Social deprivation and the causes of stillbirth and infant mortality

AIMS

To investigate the relation between social deprivation and causes of stillbirth and infant mortality.

METHODS

Stillbirths and infant deaths in 6347 enumeration districts in Wales were linked with the Townsend score of social deprivation. In 1993-98 there were 211 072 live births, 1147 stillbirths, and 1223 infant deaths. Poisson regression analysis was used to estimate the magnitude of effect for associations between the Townsend score and categories of death by age and the causes of death. The relative risk of death between most and least deprived enumeration districts was derived.

RESULTS

Relative risk of combined stillbirth and infant death was 1.53 (95% CI 1.35 to 1.74) in the most deprived compared with the least deprived enumeration districts. The early neonatal mortality rate was not significantly associated with deprivation. Sudden infant death syndrome showed a 307% (95% CI 197% to 456%) increase in mortality across the range of deprivation. Deaths caused by specific conditions and infection were also associated with deprivation, but there was no evidence of a significant association with deaths caused by placental abruption, intrapartum asphyxia, and prematurity.

CONCLUSIONS

Collaborative public health action at national and local level to target resources in deprived communities and reduce these inequalities in child health is required. Early neonatal mortality rates and deaths from intrapartum asphyxia and prematurity are not significantly associated with deprivation and may be more appropriate quality of clinical care indicators than stillbirth, perinatal, and neonatal mortality rates.

Influence of antenatal steroids and sex on maturation of the epidermal barrier in the preterm infant

BACKGROUND

The epidermal barrier is well developed in term infants but defective in the immature infant with important clinical consequences. The development of the barrier shares similarities with production of pulmonary surfactant. Studies in the rat have shown that barrier maturation is accelerated by antenatal steroids, both structurally and functionally. Females have a more mature barrier than males at the same gestational age. These factors have not been studied in the human.

AIM

To examine the influence of antenatal steroids and sex on maturation of the epidermal barrier in the preterm infant.

SUBJECTS

A total of 137 infants born before 34 weeks gestation, 80 boys and 57 girls, were studied: 87 had been exposed to antenatal steroids, and 50 had not; 99 were studied prospectively, and 38 had been studied previously.

METHOD

Barrier function was measured as transepidermal water loss from abdominal skin by evaporimetry. Measurements were made within the first 48 hours and corrected to a standard relative humidity of 50% (TEWL(50)).

RESULTS

The relation between TEWL(50) and gestation was exponential with very high levels in the most immature infants. No influence of antenatal steroids or sex could be shown. When infants who were optimally exposed to antenatal steroids were considered alone, no effect could be shown.

CONCLUSION

Epidermal maturation in the preterm infant does not appear to be influenced by antenatal steroids or sex, suggesting that the mechanism of maturation differs from that of the rat.

Maternal cigarette smoking and pregnancy outcome

Maternal smoking rates in pregnancy have declined, particularly in the non-manual social classes, and perinatal mortality rates have fallen over the last 20 years. We have therefore re-evaluated the relationship between maternal cigarette smoking and pregnancy outcome against this background. A total of 608 stillbirths and 634 infant deaths were identified using the All Wales Perinatal Survey. The cause of death was classified using the clinicopathological system. Maternal smoking rates and social class groupings were compared with those in a cohort of 16047 survivors born to women resident in South Glamorgan. The smoking rate was 37.8% in mothers of babies who died compared with 27.2% in mothers of survivors, an odds ratio (OR) of 1.63 [95% CI 1.44, 1.84]. The OR for unexplained stillbirth was 1.72 [95% CI 1.38, 2.13], placental abruption 2.07 [95% CI 1.29, 3.31], infection 3.70 [95% CI 2.23, 6.13] and sudden infant death syndrome 4.84 [95% CI 3.05, 7.69]. Maternal smoking was not associated with death due to prematurity or a congenital anomaly. Despite changes in smoking habits and the causes of perinatal death, smoking during pregnancy continues to be strongly associated with fetal and infant mortality. It is important that health promotion activities are effective in reducing smoking during pregnancy.

Confidential enquiry into deaths due to prematurity

The aim of this study was to audit the management of neonatal respiratory distress syndrome (RDS) in a geographically defined population using a retrospective peer review of case notes. The subjects were 49 infants of 24-36 wk gestation with a birthweight >499 g, and dying as a consequence of prematurity at <1 y of age in Wales during 1996. Forty-four infants (90%) were delivered in a unit with staff experienced in the management of preterm birth. Of the 30 infants <30 weeks' gestation, 29 (97%) received neonatal intensive care on a (sub)regional unit. Predelivery corticosteroids were indicated in 34 cases and administered in 31 (91%). Resuscitation at birth was indicated in 47 infants and conducted satisfactorily in 42 (89%). Temperature on admission to the neonatal unit was not recorded in 7 infants; in the other 42 it was >35.5 degrees C in 21 (50%). Early surfactant therapy was administered to 31/34 (91%) infants still intubated 120 min after birth, but was given within 30 min to only 8 (24%). Mechanical ventilation was assessed in 41 infants and considered to be good in 23 (56%). Cardiovascular therapy was evaluated in 40 infants requiring active support and considered to be good in 31 (78%). We concluded that neonatal RDS was generally well managed, thermal care during resuscitation was poor, surfactant should be administered more promptly, and deficiencies in the management of ventilation were common and related mainly to poor anticipation and a slow response to problems.

Improving the quality of perinatal and infant necropsy examinations: a follow up study

AIM

To compare the quality of perinatal and infant necropsy examinations in 1996 with those performed in 1993.

METHODS

Cohort analysis, with data from the All Wales Perinatal Survey, of 1027 deaths (540 in 1993; 487 in 1996) of babies between 20 weeks' gestation and one year of age. The quality of the necropsy was assessed by scoring aspects identified as being part of the investigation.

RESULTS

Necropsy was performed in 335 cases (62%) in 1993 and in 320 cases (66%) in 1996. The proportion done in a regional centre increased significantly from 39% (131/335) in 1993 to 76% (243/320) in 1996 (p < 0.0001). The quality of necropsy was above the minimum standard in 54% of cases in 1993 (171/314) compared with 93% in 1996 (289/312) (p < 0.0001). Improvement occurred in all categories. For stillbirths, 35% (46/133) were above the minimum standard in 1993 compared with 90% (104/116) in 1996 (p < 0.0001); for cases not classified as sudden unexpected death in infancy (SUDI), the improvement was from 62% in 1993 (40/65) to 97% in 1996 (73/75) (p < 0.0001); and for SUDI cases, the improvement was from 32% in 1993 (10/31) to 91% in 1996 (21/23) (p < 0.0001). The quality of both non-regional and regional necropsies improved. For non-regional cases, the score was above the minimum standard in 28% (51/183) in 1993 compared with 69% (52/75) in 1996 (p < 0.0001); for regional cases it improved from 92% (120/131) in 1993 to 100% (237/237) in 1996 (p < 0.0001).

CONCLUSIONS

The quality of perinatal and infant necropsies improved considerably between 1993 and 1996, reflecting better awareness of the importance of good quality examination and an increase in referrals to paediatric centres.

Late death of very low birthweight infants

The causes of 59 postneonatal deaths of very low birthweight infants were determined. Bronchopulmonary dysplasia (BPD) was the cause of 19 deaths. It also coexisted in 12/20 deaths from infection and 9/20 deaths from other causes. Improvement will be best achieved by advances in the prevention and treatment of BPD.

Growth and metabolic responses in preterm infants fed fortified human milk or a preterm formula

Preterm infants fed human milk have been shown to grow poorly and develop mineral deficiencies that may lead to osteopenia. This study has investigated the efficacy of a human milk fortifier made up of glucose polymers, a mixture of bovine milk protein fractions and free amino acids, minerals and vitamins designed to improve these nutritional deficiencies. Growth and bone mineral deficiencies were compared in 38 preterm infants fed fortified mother's milk and 21 preterm infants fed a preterm formula until they reached 1800 g; all had a birthweight below 1600 g. Weight gain was similar in each group with a mean (SD) increase of 19.6 (3.5) g/kg/day in the fortified group and 19.9 (4.1) g/kg/day in the preterm formula group. There were also no significant differences in linear growth, head circumference, skin fold thickness or mid-arm circumference. Serum phosphate, alkaline phosphatase and plasma urea concentrations were similar and there was no clinical evidence of osteopenia. These results indicate that the growth and metabolic disadvantages associated with feeding human milk to preterm infants are ameliorated by the addition of a milk fortifier that increases the calorific, protein and mineral content of breast milk.

Numbers of deaths related to intrapartum asphyxia and timing of birth in all Wales perinatal survey, 1993-5

OBJECTIVES

To investigate the relation between the timing of birth and the occurrence of death related to an intrapartum event.

DESIGN

Analysis of 107,206 births to Welsh residents in 1993-5, including 608 cases of stillbirth and 407 of neonatal death identified in the all Wales perinatal survey, the cause of death classified with the clinicopathological system.

SUBJECTS

79 normally formed babies stillborn or who died in the neonatal period, birth weight > 1499 g, for whom cause of death was related to an intrapartum event.

MAIN OUTCOME MEASURES

Relative risk of death due to an intrapartum event according to the hour, day, and month of birth.

RESULTS

Mortality was higher in babies born between 9.00 pm and 8.59 am than in those born between 9.00 am and 8.59 pm; relative risk (95% confidence interval) 2.18 (1.37 to 3.47). July and August births also had a higher death rate than births in other months; relative risk 1.99 (1.23 to 3.23). Weekened births had a higher death rate but it was not significant.

CONCLUSIONS

The excess of deaths at night and during months when annual leave is popular may indicate an overreliance on inexperienced staff at these times. Errors of judgement may also be related to physical and mental fatigue, demanding a more disciplined systematic approach at night. Mistakes may be ameliorated by increasing shiftwork, but shifts should be carefully designed to avoid undue disruption of circardian rhythms. In addition, greater supervision by senior staff may be required at night and during summer months.

Deformation of the palate in preterm infants

AIM

To investigate the effect of gestation, postmenstrual age, and orotracheal intubation on palate morphology.

METHODS

A prospective study was made of 76 newborn infants of 25 to 41 weeks' gestation. Palate dimensions were measured on plaster models produced from serial palatal impressions. Palate size relative to that of the mouth was assessed using a ratio of palate depth to palate width (Palatal Index).

RESULTS

Palate depth and width were related to postmenstrual age and gestation. Palatal Index ranged from 0.15 to 0.57, indicating a wide variation in palate shape, but gestation and postmenstrual age had no effect. Prolonged intubation had a small effect, equivalent to an increase in palatal depth of less than 2 mm at 32 weeks' postmenstrual age. The effect was transient.

CONCLUSION

Prolonged orotracheal intubation (> 10 days) leads to a small and temporary increase in palatal depth. However, this is unlikely to account for palatal grooving, which is probably caused by an overgrowth of the lateral palatine ridges.

Survival of very low birthweight and very preterm infants in a geographically defined population

OBJECTIVE

To determine in a geographically defined population 1 year survival of infants with a birthweight of less than 1500 g or gestational age less than 32 weeks, and to establish the effect of postnatal age on predicted survival.

DESIGN

Cohort analysis of 72,427 births to Welsh residents in 1993-94. Deaths were identified using the All Wales Perinatal Survey, a population-based surveillance of mortality between 20 weeks of gestation and 1 year of age.

MAIN OUTCOME MEASURES

Birthweight- and gestation-specific infant mortality, and the effect of postnatal age, gender, and multiple pregnancy on predicted survival.

RESULTS

In normally formed infants 1 year survival at 24-25 weeks gestation was 35%, compared to 75% at 27-28 weeks, and 95% at 30-31 weeks. In infants with a birthweight of 500-699 g 1 year survival was 18% compared to 70% at 800-999 g, and 97% at 1300-1499 g. The chances of survival improved markedly with increasing postanatal age; at 24-25 weeks gestation it was 35% at birth, 50% at 12 h. 66% at 7 days and 78% at 4 weeks. Infant mortality was higher in males, but multiple pregnancy had no effect.

CONCLUSIONS

Up-to-date birthweight- and gestation-specific survival rates are essential for predicting the outcome of a newborn infant. The rapid change in the chances of survival with increasing postnatal age emphasises especially the importance of revising the prediction as the infant gets older, particularly during the first few days of life.

The regionalization of perinatal care in Wales and Washington State

OBJECTIVES

The purpose of this study was to compare perinatal regionalization and neonatal mortality in Wales and Washington State.

METHODS

The 28 hospitals in Wales and the 80 hospitals in Washington State that offered maternity services and the 218,326 births that occurred in these hospitals in 1989 and 1990 were studied. Surveys were used to identify the neonatal technology and the referral policies of each hospital, and linked data from birth and death certificates were used to examine birthweight-specific neonatal mortality rates for all babies born in these hospitals.

RESULTS

Welsh district general hospitals (broadly equivalent to Level II perinatal centers in the United States) have more sophisticated neonatal technology than their Washington State counterparts and appear less likely to refer small or preterm babies to regional or subregional centers. Neonatal mortality rates were quite similar in the two settings.

CONCLUSIONS

Perinatal care in Wales appears to be less regionalized than in a similar region in the United States. The relative lack of perinatal regionalization in Wales may contribute to duplication and underutilization of expensive neonatal technologies. National health care systems do not, in and of themselves, lead to optimal regionalization of services.

Perinatal and infant postmortem examinations: how well are we doing?

AIM

To investigate the quality of perinatal and infant necropsies and assess the relation between the quality and value of this investigation in different outcome groups.

METHODS

Cohort analysis of 540 deaths during 1993 of babies between 20 weeks' gestation and one year of age born to women usually resident in Wales. Cases were identified from the All Wales Perinatal Survey. Each case was assessed to establish whether the necropsy yielded clinically relevant information. The quality of necropsy was assessed by scoring aspects identified as being part of the necropsy.

RESULTS

Necropsy was performed in 335 (62%) cases, and the report was available for assessment in 314 cases. The quality of necropsy was below the minimum standard in 46% (143/314) of cases. The highest quality necropsies were carried out on fetal deaths at 20 to 23 weeks' gestation (12% (10/85) below standard), compared with 65% (87/133) below standard on stillbirths and 68% (21/31) on sudden unexpected infant death. Overall, 42% (131/314) of necropsies were performed in a regional paediatric pathology centre including 88% (76/88) of fetal deaths, 23% (31/133) of stillbirths and 30% (29/96) of infant deaths. The quality score for the necropsy performed in a regional centre failed to achieve the minimum acceptable score in 8% (11/131) of cases compared with 72% (132/182) for those done elsewhere. The cause of death was detected by necropsy in 17% (52/314) of cases. The quality of necropsy was significantly higher when the cause of death was revealed than when nothing new was found.

CONCLUSIONS

The overall quality of the perinatal and infant necropsy is poor. This is regrettable as valuable information can be revealed frequently by a good quality necropsy. Adherence to Guidelines for Postmortem Reports recently published by the Royal College of Pathologists should improve the situation.

Effect of changing the stillbirth definition on evaluation of perinatal mortality rates

The perinatal mortality rate is widely used as a summary statistic for evaluating the effectiveness of perinatal care. Since October, 1992, it has been a legal requirement in England and Wales to register fetal deaths at 24-27 completed weeks of gestation as stillbirths (in addition to those after 28 weeks), thereby altering the definition of perinatal death. In a cohort analysis of all babies born to women resident in Wales during 1993, we assessed whether the revised definition of perinatal mortality rate more appropriately measures effectiveness of care. There were 36,793 births and 313 perinatal deaths (221 stillbirths, 92 early neonatal deaths). At 24-27 weeks' gestation there were 59 (39%) survivors and 93 deaths (52 stillbirths, 36 neonatal deaths [28 early, eight late], and 5 postneonatal deaths). 119 babies had a birthweight below 500 g; one survived and 24 were perinatal deaths. Of the 36 late neonatal deaths all were attributed to perinatally related events. Increased survival of infants at 24-27 weeks' gestation emphasises the importance of including all these infants in the perinatal mortality rate, but it would be a more useful measure of the effectiveness of perinatal care if it excluded babies below 500 g, and included late neonatal deaths.

Value and quality of perinatal and infant postmortem examinations: cohort analysis of 400 consecutive deaths

OBJECTIVES

To evaluate the contribution that perinatal and infant necropsy makes to clinical practice and to see how this might be influenced by the quality of the investigation.

DESIGN

Cohort analysis, with data from the all Wales perinatal survey, of perinatal and infant deaths during 1993 of babies born to mothers usually resident in Wales. The clinicopathological classification of death based on clinical details was compared with the classification after necropsy. Similarly, cases in which necropsy yielded new information were identified. The quality of the necropsy was assessed by scoring six aspects of the examination.

SUBJECTS

400 consecutive deaths at 20 weeks of gestation to 1 year of age.

MAIN OUTCOME MEASURES

Necropsy rate, effect of necropsy on clinicopathological classification, new information disclosed by necropsy, quality of necropsies, and the link between new information and quality of the necropsy.

RESULTS

Necropsy was performed in 232 cases (58%). The clinicopathological classification was altered by necropsy in 29 cases (13%). New information was obtained in 60 cases (26%), and in 42 (18%) it disclosed the cause of death. The quality of necropsy was substantially higher when the main cause of death was detected than when nothing new was found.

CONCLUSION

Necropsy is underused. Clinicians should be more positive about necropsies and realise how much clinically relevant information can be obtained from a good quality examination.

Screening for hearing loss in an at-risk neonatal population using evoked otoacoustic emissions

The present study examines the performance of a transient evoked otoacoustic emissions hearing screening programme for neonates with risk factors for hearing loss. The programme has run for 5 years, and 772 babies with various risk factors have been screened using the Programmable Otoacoustic Emissions Measurement System (POEMS) designed by the Medical Research Council Institute of Hearing Research. Fourteen cases of significant hearing loss have been detected, with no false negative results. However, a very high false positive rate is reported, especially in babies with a birthweight of less than 1500 g.

Persistent mild hip deformation in preterm infants

Preterm infants often develop a postural deformation of the legs with wide hip abduction and external rotation giving a 'frog leg' posture. It has been shown that the deformation persists at the age of 3-4.5 years and the use of postural techniques aimed at reducing the deformation is recommended.

Do preterm infants always have flattened heads?

It has previously been shown that a soft mattress lessens the degree of head flattening that occurs in preterm infants in the early weeks of life. A follow up study of 31 infants of < 32 weeks' gestation found head flattening had resolved by 3-4 years of age, regardless of the type of mattress used in the neonatal period, and the children had heads similar in shape to full term controls.

Routine examination in the neonatal period

OBJECTIVE

To assess the value of the second neonatal examination as a medical surveillance procedure.

DESIGN

Prospective survey of routine neonatal examinations and the abnormalities identified during 8 March-30 June 1988.

SETTING

Maternity unit with an annual birth rate of 5700.

SUBJECTS

For first neonatal examination: 1795 babies born in the unit during the 115 day observation period. For second routine examination: 1747 babies (97.3%) discharged from postnatal ward.

MAIN OUTCOME MEASURES

Missed abnormalities (present but not previously noted); minor abnormalities (superficial infection or trivial or transient abnormalities not requiring intervention); and important abnormalities (unlikely to have been present at first examination but requiring intervention).

RESULTS

An abnormality was detected in 158 (8.8%) infants on first neonatal examination. 1428 (79.6%) babies had a routine second examination, which disclosed 63 previously undetected abnormalities. Of these, seven (11%) would have been present on first examination, 49 (78%) were considered minor, and seven (11%) important--the most consequential being dislocatable hips (four infants). Thus an important finding was detected by only 0.5% of second examinations.

CONCLUSIONS

A second thorough examination in the early neonatal period cannot be justified as a screening procedure. A repeat examination of the hips alone in the first week of life is necessary.

Maternal listeriosis in pregnancy without fetal or neonatal infection

Maternal infection with Listeria monocytogenes without fetal or neonatal involvement is relatively rare. Eleven cases arising in England and Wales between 1967 and 1988 are presented.

Transdermal delivery of theophylline to premature infants using a hydrogel disc system

1. Preterm infants show incompletely developed skin with reduced barrier function. The possibility of transdermal delivery of theophylline from hydrogel discs swollen with choline theophyllinate has been investigated. 2. Drug loaded hydrogel discs 2 cm2 in area were applied to the abdomen and occluded. Serum theophylline concentrations were measured in twenty-one infants of less than 31 weeks gestation. 3. Therapeutic concentrations were achieved in 18 individuals, and maintained for up to 15 days after repeated application of discs. A correlation between maximum serum drug concentration and transepidermal water loss, gestation and birthweight was demonstrated.

Percutaneous carbon dioxide excretion in the newborn infant

Percutaneous carbon dioxide excretion was studied in 42 newborn infants between 25 and 39 weeks gestation, using a closed skin cell attached to the abdomen. The rate of excretion during the first few days of life was inversely related to gestation, increasing from a mean of 31 ml/m2/h at term to 198 ml/m2/h below 30 weeks gestation. Postnatally there was a rapid fall in the rate of excretion in very preterm infants to values about twice those found at term. The rate of excretion was linearly related to the CO2 diffusion gradient, and zero diffusion would be expected when there was no diffusion gradient. It is estimated that up to 15% of resting CO2 excretion occurs through the skin of very preterm infants, and more if the tissue PCO2 is elevated.

The scars of newborn intensive care

Many techniques used in neonatal intensive care are invasive and the risk of producing skin damage is high. To investigate this, 100 consecutive survivors of neonatal intensive care (gestation 26-42 weeks, median 32) were examined in detail by a single observer at 16-29 months of age, and the scar severity, site and likely cause noted. Scarring was present in all infants although it was usually trivial. The total number of scars was inversely related to gestational age and directly related to the duration of intensive care. Eleven children had cosmetically or functionally significant lesions caused by chest drain insertion, extravasation of intravenous fluid or skin stripping by adhesive tape. To reduce the frequency and severity of skin damage, neonatal staff need to be aware that many routine procedures may lead to long term scarring. In particular, more careful wound closure after chest drain removal is needed.

Transient intracranial hypertension of infancy

Four infants were seen on six separate occasions with febrile illnesses associated with a bulging anterior fontanelle and irritability. They had signs of a transient form of intracranial hypertension.

Reduction of head flattening in preterm infants

During the first few weeks of life many preterm infants develop flattened heads. We have shown that this deformity can be reduced by nursing preterm infants on soft, air filled mattresses of the type used for detecting apnoea.

Percutaneous oxygen delivery to the preterm infant

The feasibility of delivering therapeutically useful amounts of oxygen percutaneously was investigated in 13 preterm infants. Their gestation ranged from 25 to 31 weeks and all were being ventilated for severe respiratory distress. Raising the ambient oxygen concentration resulted in an increase in arterial oxygen tension of 4.5 to 13.8 mm Hg (mean 8.9 mm Hg) as a result of percutaneous oxygen absorption. The change was greatest in the least mature infants and in those with the weakest epidermal barrier. Transdermal oxygen therapy can usefully supplement oxygen delivery to very premature infants with poor pulmonary gas exchange.

Percutaneous respiration in the new-born infant. Effect of ambient oxygen concentration on pulmonary oxygen uptake

The effect of increasing ambient oxygen concentration on percutaneous oxygen absorption was studied by measuring pulmonary oxygen uptake before and after exposure of the skin to 90% oxygen; assuming the metabolic demands of the infant remain unchanged, the pulmonary oxygen uptake should fall as percutaneous absorption increases. During the first few days of life, in infants between 28 and 30 weeks gestation, there was a significant reduction in the mean pulmonary oxygen uptake of 0.27 ml/kg/min (6.2%) when the trunk and limbs were surrounded by 90% oxygen. The calculated fall in pulmonary uptake if the whole body was surrounded by 90% oxygen would be 8-10%. In contrast, the changes seen in more mature infants (32-39 weeks gestation) and older infants (28-29 weeks gestation and 7-17 days old) were small and not significant. Percutaneous oxygen delivery may usefully contribute to the total oxygen requirements of very preterm infants during the early neonatal period.

Karaya gum electrocardiographic electrodes for preterm infants

Changes in transepidermal water loss were used to measure skin damage caused by removal of electrocardiograph electrodes in 20 preterm infants. Electrodes secured by conventional adhesive damaged the skin, leading to a potentially dangerous increase in skin permeability. In contrast, those secured by karaya gum caused no skin damage.

Salbutamol and ipratropium in acute asthma

Thirty seven children with acute asthma were given nebulised ipratropium or placebo 30 minutes after their first dose of salbutamol and eight hourly thereafter. There were no significant differences between the two groups in clinical scores, peak expiratory flow rates, length of stay in hospital, or the need for oral steroids.

gamma-Glutamyltransferase in the newborn

gamma-Glutamyltransferase activity was measured serially in newborn infants. Median activity was 94 units/l, with the 95th centile at 243 units/l. It was unrelated to gestation. Significant increases occurred after treatment with phenobarbitone and with the introduction of oral feeding after parenteral nutrition. It was a poor indicator of total parenteral nutrition (TPN) liver damage.

Percutaneous respiration in the newborn infant. Effect of gestation and altered ambient oxygen concentration

Percutaneous respiration was studied in 32 newborn infants between 25 and 41 weeks gestation, using a closed skin cell attached to the abdomen. Gas exchange rates in the first few days of life were 6-11 times faster in infants below 30 weeks gestation than in term infants (mean O2 absorption 25.0 vs. 206.5 ml/m2/h, and CO2 excretion 26.0 vs. 294.6 ml/m2/h), but rates were similar by 3 weeks of age. Increasing the ambient oxygen concentration resulted in a non-linear increase in oxygen absorption, particularly in the most immature infants. Below 30 weeks gestation, O2 absorption increased from a mean of 206.5 ml/m2/h in air, to 357.2 ml/m2/h in 40% oxygen and 573.5 ml/m2/h in 90% oxygen. We estimate that an infant below 30 weeks gestation, nursed naked in 90% oxygen, would obtain up to 20% of resting oxygen requirements percutaneously.

Preoperative stabilisation in congenital diaphragmatic hernia

Critically ill infants with congenital diaphragmatic hernia were treated by either early surgery or delayed surgery after preoperative stabilisation. The preoperative stabilisation was aimed at correcting acidosis and hypoxia, thereby reducing the severity of persistent fetal circulation. Survival improved from 12.5% after early surgery to 52.9% after delayed surgery.

Serum albumin concentrations and oedema in the newborn

Serum albumin concentration was measured in 195 infants of 25 to 42 weeks' gestation during the neonatal period. Concentrations were significantly lower in preterm infants, rising from a mean of 19 g/l at 26 weeks to 31 g/l at term. There was a 15% increase in albumin concentrations in the first three weeks of life. Oedema in the early and late neonatal period was common in preterm infants but correlated poorly with hypoalbuminaemia. Measurement of serum albumin concentrations in preterm infants either routinely or because of oedema is not clinically useful.

Specific malabsorption of vitamin B12 in Down's syndrome

A 3 year old girl with Down's syndrome became lethargic and withdrawn, and investigations showed a specific malabsorption of vitamin B12 without proteinuria.

Chest physiotherapy in acute bronchiolitis

Forty four children with acute bronchiolitis were given twice daily chest physiotherapy in addition to standard supportive measures and were compared with 46 controls who were not given physiotherapy. There was no clinically discernable benefit on the course of their illness.