High burden of RSV hospitalization in very young children: a data linkage study.

Linked administrative population data were used to estimate the burden of childhood respiratory syncytial virus (RSV) hospitalization in an Australian cohort aged <5 years. RSV-coded hospitalizations data were extracted for all children aged <5 years born in New South Wales (NSW), Australia between 2001 and 2010. Incidence was calculated as the total number of new episodes of RSV hospitalization divided by the child-years at risk. Mean cost per episode of RSV hospitalization was estimated using public hospital cost weights. The cohort comprised of 870 314 children. The population-based incidence/1000 child-years of RSV hospitalization for children aged <5 years was 4·9 with a rate of 25·6 in children aged <3 months. The incidence of RSV hospitalization (per 1000 child-years) was 11·0 for Indigenous children, 81·5 for children with bronchopulmonary dysplasia (BPD), 10·2 for preterm children with gestational age (GA) 32-36 weeks, 27·0 for children with GA 28-31 weeks, 39·0 for children with GA <28 weeks and 6·7 for term children with low birthweight. RSV hospitalization was associated with an average annual cost of more than AUD 9 million in NSW. RSV was associated with a substantial burden of childhood hospitalization specifically in children aged <3 months and in Indigenous children and children born preterm or with BPD.

A safety and feasibility study of the use of 670 nm red light in premature neonates.

OBJECTIVE: Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina affecting extremely preterm or low birth weight infants The aim of this study was to assess the feasibility and safety of 670 nm red light use in a neonatal intensive care unit. STUDY DESIGN: Neonates <30 weeks gestation and <1150 g were enrolled within 48 h of birth. Data collected included cause of preterm delivery, Apgar scores and birthweight. 670 nm red light was administered for 15 min per day from a distance of 25 cm, delivering 9 J cm(-)(2), from the time of inclusion in the study until 34 weeks postmenstrual age. Infants were assessed daily for the presence of any skin burns or other adverse signs. RESULT: Twenty-eight neonates were enrolled, seven 24 to 26 weeks and twenty-one 27 to 29 weeks gestation. The most common cause for preterm delivery was preterm labor (14/28) with five of these having evidence of chorioamnionitis. There were no skin burns or other documented adverse events. Entry into the study was readily achieved and treatment was well accepted by parents and nursing staff. CONCLUSION: 670 nm red light appears to be a safe and feasible treatment for further research in respect to ROP.

Do maternal opioids reduce neonatal regional brain volumes? A pilot study.

OBJECTIVE: A substantial number of children exposed to gestational opioids have neurodevelopmental, behavioral and cognitive problems. Opioids are not neuroteratogens but whether they affect the developing brain in more subtle ways (for example, volume loss) is unclear. We aimed to determine the feasibility of using magnetic resonance imaging (MRI) to assess volumetric changes in healthy opioid-exposed infants. STUDY DESIGN: Observational pilot cohort study conducted in two maternity hospitals in New South Wales, Australia. Maternal history and neonatal urine and meconium screens were obtained to confirm drug exposure. Volumetric analysis of MRI scans was performed with the ITK-snap program. RESULT: Scans for 16 infants (mean (s.d.) gestational age: 40.9 (1.5) weeks, birth weight: 3022.5 (476.6) g, head circumference (HC): 33.7 (1.5 cm)) were analyzed. Six (37.5%) infants had HC <25th percentile. Fourteen mothers used methadone, four used buprenorphine and 11 used more than one opioid (including heroin, seven). All scans were structurally normal whole brain volumes (357.4 (63.8)) and basal ganglia (14.5 (3.5)) ml were significantly smaller than population means (425.4 (4.8), 17.1 (4.4) ml, respectively) but lateral ventricular volumes (3.5 (1.8) ml) were larger than population values (2.1(1.5)) ml. CONCLUSION: Our pilot study suggests that brain volumes of opioid-exposed babies may be smaller than population means and that specific regions, for example, basal ganglia, that are involved in neurotransmission, may be particularly affected. Larger studies including correlation with neurodevelopmental outcomes are warranted to substantiate this finding.

Cannabis, the pregnant woman and her child: weeding out the myths.

To review and summarise the literature reporting on cannabis use within western communities with specific reference to patterns of use, the pharmacology of its major psychoactive compounds, including placental and fetal transfer, and the impact of maternal cannabis use on pregnancy, the newborn infant and the developing child. Review of published articles, governmental guidelines and data and book chapters. Although cannabis is one of the most widely used illegal drugs, there is limited data about the prevalence of cannabis use in pregnant women, and it is likely that reported rates of exposure are significantly underestimated. With much of the available literature focusing on the impact of other illicit drugs such as opioids and stimulants, the effects of cannabis use in pregnancy on the developing fetus remain uncertain. Current evidence indicates that cannabis use both during pregnancy and lactation, may adversely affect neurodevelopment, especially during periods of critical brain growth both in the developing fetal brain and during adolescent maturation, with impacts on neuropsychiatric, behavioural and executive functioning. These reported effects may influence future adult productivity and lifetime outcomes. Despite the widespread use of cannabis by young women, there is limited information available about the impact perinatal cannabis use on the developing fetus and child, particularly the effects of cannabis use while breast feeding. Women who are using cannabis while pregnant and breast feeding should be advised of what is known about the potential adverse effects on fetal growth and development and encouraged to either stop using or decrease their use. Long-term follow-up of exposed children is crucial as neurocognitive and behavioural problems may benefit from early intervention aimed to reduce future problems such as delinquency, depression and substance use.

Neurodevelopmental outcomes of extremely premature infants conceived after assisted conception: a population based cohort study.

OBJECTIVE: To compare neurodevelopmental outcomes of extremely preterm infants conceived after assisted conception (AC) compared with infants conceived spontaneously (non-AC). DESIGN: Population-based retrospective cohort study. SETTING: Geographically defined area in New South Wales and the Australian Capital Territory, Australia served by a network of 10 neonatal intensive care units. PATIENTS: Infants <29 weeks' gestation born between 1998 and 2004. INTERVENTION: At 2-3 years corrected age, 1473 children were assessed with either the Griffiths Mental Developmental Scales or the Bayley Scales of Infant Development. MAIN OUTCOME MEASURE: Moderate/severe functional disability defined as developmental delay (Griffiths General Quotient or Bayley Mental Developmental Index >2 SD below the mean), cerebral palsy (unable to walk without aids), deafness (bilateral hearing aids or cochlear implant) or blindness (visual acuity <6/60 in the better eye). RESULTS: Mortality and age at follow-up were comparable between the AC and non-AC groups. Developmental outcome was evaluated in 217 (86.5%) AC and 1256 (71.7%) non-AC infants. Using multivariate adjusted analysis, infants born after in-vitro fertilisation at 22-26 weeks' gestation (adjusted OR 1.79, 95% CI 1.05 to 3.05, p=0.03) but not at 27-28 weeks' gestation (adjusted OR 0.81, 95% CI 0.37 to 1.77; p=0.59) had higher rate of functional disability than those born after spontaneous conception. CONCLUSIONS: AC is associated with adverse neurodevelopmental outcome among high risk infants born at 22-26 weeks' gestation. This finding warrants additional exploration.

Amphetamines, the pregnant woman and her children: a review.

The objective of this study is to review and summarize available evidence regarding the impact of amphetamines on pregnancy, the newborn infant and the child. Amphetamines are neurostimulants and neurotoxins that are some of the most widely abused illicit drugs in the world. Users are at high risk of psychiatric co-morbidities, and evidence suggests that perinatal amphetamine exposure is associated with poor pregnancy outcomes, but data is confounded by other adverse factors associated with drug-dependency. Data sources are Government data, published articles, conference abstracts and book chapters. The global incidence of perinatal amphetamine exposure is most likely severely underestimated but acknowledged to be increasing rapidly, whereas exposure to other drugs, for example, heroin, is decreasing. Mothers known to be using amphetamines are at high risk of psychiatric co-morbidity and poorer obstetric outcomes, but their infants may escape detection, because the signs of withdrawal are usually less pronounced than opiate-exposed infants. There is little evidence of amphetamine-induced neurotoxicity and long-term neurodevelopmental impact, as data is scarce and difficult to extricate from the influence of other factors associated with children living in households where one or more parent uses drugs in terms of poverty and neglect. Perinatal amphetamine-exposure is an increasing worldwide concern, but robust research, especially for childhood outcomes, remains scarce. We suggest that exposed children may be at risk of ongoing developmental and behavioral impediment, and recommend that efforts be made to improve early detection of perinatal exposure and to increase provision of early-intervention services for affected children and their families.

Perinatal characteristics and outcome of preterm singleton, twin and triplet infants in NSW and the ACT, Australia (1994-2005).

OBJECTIVE: To compare the perinatal characteristics, neonatal morbidity and mortality of preterm singletons, twins and triplets born at 22-31 weeks' gestation and admitted to neonatal intensive care units (NICU) in New South Wales and Australian Capital Territory between 1994 and 2005. METHODS: Perinatal characteristics and neonatal outcome data were obtained from the regional NICUS data collection to test for a priori hypothesis. The 10 068 very premature infants studied included 7304 (72.5%) singletons, 2444 (24.2%) twins and 320 (3.2%) triplets. RESULTS: Assisted conception was associated with a higher maternal age and increased twins and triplets admissions into NICU than spontaneous conceptions (twins OR 6.9, 95% CI 6.1 to 8.0; and triplets OR 35.6, 95% CI 27.6 to 45.8). Major neonatal morbidities were similar between the three groups of singletons, twins or triplets. While twins of 22-27 weeks' gestation (adjusted OR 1.39, 95% CI 1.12 to 1.72) had higher mortality compared with singletons, mortality only diverged below 24 weeks' gestation. Mortality was predicted by decreasing gestational age, male gender and lack of antenatal steroids, whereas assisted conception was protective against mortality (adjusted OR 0.69, 95% CI 0.57 to 0.86). CONCLUSIONS: Assisted conception contributed to higher very premature NICU admissions of twins and triplets. Preterm twins at the very extreme of viability had higher mortality compared with singletons. The protective effect of assisted conception against mortality requires further research.

Short-term outcomes of mothers and infants exposed to antenatal amphetamines.

AIM: To determine the short-term outcomes of newborn infants and mothers exposed to antenatal amphetamines in the state of New South Wales and the Australian Capital Territory during 2004. METHODS: Amphetamine exposure was determined retrospectively using ICD-10 AM morbidity code searches of hospital medical records and from records of local drug and alcohol services. Records were reviewed on site. All public hospitals (n = 101) with obstetric services were included. RESULTS: Amphetamines were used by 200 (22.9%) of the 871 identified drug-using mothers. Most women (182, 91%) injected amphetamines intravenously. Compared with the other 669 drug users, amphetamine-using mothers were significantly more likely to use multiple classes of drugs (45.0% vs 7.8%), be subject to domestic violence (32.1% vs 17.5%), be homeless (14.8% vs 4.9%) and be involved with correctional services (19.8% vs 9.7%). The incidence of comorbid psychiatric illnesses were significantly higher (57.4% vs 41.7%) and their infants were more likely to be preterm (29.5% vs 20.4%), notified as children at risk (67.0% vs 32.8%), fostered before hospital discharge (14.5% vs 5.5%) and less likely to be breastfed (27.0% vs 41.6%). CONCLUSIONS: Amphetamine-exposed mothers and infants in public hospitals of NSW and the ACT are at significantly higher risk of adverse social and perinatal outcomes even when compared with mothers and infants exposed to other drugs of dependency. Increased vigilance for amphetamine exposure is recommended due to a high prevalence of use, especially in Australia, as a recreational drug.

Analysis of the retrieval times of a centralised transport service, New South Wales, Australia.

OBJECTIVES: To examine the transport times of immediate and emergency retrievals for neonatal and paediatric patients retrieved by ground and air from general hospitals to tertiary centres. DESIGNS: We conducted a database review of the records of 17 011 requests for retrieval to a centralised transport service in New South Wales and the Australian Capital Territory, Australia from 2000 to 2006. RESULTS: Immediate and emergency retrievals included 4575 (43.7%) neonatal and 5887 (56.3%) paediatric retrievals. The median stabilisation time was 97 min for neonatal compared with 50 min for paediatric retrievals. Neonatal retrievals had a significantly longer stabilisation time (approx x2), handover time (approx x1.2) and mission time (approx x1.3) compared to paediatric retrievals. CONCLUSIONS: Establishing reference times for the transport process is a valuable quality assurance tool. Such data will be valuable for staff and budgeting purposes and for evaluating new interventions that reduce retrieval times.

Preterm outcome table (POT): a simple tool to aid counselling parents of very preterm infants.

BACKGROUND: Outcome figures published in scientific journals are often cumbersome and difficult to understand by parents during counselling before or immediately after a very premature birth. AIM: To provide simplified up-to-date outcome information in a table for ease of counselling. METHODS: Regional perinatal mortality rates for very premature births (23-31 weeks gestation) and incidence of significant neonatal events for those admitted to neonatal intensive care units (NICU) were obtained from the NSW Midwives Data Collection, ACT Maternal and Perinatal Data Collection and the NSW and ACT NICUS Data Collection for 2000 and 2001. Neurodevelopmental outcome was obtained for the same cohort at 2-3 years of age, corrected for prematurity. The percentage outcomes were rounded off to the closest conservative multiple of 5 for each data point in a table. RESULTS: The preterm outcome table (POT) for each gestational week was constructed from a total of 2315 births. Of these, 401 (17.3%) were reported as stillborn and were predominantly of 23 to 25 weeks gestation. Of those admitted to NICU, hospital survival rates were 30, 50, 65, 75, 80, 90 and > 95% for 23, 24, 25, 26, 27, 28-29 and 30-31 weeks, respectively. Neurodevelopmental outcome was available for 470 (75%) children, of whom 15% had a moderate to severe functional disability at 2-3 years of age, corrected for prematurity. Simplified data on survival to discharge and outcome were tabulated. CONCLUSION: POT appears simple and easy to use but also provides realistic data to assist clinicians in the counselling process.

Does rural or urban residence make a difference to neonatal outcome in premature birth? A regional study in Australia.

BACKGROUND: Patients living in rural areas may be at a disadvantage in accessing tertiary health care. AIM: To test the hypothesis that very premature infants born to mothers residing in rural areas have poorer outcomes than those residing in urban areas in the state of New South Wales (NSW) and the Australian Capital Territory (ACT) despite a coordinated referral and transport system. METHODS: "Rural" or "urban" status was based on the location of maternal residence. Perinatal characteristics, major morbidity and case mix adjusted mortality were compared between 1879 rural and 6775 urban infants <32 weeks gestational age, born in 1992-2002 and admitted to all 10 neonatal intensive care units in NSW and ACT. RESULTS: Rural mothers were more likely to be teenaged, indigenous, and to have had a previous premature birth, prolonged ruptured membrane, and antenatal corticosteroid. Urban mothers were more likely to have had assisted conception and a caesarean section. More urban (93% v 83%) infants were born in a tertiary obstetric hospital. Infants of rural residence had a higher mortality (adjusted odds ratio (OR) 1.26, 95% confidence interval (CI) 1.07 to 1.48, p = 0.005). This trend was consistently seen in all subgroups and significantly for the tertiary hospital born population and the 30-31 weeks gestation subgroup. Regional birth data in this gestational age range also showed a higher stillbirth rate among rural infants (OR 1.20, 95% CI 1.09 to 1.32, p<0.001). CONCLUSIONS: Premature births from rural mothers have a higher risk of stillbirth and mortality in neonatal intensive care than urban infants.

Treating childhood acute myeloid leukaemia with the AML-BFM-83 protocol: experience in a developing country.

Treatment for childhood acute myeloid leukaemia (AML) consists of remission induction chemotherapy followed by postremission chemotherapy with or without bone marrow transplantation. The AML Berlin-Frankfurt-Munster (BFM)-83 protocol with induction-consolidation-maintenance chemotherapy for 2 years has been reported to result in a 6-year event-free survival (EFS) and event-free interval (EFI) of 49% and 61% respectively. A total of 174 Malaysian children were treated with this protocol between 1985 and 1999. The 5-year EFS and EFI was 30.7% and 48.0% respectively. The overall mortality from sepsis was 24%, which needs urgent address. The 5-year EFS for patients treated before 1993 and after 1993 was 18.6% and 41.3%, respectively (P = 0.04), while the EFI was 32% and 60.6% respectively (P = 0.034). The improvement seen after 1993 was related to a reduction in induction deaths for that period and probably reflected increased capability and familiarity to cope with the demands of the AML-BFM-83 protocol and accompanying complications in the treatment of AML.

Cost of hospitalization for respiratory syncytial virus chest infection and implications for passive immunization strategies in a developing nation.

UNLABELLED: Respiratory syncytial virus (RSV) chest infection is a common cause of hospitalization in the very young child. The aim of this study was to determine the direct cost of resource utilization in the treatment of children hospitalized with RSV chest infection and the potential cost-savings with passive immunization for high-risk infants. An audit of the hospital resource consumption and its costs was performed for 216 children aged < 24 mo admitted with RSV chest infection between 1995 and 1997. The cost-saving potential of passive immunization using monoclonal RSV antibodies during the RSV season was determined by assuming an 0.55 efficacy in hospitalization reduction when administered to "high-risk" infants according to the guidelines outlined by the American Academy of Pediatrics (AAP). The hospital treatment cost of 1064 bed-days amounted to USD 64 277.70. Each child occupied a median of 4.0 bed-days at a median cost of USD 169.99 (IQ1 128.08, IQ3 248.47). Children, who were ex-premature or with an underlying illness were more likely to have a longer hospital stay, higher treatment costs and need for intensive care. Ten (42%) of 24 ex-premature infants fulfilled the recommended criteria for passive immunization. Its use resulted in an incremental cost of USD 31.39 to a potential cost saving of USD 0.91 per infant for each hospital day saved. CONCLUSION: Ex-prematurity and the presence of an underlying illness results in escalation of the direct treatment cost of RSV chest infection. Current guidelines for use of passive RSV immunization do not appear to be cost-effective if adopted for Malaysian infants.

Impact of 24 hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care.

The 24 h availability of intensive care consultants (intensivists) has been shown to improve outcomes in adult intensive care units (ICU) in the UK. We tested whether such availability would improve standardised mortality ratios when compared to out-of-hours cover by general paediatricians in the paediatric ICU setting of a medium-income developing country. The standardised mortality ratio (SMR) improved significantly from 1.57 (95%CI 1.25-1.95) with non-specialist care to 0.88 (95%CI 0.63-1.19) with intensivist care (rate ratio 0.56, 95% CI 0.47-0.67). Mortality odds ratio decreased by 0.234, 0.246 and 0.266 in the low, moderate and high-risk patients. 24 h availability of intensivists was associated with improved outcomes and use of resources in paediatric intensive care in a developing country.