INFANTS WEIGHING LESS THAN AND NEW HAMPSHIRE 1500 g IN VERMONT

(NH)

(VT)

INTENSIVE-CARE NURSERIES

sophisticated enough

Department of Child Health, and Department of Pædiatrics, University of Bristol, Southmead Hospital, Bristol BS10 5NB

,

, .

,

,

Department of Paediatrics University of Vermont Burlington, Vermont 05405,

U.S.A.

ALISTAIR G. S. PHILIP

PERINATAL MORTALITY P. M. DUNN B. D. SPEIDEL P. J. FLEMING

at the effect or approwhether or not infants were small and of birth weight priate for gestational age. Dr Gordon’s letter compounds the problem by focusing only on birthweight as it relates to mortality. As Lubchenco has pointed out the important consideration is birthweight/gestational-age categories. To lump together all babies under 1500 g (as Gordon does) is a gross simplification of a complex problem. Surely the best assessment of "superintensive care" is what happens to the baby who reaches an intensive-care nursery. In the period 1976-78, two intensive-care nurseries were closely linked by the Vermont/New Hampshire Regional Perinatal Program. During this time the mortality-rate for babies less than 1500 g in Burlington, Vermont, was 44/178 (24.7%), while in Hanover, New Hampshire, it was 74/210 (35.2%). The apparently better results in Burlington are seen to be due to bias in the referral population when birthweight/gestational-age groupings are examined (table). It also suggests that "modern" intensive care (1976-78 may be improving, with a survival-rate of 41% between 500 and 999 g (compare the

SIR,-Dr Jones and her colleagues looked only

.

13% figure at the Hammersmith, 1971-75), but without gestational age categories a valid comparison is not possible. In addition, of our inborn deliveries at the Medical Center Hospital of Vermont in Burlington, the neonatal mortalityrate for babies less than 1500 g has declined from 64% (36/46) to 37% (23/63) between 1975-76 and 1977-78. When those immature babies who died in the delivery room are excluded, those babies who were admitted to our intensive-care nursery had neonatal mortality-rates of 62% and 29%, respectively, for 1975-76 and 1977-78. While I cannot dispute the fact that we should be trying to prevent spontaneous premature labour, I believe that intensive care for the very-low-birthweight infant has played a significant part in reducing mortality. Perhaps more importantly it has improved the survival and outcome of infants who are somewhat larger or more mature (the combined neonatal mortality rate for infants weighing 1500-1999 g in Vermont/New Hampshire, 1976-78 was 11/355 (3-1%) in those admitted to intensive-care nurseries).

1. Bowes WA, Halgrimson M, Simmons MA. In: Preterm labour: proceedings of 5th study group, Royal College of Obstetricians and Gynæcologists. London: R.C.O.G., 1978 331-55. 2. Drillien CM. Pediatrics 1967; 39: 238. 3. Lubehenco LO, Searls DT, Brazie JV J. Pediat 1972; 81: 814. 4. Lubchenco LO. Intra-uterine growth and neonatal morbidity and mortality. In: The High Risk Infant: Philadelphia: WBE Saunders, 1976: chap 4.

SIR,-In your note on the Children’s Committee’s discussion document The Reduction of Perinatal Mortality and Morbidity (June 30, p. 1416) the perinatal mortality-rate (PMR) you cited as that for 1976, 19.3 per 1000 total births, was in fact that for 1975. The rate in England and Wales for 1976 was 17.7 per 1000 births. Since then the rate has continued to fall. It was 17.0 in 1977. The figure for England and Wales has yet to be published for 1978, but in England alone the PMR was 15-4 per 1000 births. So, if the differential seen in previous years was maintained, it is likely that the PMR for England and Wales in 1978 was about 15-5per 1000 births. PERINATAL MORTALITY IN ENGLAND AND WALES

*Estimated.

The percentage fall in perinatal years for which data are complete,

mortality over the last five can be compared with that