P138a
DO VERY SICK NEONATES BORN AT TERM HAVE ANTENATAL RISKS? 1. INFANTS
VENTILATED PRIMARILY FOR ASPHYXIA
Sutton L, Sayer GP, Bajuk B, Richardson V, Berry G, Henderson-Smart DJ
NSW Neonatal Intensive Care Units’ Data Collection, NSW Centre for Perinatal Health Services
Research, Building DO2, Sydney University NSW 2006
E-mail: lsutton@mail.usyd.edu.au
Aims: To describe the morbidity and mortality in a group of term neonates ventilated primarily for
‘perinatal asphyxia’, and ascertain antenatal and intrapartum risk factors for the neonatal morbidity.
Methods: This was a population-based case control cohort study, conducted in Sydney and 4 large
rural/urban Health Areas in New South Wales. The subjects, singleton term infants without a major
congenital anomaly, were 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for
mechanical ventilation for > 4 hrs, and 550 randomly selected controls. This paper compares the
93 case infants ventilated primarily for ‘asphyxia’ related reasons with the controls. Risk factors for
case/control status were analysed by maternal, antenatal, labour, delivery and combined epochs
using logistic regression with results expressed in Odds Ratios (OR) and 95% Confidence Intervals
(CI), p<0.05.
Results: Significant predictors of case status were: Maternal epoch - Mother with no tertiary
education (OR 2.56 [1.23, 5.32] p=0.012), primigravida (OR 1.98 [1.20, 3.26] p=0.007), pre-existing
medical problem (OR 2.06 [1.05, 4.04] p=0.035). Antenatal epoch – any antenatal complication
(OR 5.22 [3.17, 8.61] p=0.0001), birth weight <10th percentile (OR 2.20 [1.12, 4.33] p=0.02), male
gender (OR 2.07 [1.27, 3.36] p=0.003). Labour epoch – rupture of membranes >24 hours but <8
days (OR 7.81 [1.05, 58.17] p=0.044), any complication of labour (OR 5.88 [3.33, 10.37]
p=0.0001), induction of labour (OR 2.26 [1.34, 3.84] p=0.002). Prostaglandins was significant at
(OR 2.42 [1.27, 4.60] p=0.007) in another model. Delivery epoch – forceps delivery (OR 3.56 [1.72,
7.38] p=0.0006), caesarean section in labour (OR 4.78 [2.67, 8.54] p=0.0001). The combined
epochs – primigravida (OR 1.81 [1.05, 3.14] p=0.03), mother not having a tertiary education (OR
3.07 [1.36, 7.0] p=0.007), any antenatal complication (OR 3.49 [1.95, 6.23] p=0.0001), any
complication of labour (OR 5.038 [2.61, 9.72] p=0.0001), caesarean section in labour (OR 2.00
[1.02, 4.04] p=0.049).
Case infants had significantly higher rates than controls of thick meconium liquor (univariate OR
8.98 [5.08, 15.90] p=0.001) and antenatal fetal distress (OR 11.93 [7.26, 19.59] p=0.001). The
median (25%, 75%) 5 minute Apgar for cases was 5 (3,8) and controls 9 (9,10). 40% of the cases
had fits treated with anticonvulsants. 20 case infants (21.5%) died, 14 in the first 3 days. Of the 79
infants still alive on day 3, 39% were sedated/paralysed (3 died), 42% were neurologically normal,
19% were neurologically abnormal (3 died). Median (25%, 75%) age at discharge home varied
from 10.5 (7, 15) days for the infants neurologically normal on day 3, to 18 (12,26) days for the
survivors who had been sedated/paralysed on day 7. The median duration of hospital stay for
control infants was 5 (3,6) days, and none died. 14% of controls were transferred to a special care
nursery for feeding problems, respiratory distress, jaundice, and hypoglycaemia.
Conclusions: This representative cohort of term infants ventilated primarily for ‘asphyxia’ had a
significant burden of neonatal and longterm morbidity and mortality. Their mothers were more likely
to have had medical problems before the pregnancy, antenatal complications, a complicated or
induced labour and operative delivery. More detailed studies are needed to further elucidate the
causal pathways to this morbidity, and devise preventative strategies.
This study was supported by The Financial Markets Foundation for Children
270
P138b
DO VERY SICK NEONATES BORN AT TERM HAVE ANTENATAL RISKS? 2. INFANTS
VENTILATED PRIMARILY FOR RESPIRATORY PROBLEMS
Sutton L, Sayer GP, Bajuk B, Richardson V, Berry G, Henderson-Smart DJ
NSW Neonatal Intensive Care Units’ Data Collection, NSW Centre for Perinatal Health Services
Research, Building DO2, Sydney University NSW 2006
E-mail: lsutton@mail.usyd.edu.au
Aims: To describe the morbidity and mortality in a group of term neonates ventilated primarily for
respiratory problems, and ascertain antenatal and intrapartum risk factors for the neonatal
morbidity.
Methods: This was a population-based case control cohort study, conducted in Sydney and 4
large rural/urban Health Areas in New South Wales. The subjects, singleton term infants without a
major congenital anomaly, were 182 cases admitted to a tertiary neonatal intensive care unit
(NICU) for mechanical ventilation for > 4 hrs, and 550 randomly selected controls. This paper
compares the 86 case infants ventilated primarily for respiratory problems with the controls. Risk
factors for case/control status were analysed by individual and combined epochs using logistic
regression with results expressed in Odds Ratios (OR) and 95% Confidence Intervals (CI), p<0.05.
Results: Significant predictors of case status were: Maternal epoch – mother’s age > 34 years
(OR 2.13 [1.23, 3.71] p0.007), primigravida (OR 1.92 [1.2, 3.05] p=0.006). Antenatal epoch – any
antenatal complication (OR 3.34 [2.08, 5.37] p=0.0001), birth weight <10th percentile (OR 2.81
[1.51, 5.24] p=0.001). Delivery epoch – forceps (OR 4.52 [2.16, 9.47] p=0.0001), caesarean
section not in labour (OR 3.38 [1.83, 6.24] p=0.0001), caesarean section in labour (OR 4.00 [2.05,
7.80] p=0.0001), birth weight >90th percentile (OR 1.93 [1.08, 3.47] p=0.028). Infant characteristics
– gestational age 37-38 weeks (OR 2.08 [1.28, 3.40] p=0.003), birth weight <10th percentile (OR
4.35 [2.32, 8.15] p=0.0001), birth weight >90th percentile (OR 2.75 [1.53, 4.95] p=0.0007).
Combined epochs – any antenatal complication (OR 2.45 [1.47, 4.08] p=0.0006), birth weight
<10th percentile (OR 3.36 [1.72, 6.55] p=0.0004), birth weight >90th percentile (OR 2.40 [1.29,
4.45] p=0.005), gestational age 37-38 weeks (OR 1.76 [1.03, 3.02] p=0.039), forceps delivery (OR
3.69 [1.69, 8.06] p=0.001), caesarean section not in labour (OR 2.37 [1.21, 4.63] p=0.012),
caesarean section in labour (OR 2.76 [1.36, 5.63] p=0.005).
37% of the cases were 37-38 weeks gestation, compared with 22% of study controls. 36% (n=12)
of the 37-38 week cases were born by caesarean section not in labour, compared with 23% of
study controls. 9 of the 12 cases born at 37-38 weeks by caesarean section not in labour
developed hyaline membrane disease. The median (25%, 75%) 5 minute Apgar for respiratory
cases was 8 (7, 9) compared with 5 (3,8) for cases with perinatal asphyxia, and 9 (9,10) for
controls. The median SNAP score for respiratory cases was 13 (9, 18) compared with 15 (9, 23) for
cases with ‘perinatal asphyxia’. Their mortality rate was 5.6% (5/89). For the survivors the median
(25%, 75%) duration of mechanical ventilation was 3 (2, 5.5) days and tube feeds 3 (1, 8) days.
Age at discharge home (median, 25% 75%), varied from 8 (6,12) days for infants not sedated or
paralysed and neurologically normal on day 3, to 29 (26,31) days for those sedated/paralysed on
days 3 and 7.
Conclusion: This representative cohort of term infants ventilated primarily for respiratory
problems, had less neonatal morbidity and mortality than those infants ventilated for perinatal
asphyxia. Their mothers were more likely to be > 35 years and have a complicated pregnancy.
These babies were more likely to have been born by caesarean section, to be 37-38 weeks
gestation, and to be either growth restricted or large for gestational age.
This study was supported by The Financial Markets Foundation for Children
271
P139
NEONATAL STATUS AND DEVELOPMENT AND TEMPERAMENT AT SIX MONTHS
Hardy H, Spence K, Halliday R
Grace Neonatal Nursery, Royal Alexandra Hospital for Children/New Children’s Hospital, Sydney
NSW 2000
In several studies, benefits from individualized family-focused care have been demonstrated for
preterm infants. Reduced duration of illness and hospitalization, and improved development and
behaviour are amongst the benefits. Similar advantages may also apply to full-term infants. Both
groups of infants are represented in the NICU of a Children’s Hospital. Before commencing the
formal introduction of a programme of family-focused care in Grace Neonatal Nursery, a base line
profile of the neonatal and developmental/behavioural outcome characteristics of infants admitted
to this unit was required, and an indication of the existing relationship between neonatal status and
subsequent behaviour and development.
Aims: To describe the neonatal characteristics of a cohort of infants, prior to implementing a
programme of family-focused care in the NICU, to obtain measures of development and
temperament at six months of age (adjusted for prematurity), and to compare gestational age and
severity of illness with development and temperament at six months.
Method: Neonatal data – gestational age, birthweight, age on admission, length of stay and
severity of illness (SNAP score) – for each infant were collected from the unit database for a three
month period, from December 1997 to February 1998.
With informed consent, a postal
questionnaire which included the Revised Gesell Parent Developmental Questionnaire and the
Short Infant Temperament Questionnaire was sent to the parents when their infant was six months
of age (adjusted for prematurity).
Approval for the survey was obtained from the Ethics
Committee of the Hospital.
Results: There were 125 infants (77 male, 48 female) in the three month cohort. The average
gestational age was 37 weeks, birthweight 2920g, age on admission 14 days and length of stay 10
days. The median SNAP score was 6 (range 0 to 29). Consent was obtained from 113 families
but 12 were not sent the questionnaire as either the mother or baby had died, the baby was
receiving terminal care, or the parents were non-English speaking or were foster parents. Two
families could not be traced. The questionnaire was sent to 99 families, and 54 (54.5%) returned
the completed questionnaire. Development and temperament scores were comparable to those of
a normal sample, with a tendency for gross motor development to be delayed in comparison with
other areas of development. Neither development nor temperament was significantly correlated
with either gestational age or severity of illness.
Conclusion: A pre-intervention base line has been successfully established, and the feasibility of
obtaining follow-up data by postal questionnaire has been demonstrated.
272
P140
MOTOR DEVELOPMENT OF HIGH RISK INFANTS AT 18 MONTHS, 3 AND 5 YEARS
Goyen T-A1, Lui K2
1
Department of Neonatology, Westmead Hospital, Westmead, NSW, 2145; 2 University of New
South Wales, Sydney
E-mail: mumbersj@ozemail.com.au
Introduction:
We previously reported fine motor deficits in NICU survivors, even amongst
fine motor development of a group of high-risk infants who did not have a major disability at 18
months, 3 and 5 years. The motor development of “micropreemies” (born <27 weeks and/or <750
g) over this period was also examined.
Methods: High- risk infants (<29 weeks gestation or <1000 grams) born between 1992 - 1993
were enrolled in the Growth and Development Clinic at Westmead Hospital for long term follow up. Infants who were identified with a neurological or intellectual disability at 12 months corrected
age were excluded from the study. Gross and fine motor skills were assessed by an occupational
therapist with the Peabody Developmental Motor Scales at 18 months corrected, 3 and 5 years of
age.
Results: A total of 58 eligible infants completed all assessments at the specified ages. The
median (interquartile range) gestational age and birthweight for the sample was 28 weeks (27-29)
and 942.5 grams (793.8-1090) respectively.
STAGE
18 m
3y
5y
p-value
GROSS
DMQ
90.0 (87-100)
91.0 (81-98)
79.0 (75-82)
0.000*
MOTOR
Deficit (%)
13.8
32.8
81.1
<0.001**
FINE
DMQ
84.0 (82-89)
89.0 (77-97)
84.0 (78-90)
0.56
MOTOR
Deficit (%)
53.5
46.5
63.8
0.26
Median (interquartile range) are shown, DMQ= Developmental Motor Quotient
*p<0.05 Friedman Test for repeated measurements; **p<0.05 Chi Square Test for Trend
Gross motor quotient significantly decreased over time, and this trend was not confined to the
subgroup of “micropreemies”. These children had particular difficulties with items of balancing and
ball skills. However “micropreemies” (n=16) consistently performed lower on tests of gross and fine
motor skills compared with the rest. Quotients were significantly lower at 5 years (gross motor
p=0.007; fine motor p=0.003). Furthermore gross motor skills at 18m were significantly lower for
the “micropreemies” (p=0.02).
Conclusion: A significant proportion of infants without a major disability continued to have fine
motor deficits from 18 months to 5 years, reflecting an underlying problem with fine motor skills.
The proportion of infants with gross motor deficits significantly increased over this period as test
demands became more challenging, particularly for the “micropreemies”.
273
P141
BEHAVIOURAL ADJUSTMENT, ADAPTIVE FUNCTIONING AND SELF-PERCEPTION AT 8
YEARS FOR CHILDREN BORN EXTREMELY PREMATURE
Gibson F L, Bowen J R, Hand P J
Neonatal Follow-up Program, Dept of Neonatology, Royal North Shore Hospital, St Leonards,
NSW, 2065
E-mail: frgibson@laurel.ocs.mq.edu.au
Aim: An increased incidence of behavioural difficulty among children born premature has been
identified, however, few studies to date have examined premature children’s adaptive functioning
or their self-perceptions. Behavioural adjustment outcomes have also been inconsistent partly due
to the diversity between and within the samples studied, in addition to informant and measure
issues such as reliability. This study aimed to examine the behavioural adjustment, adaptive
functioning, and sense of competence and social acceptance of school-age children born
extremely premature across home and school contexts.
Methods: As part of a larger birth cohort study, 48 children born at <28 weeks gestational age
and/or with a birthweight of <1000 grams, who attended a regular school at 8 years, were seen for
follow-up assessments. A control group matched for gender, age, and school was also recruited.
Demographic and social information was gathered through parent interview and questionnaires.
Child behaviour was assessed with parent and teacher completed forms of the Child Behaviour
Checklist (CBCL) and the Conners’ Rating Scales. The Vineland Adaptive Behaviour Scales were
administered to assess child adaptive function and teachers completed the CBCL adaptive
functioning scale. The Pictorial Scale of Perceived Competence (physical, cognitive), and
Acceptance (peer, maternal) was administered to the children. Clinical cut-off scores were used to
determine the incidence of behaviour problems and below adequate adaptive functioning within
both groups.
Results: There were no significant between group differences in demographic characteristics. The
results of logistic regression revealed that significantly more premature children (13) than controls
(2) were identified with behaviour problems on both of the parent completed measures (p =.01),
however, only 4 premature children and 1 control child were identified with behaviour problems on
both of the teacher completed measures. Very few children had clinical problems identified across
all four measures, that is, on the parent and teacher completed CBCL, as well as the Conners’
scales. In terms of adaptive functioning, significantly more premature children were below
adequate at home (premature 25%; controls 4%, p = .025) or in the problem range at school
(premature 21%; 5% controls, p = .021). Finally, multivariate analyses indicated that premature
children had a lower sense of competence than their peers (p = .025), although they did not differ
in their sense of acceptance by others (p = .546).
Conclusion: At early primary school age, children born extremely premature are more likely to
have behaviour problems based on parent report and poorer adaptive functioning, both at home
and at school, than their classmates While premature children may perceive that they have a lower
level of physical and cognitive competence than their peers, this does not appear to impact
negatively on their sense of acceptance by either their mothers or their friends.
274
P142
PERINATAL DETERMINANTS OF INTELLIGENCE AT AGE ELEVEN
McConnell BA1, Thompson AJ2, Dornan JD3, Hepper PG1
1
School of Psychology, Queen’s University, Belfast, 2Department of Child Health, Queen’s
University, Belfast, 3Department of Obstetrics and Gynaecology, Royal Group of Hospitals, Belfast
Increasing attention has focused on the perinatal environment as an important period in
determining outcome in later life. Much interest has been assigned to the Barker theory, relating
low birth weight to adverse medical outcomes such as ischaemic heart disease. 1 However, there is
limited research relating perinatal factors to developmental outcome measures such as intelligent
quotient (IQ).
Objective: This study aimed to compare fetal and early neonatal parameters with subsequent IQ
scores in children aged 11 years.
Design: 160 children (80 males), average age 11.9 years were included in the study. Previous
perinatal measurements included birth and placental weight, skinfold thickness and mid-arm
circumference, occipitofrontal circumference (OFC), length, ponderal index (birth weight (g) x
100/crown-heel length (cm3)), apgar scores and cord pH. Developmental outcome scores were
measured using the British Ability Scales (version 2). IQ scores at age eleven were correlated with
the perinatal measures using SPSS statistical package.
Results: Pearsons Correlations (2 talied )
Cord
pH
-.156
.100
PL
WT
.095
.239
Lgth
Head
Scap
Tricp
.099
.222
-.096
.234
.107
.205
SNVA
-.123
.193
.101
.209
.025
.754
.047
.562
SSA
-.044
.641
.115
.152
.130
.109
-.061
.452
SVA
SVA
SNVA
SSA
BWT
Pond
.068
.418
Apgar
5
-.077
.339
.053
.511
-.040
.624
.090
.283
.149
.075
-.053
.512
.138
.085
.139
.087
.067
.428
.064
.446
-.067
.427
.121
.134
-.004
.964
Standard Verbal Ability
Standard Non Verbal Ability
Standard Spatial Ability
Conclusion: Perinatal measurements did not correlate with developmental outcome measures
(IQ) at age eleven years. There is no evidence that there is fetal programming of intelligence in
later childhood.
Barker DJB, ed. Fetal and infant origins of adult disease. London: BMJ Publishing Group, 1992.
275
P143
DO NEONATAL FACTORS INFLUENCE COMPLIANCE WITH 1-YEAR FOLLOW-UP
McAvoy E, Bajuk B, Rochefort M
Neonatal Intensive Care Unit, Westmead Hospital, Westmead NSW 2145
E-mail: bbajuk@mail.usyd.edu.au
Aims: To identify the neonatal factors influencing compliance with the 1-year follow-up program for
infants less than 29 weeks gestation at Westmead Hospital.
Methods: All infants <29 weeks gestational age who were born 1/1/92 –30/6/98 and registered
with the Growth and Development Clinic at Westmead Hospital. The data were analysed using
SAS version 6.12 for Windows.
Key Findings: There were 454 infants born during the study period. Of these infants 119 died
before hospital discharge, 3 died before their first birthday and 332 were eligible for follow-up at 12
months of age (corrected for premature). 286 (86%) infants were assessed 46 (14%) infants were
either lost to follow-up or refused to attend. The table shows the significant and non-significant
factors associated with compliance at follow-up.
Variable
Multiple gestation
Male gender
Antenatal steroids
Tertiary birth
Caucasian
Primipara
Maternal age <25
HDP
TPL
ROM>24hrs
APH
Fetal distress
IUGR
Caesarian
ROP grade 3 or 4
IVH grade 3 or 4
Infection
BW
GA
TPN
VENT
LOS
Apgar1
Apgar5
Not Attend
23.9
45.6
82.6
97.8
91.3
43.5
58.7
4.4
89.1
39.1
28.3
15.2
4.4
32.6
12.5
2.2
58.7
Median [25, 75]
946.5 [800, 1195]
27 [26, 28]
18.5 [13, 25]
42.5 [25, 55]
85 [69, 98]
5 [3, 6]
7.5 [6, 9]
Attend
23.4
50.4
77.3
95.8
83.9
42.7
19.2
16.8
73.4
29.7
33.2
18.2
5.9
38.8
12.9
7.3
40.2
Median [25, 75]
940 [790, 1130]
27 [26, 28]
21 [14, 29]
45 [30, 62]
84 [70, 102]
5 [3, 7]
8 [6, 9]
P value
NS
NS
NS
NS
NS
NS
0.001
0.029
0.021
NS
NS
NS
NS
NS
NS
NS
0.019
OR
95% CI
3.05
0.24
1.21
2.174-4.285
0.065-1.030
1.074-1.372
1.46
1.103-1.933
Conclusions: The mothers of infants who did not attend follow-up are more likely to be younger
and have had threatened preterm labour. The infants are more likely to have had neonatal sepsis,
and have had slightly less assisted ventilation and total parenteral nutrition.
276
P144
SIDE EFFECTS AND NEURODEVELOPMENTAL OUTCOME OF EARLY POSTNATAL
CORTICOSTEROIDS IN PRETERM INFANTS
Rajadurai VS, Agarwal P, Sriram B, Malathi I
Department of Neonatology KK Women’s and Children’s Hospital, 100 Bukit Timah Road,
Singapore 229899
E-mail: samuel@kkh.com.sg
Background: Our centre was one of the centres that participated in the open study of early
corticosteroids treatment (OSECT) in preterm infants with respiratory illness, the primary outcome
measure being death or oxygen dependence at 36 weeks post-conceptional age (Trial
Coordinator: Prof HL Halliday, Royal Maternity Hospital, Belfast). We report the adverse effects
and neurodevelopmental follow-up of the infants enrolled into the trial from our centre.
Objectives: To document the side effects and neurodevelopmental outcome at two years of
infants exposed to early postnatal corticosteroids.
Methods: Prospective randomised controlled trial. The entry criteria were gestation < 30 weeks,
FiO2 > 0.30, age less than 72 hours, need for intubation and ventilation. Treatment allocation
consisted of early steroids (within 72 hours), group 1 dexamethasone at weaning doses of
0.5mg/kg, 0.25mg/kg, 0.10mg/kg and 0.05mg/kg per day for a total of 12 days; group 2 Inhaled
budesonide using aerochamber 400mcg twice daily for infants under 1000g and 600mcg twice
daily for infants 1000g – 1500g for 12 days or until extubated. Late steroids (> 14 days)
dexamethasone (group 3) or budesonide (group 4) was considered if the infants needed
mechanical ventilation and oxygen. Follow-up at 2 years of corrected age: growth parameters,
neurological examination, evaluation of hearing and vision, psychological assessment using Bayley
Scales of Infant Development – 2nd edition and Vineland Adaptive Behaviour Scale).
Results: Fifty infants were enrolled (group 1 = 13, group 2 = 12, group 3 = 13, group 4 = 12).
There were 6 deaths (24%) in the early steroid (groups1 and 2) and 2 (8%) in the late steroid
groups (groups 3 and 4). Survivors without CLD were not different between the early and late
steroid groups, 11 (44%) vs 12 (48%) respectively. Overall, infants exposed to dexamethasone
(groups 1 and 3, n = 26) had higher incidence of complications as compared against budesonide
(groups 2 and 4, n = 24), namely severe hyperglycaemia 8 (31%) vs 2 (8%), gastrointestinal
haemorrhage (GIH) 6 (23%) vs 3 (12%), gastrointestinal perforation (GIP) 3 (12%) vs 1 (4%),
proven sepsis 11 (42%) vs 1 (4%), hypertension 1(4%) vs 0 (0%) in the respective groups
(p=0.049). Early dexamethasone (group 1) had higher incidence of complications compared to the
late dexamethasone (group 3) – severe hyperglycaemia 6 (46%) vs 2 (15%), GIH 5 (38%) vs 1
(8%), GIP 2 (15%) vs 1 (8%), and sepsis 7 (54%) vs 4 (31%) (p=0.10). Neurodevelopmental
follow-up at 2 years of the 9 survivors of early dexamethasone (group 1) revealed normal cognitive
development in 4 (44%), mild delay in 1 (11%), cerebral palsy 1 (11%) and significant
developmental delay (MDI < 70) in 4 (44%).
Conclusion: Early postnatal exposure of dexamethasone in very preterm infants seems to be
associated with increased incidence of short-term adverse effects and also neurodevelopmental
handicap at 2 years. A large-scale randomised trial, with survival free of neurodevelopmental
handicap as the major end point needs to be done before its use can be recommended.
277
P145
HIGH HOSPITALIZATION RATE FOR RSV BRONCHIOLITIS (RSVB) IN TOWNSVILLE,
AUSTRALIA: WOULD VACCINATION OF HIGH-RISK INFANTS BE COST EFFECTIVE?
Whitehall JF, Bolisetty S, Norton R, Patole SK, Whitehall JS
Kirwan Hospital for Women, Townsville, Australia
E-mail: Whitehaj@health.qld.gov.au
Background: An unusually high rate of hospitalization for RSV positive bronchiolitis (RSVB) exists
in Townsville where 10% of the population is Aboriginal and Islander (AI). Palivizumab vaccine is
known to reduce the hospitalization rate of RSVB.
Aim: To study the rate of hospitalization, demographic & clinical characteristics of RSVB & the
possible role of Palivizumab in Townsville.
Design: Retrospective analysis of data on all children hospitalized in Townsville General Hospital
for RSVB between Jan 97-Oct 99.
Methods: Rate of hospitalization /1000 live births & severity of illness (duration of hospitalization &
oxygen therapy) were analyzed according to-ethnicity (AI Vs non- AI), gender, birth weight, age &
date of admission. RSVB cases were defined as those with positive immunofluorescence &/or
culture. Based on reported efficacy of Palivizumab in reducing hospitalizations, the cost of routine
vaccination of high-risk infants ( 2.5 kg at birth) was compared with the estimated cost of their
hospitalization.
Results: 88 cases of RSVB (AI: 30, non-AI: 58) were hospitalized during the study period. One
(1%) died, 3 (3.4%) required admission in intensive care unit, 24(27%) added oxygen, 25 (28%)
intravenous fluids. The overall hospitalization rate/1000 live births was 46 and 14 for AI and non-AI
respectively (p<0.001); for those < 2.5 kg at birth it was 90 and 67 respectively. Severity of illness
did not differ in the two ethnic groups. Mean duration of hospital stay was longer in those <2.5kg
compared with those >2.5kg at birth [6 Vs 4 days, p 0.005] For those <2 kg at birth it was even
longer [8 Vs 4 days, p 0.001]. Male: female ratio was 1:1.5 and 2.4:1 in AI and non-AI at all ages.
45 (51%) of children were admitted under 6 months of life, 66 (75%) under one year. A marked
seasonal variation was noted in AI, with 28(93%) hospitalized in the first six months of the year.
The peak month was March. An estimated cost of vaccine for all babies <2.5kg at birth during first
5 months of the year approximated A$190,000 compared with estimated hospitalization cost
A$30960.
Discussion: Our overall & birth weight specific (<2.5kg) hospitalization rates for AI
(46/1000,90/1000) are significantly higher than those reported so far (USA: 4.7, UK: 14.3, Bedouin
in South Israel: 18/1000). Our peak of admissions occurred during hot, late summer rains rather
than in winter. Female predominance, as in AI, has not been reported.
Conclusion: Even though, our high rate of hospitalization for RSVB, doubtless underestimates the
true incidence, the cost of routine vaccination of all babies <2.5 Kg appears very high.
278
P146
THE QUALITY OF LIFE OF MOTHERS AND FAMILIES CARING FOR PRETERM INFANTS
REQUIRING HOME OXYGEN THERAPY: A BRIEF REPORT
McLean A3; Townsend A3; Clark J1; Sawyer MG1; Baghurst P1; Haslam R2; Whaites L1
Research & Evaluation Unit, Division of Mental Health1 & Department of Perinatal Medicine2,
Women's and Children's Hospital, North Adelaide, 5006 and Adelaide Medical School3, Adelaide,
5000
E-mail: haslamr@wch.sa.gov.au
Objective: To investigate the impact on mothers and families of caring for a premature infant
requiring home oxygen therapy (HOT).
Methodology: The subjects were the mothers of premature infants discharged home with oxygen
from the Women's and Children's Hospital, Adelaide between September 1996 and February 1998.
Mothers of preterm infants matched to within one month of age and not discharged on oxygen
were used as controls. Twenty-six HOT infants were identified. Four mothers could not be
contacted and 2 declined interview. HOT infants were divided into HOT and OFF-HOT groups
depending on whether they were still on oxygen at the time of interview. After initial consent by
letter, parents were interviewed. Standard questionnaires were used to assess family and
maternal functioning. Their responses were analysed using a series of simple and multiple
regression analyses.
Results: HOT infants were more premature (25.2 vs 27.0 weeks) and of lower birthweight (737 vs
937 grams) than controls and there was a higher proportion of males (60% vs 35%). Mean scores
on the Impact on Family Scale were significantly higher for those still on HOT (64.8±11.3)
compared with those OFF-HOT (53.3±9.8) and the controls (49.0±9.2). Similarly, parental Quality
of Life scores as assessed by the SF-36 were consistently lower for the HOT group, with OFF-HOT
and control group scores being similar. After adjustment for gestational age, chronological age,
birth weight and place of residence (urban/rural), the care required by premature infants receiving
HOT had a significantly greater impact on their families than the care of infants not receiving HOT.
Mothers of premature infants receiving HOT reported significantly less vitality and more mental
health problems than mothers of infants not receiving HOT.
Conclusions:
(1)
Caring for a premature infant on HOT may have an adverse impact on the lives of mothers
and families.
(2)
The impact of HOT on mothers and families is limited to the period of time in which the
infant is on treatment.
(3)
An increase in home supports is required for families of infants on HOT.
279
P147
SIDS AWARENESS IN NORTH QUEENSLAND: A SURVEY OF INFANT SLEEPING
PRACTICES IN INDIGENOUS AND NON-INDIGENOUS WOMEN
Panaretto K, Smallwood VE, Cole P, Whitehall J
Townsville Aboriginal and Islander Health Service (TAIHS) and Kirwan Hospital for Women,
Townsville, Thuringowa, Qld 4817
E-mail: whitehaj@health.qld.gov.au
Background: Sudden Infant Death Syndrome (SIDS) is the most common cause of postneonatal
death in Queensland (0.98 per 1000 live births, 1994-1996). SIDS rates have fallen dramatically in
the non-indigenous population due to aggressive risk reduction education. A recent review of SIDS
deaths in North Queensland suggests the rate in the indigenous population is up to 6 times that of
the non-indigenous population, consistent with other states. This may be because education
campaigns are not reaching the indigenous population.
Aim: To assess infant sleeping practices and awareness of SIDS risk factors in the indigenous and
non-indigenous population of Townsville, a large remote urban centre in North Qld.
Methods: A random sample of 60 young mothers, 30 Indigenous (Murri) women and 30 nonindigenous, with children less than 2 years of age were surveyed using sections of the West
Australian Infancy and Pregnancy Survey 1997-1998, developed by the TVW Telethon Institute for
Child Research, Princess Margaret Hospital, Perth, Western Australia. The women were
interviewed over a three week period in Townsville. The prevalence of SIDS risk factors, including
demographic data, smoking, infant feeding, sleeping position, bedding, and bed sharing have been
assessed in the two groups. SIDS awareness was also assessed, as were suggestions for
appropriate SIDS education for Murri women. Incidence, medians and univariate association (2)
between indigenous and non-indigenous groups will be performed where appropriate using SPSS.
Results: The Murri women were significantly younger and more likely to be single than the NonIndigenous women. There was no significant difference in the median age of the infants between
the two groups (8 months, range 0.3-26). 53% of the Murri women smoked during pregnancy, 23%
of Non-Indigenous women (p=0.015); 60% of Murri women were smokers at the time of the
interview; 50% of the Murri partners smoked and smoking occurred in 40% of Murri households
(27% and 20% respectively for Non-Indigenous women). 83% of women in both groups reported
having breast fed at any time, with 30% of Murri women still breast feeding at the time of interview
(cf 47% of Non-Indigenous women). 37% of Murri infants slept prone (cf 16%), 93% slept in the
same room as their parents, 77% shared a bed (cf 13% of Non-Indigenous infants). The Murri
households had significantly more members with 50% including extended family members (cf
23%). 33% of Murri women were strongly SIDS aware compared with 93% of Non-indigenous
women. However, 60-75% were aware of individual risk factors on specific questioning. The Murri
women believe that sleeping with their infants will protect them.
Conclusion: This small survey suggests prevalence of SIDS risk factors are higher in the Murri
population and a new approach to education is urgently needed to promote SIDS awareness
amongst Murri women.
280
P148
AN ANALYSIS OF SUDDEN UNEXPECTED DEATHS IN INFANCY IN QUEENSLAND, 19941997
Chandran G, Hockey R, Brookes K*, Colditz P**,Naylor C**, Payton D**
Perinatal Epidemiology Unit, Mater Hospital, Brisbane & **The Queensland Council on Obstetric
and Paediatric Morbidity and Mortality; * SIDS Queensland
E-mail: Jking@mater.org.au
Aims: To analyse all sudden unexpected deaths of infants (SUDI) in Queensland between 1994
and 1997, in order to determine the relative contribution of deaths from Sudden Infant Death
Syndrome (SIDS) and to explore differences between the Indigenous and non-Indigenous
populations.
Methods: This is a population-based study of all infant deaths registered in Queensland from
1994 to 1997. On the basis of information obtained from death certificates, autopsies and other
relevant information, predetermined criteria were applied to identify those infants whose deaths
were sudden and unexpected, and to classify them into SIDS or non-SIDS. As information on
Indigenous status has been recorded only since 1997, comparisons between Indigenous and nonIndigenous populations were only possible for that year.
Findings: There were 1333 infant deaths in the four year period 1994-1997, giving an infant
mortality rate of 7.1 per 1000 live births. Two hundred and sixteen deaths (16.2%) were
categorised as sudden and unexpected (SUDI). One hundred and eighty of the SUDI deaths were
classified as SIDS (83%), and 36 as non-SIDS. The overall rate of SUDI for this period was 1.15
deaths per 1000 live births and the SIDS rate was 0.96 per 1000 LB.
The majority (78%) of the non-SIDS cases resulted from injuries and were more likely than SIDS
cases to occur at age greater than six months. SIDS occurred predominantly (92%) prior to the age
of six months. Males were disproportionately represented in both the SIDS and non-SIDS cases
(69% and 61% respectively).
Over the four-year period, the rate of SIDS declined from 1.05 per 1000 live births to 0.96 but this
was not statistically significant. The rate of non-SIDS deaths increased from 0.17 per 1000 live
births to 0.32 per 1000 LB, again not statistically significant. In 1997, the rate of SUDI deaths was 5
times higher for Indigenous infants, (4.84 cf 0.98 per 1000 LB, p<0.01) and the SIDS rate was 5.9
times higher, (4.04 cf 0.69 per 1000LB, p<0.01).
Conclusions: The apparent marginal decline in the rates of SIDS and increase in SUDIs from
causes other than SIDS over the period 1994-1997 may be indicative of an emerging trend, and
warrants further analysis, particularly for Indigenous deaths. The disproportionate rate of SIDS
among Indigenous infants is again highlighted. Public health messages about SIDS prevention
may not be as effective for the Indigenous community. Educational interventions in the perinatal
period may also be need to be broadened to include consideration of sudden unexpected infant
deaths from other preventable causes
281
P149
CORTISOL DEFICIENCY, ANDROGEN EXCESS AND REDUCED THYROID FUNCTION IN < 30
WEEK GESTATION INFANTS  ? HORMONAL FACTORS IN THEIR MORBIDITY
Yeung MY1,2, Smyth JP2
1
Department of Pharmacy, 2 Department of Neonatal Intensive Care, Nepean Hospital, Sydney,
NSW
E-mail: yeungm@wahs.health.nsw.gov.au
Exogenous surfactant, the wider use of antenatal and postnatal steroids and improvements in
ventilation have not reduced chronic lung disease (CLD) in preterm infants < 30wks gestation to
the extent that was hoped. This may be a cost of their increased survival. Antenatal steroid therapy
reduces RDS, IVH and NEC and matures the surfactant profile briefly. Mega-dose postnatal
dexamethasone (0.5mg/kg per day starting dose) reduces CLD at 28 days of age and 36 wks postconceptional age (PCA) in these infants. This short-term benefit has however, been associated
with an increased risk of adverse neurodevelopmental outcome.
Cortisol is known to modulate fetal heart and lung development, as well as the maturation of a
variety of enzyme and biochemical pathways. Preterm infants < 30 wks gestation are relatively
cortisol deficient with elevated cortisol precursors. They have a poor cortisol response to stress in
their first postnatal weeks. These findings are consistent with the structural and biochemical
immaturity of the adrenal gland.
They also have an immature hypothalamic-pituitary-thyroid hormone axis and reduced tissue
thyroid hormone responsiveness. Superimposed on this is the further reduced thyroid function
seen in non-thyroidal illness in which elevated cytokine levels have been implicated.
Repeated antenatal steroids and high dose postnatal dexamethasone are “unphysiological”, may
not have the protective action of cortisol and appear to be deleterious to lung and brain growth.
This may be through inhibition of cell replication and catabolism, as well as decreased TSH
secretion and reduced peripheral conversion of T4 to T3.
Extremely preterm infants have elevated androgens and androgen precursors, the steroid products
of the adrenal fetal zone. The production of fetal androgens persists and the androgen levels
remain elevated in these infants until  42 wks PCA. This corresponds to the timing of involution of
the fetal zone in the adrenal gland and appears unaffected by preterm birth. Preterm boys are
known to have a worse outcome and a higher incidence of CLD for reasons that are not well
understood. Fetal androgens, e.g., androstenedione and dehydroepiandrosterone (DHEA), have
been shown, in vitro, to have an anti-glucocorticoid and an inhibitory effect on human fetal lung
growth and maturation.
Postnatal cortisol deficiency may deprive the low gestation infant of the optimum protective and
maturational effects of this hormone, resulting in over-exuberant cytokine production and
inflammatory responses. Considered together, the relative cortisol deficiency/androgen excess and
thyroid immaturity in these infants may be factors in their high level of morbidity. It is conceivable
that a period of early low-level postnatal hydrocortisone (cortisol) administration could improve the
pulmonary as well as the overall outcome of these infants. It may also reduce the need for higher
dose glucocorticoid treatment and the associated side effects. A multi-centre randomised
controlled trial of early low-dose hydrocortisone appears warranted.
282
P150
COMPARISON OF TEMPERAMENT AT 12 MONTHS BETWEEN CASES AND CONTROLS IN
THE NSW TERM BABIES’ STUDY
Sutton L, Bajuk B, Gibson F, Berry G, Henderson-Smart DJ
NSW Neonatal Intensive Care Units’ Data Collection, NSW Centre for Perinatal Health Services
Research, Building DO2, Sydney University NSW 2006
E-mail: lsutton@mail.usyd.edu.au
Aims: To compare maternal assessment of temperament at 1 year between cases and controls
enrolled in the New South Wales (NSW) term babies’ study.
Methods: This was a population-based case control cohort study, conducted in Sydney and 4 large
rural/urban Health Areas in New South Wales. The subjects, singleton term infants without a major
congenital anomaly, were 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for
mechanical ventilation, and 550 randomly selected controls. Follow-up at 1 year included physical
examination, Griffiths Mental Developmental Scales (1996 revision), Ages and Stages
Questionnaire and Toddler Temperament short questionnaire (TTQ). Risk factors for TTQ scores
of cases and controls were analysed using logistic regression, with results expressed in Odds
Ratios (OR) and 95% Confidence Intervals (CI), p<0.05.
Results: TTQ’s were completed for 91.3% of 150 eligible cases (n=137), and 90.8% of 447 eligible
controls (n=406). This included 16 of the 18 children with a provisional diagnosis of cerebral palsy.
Significantly more controls (14.3%) than cases (5.8%) were scored as being difficult on the TTQ
(p=0.031). Similar proportions of cases (16.1%) and controls (15.8%) were scored as being easy,
with more cases (78.1%) than controls (70%) in the average temperament category. There were
no significant differences between cases and controls on the TTQ subscales. In logistic regression
significant associations with difficult temperament were: Cases - non-Caucasian (OR 4.8[1.05,
22.2] p=0.04), unemployed father (OR 6.5[1.28, 33.25] p=0.02). Controls - non-Caucasian (OR
2.6[1.33, 5.15] p=0.005), on medications (OR 2.66[1.17, 6.07] p=0.02), admission for minor
surgery (OR 5.87[2.03, 16.97] p=0.001).
Significant associations for scoring in the more difficult range for the subscales were:
Withdrawn/shy – Cases: cerebral palsy (CP) (OR 7.48 [2.02,27.69] p=0.003), female (OR 4.45
[1.43,13.76] p=0.009). Controls: weight <10th percentile (OR 2.58 [1.01, 6.6] p=0.048). Overreactive – Controls: mother who had not completed the higher school certificate (OR 1.68
[1.06,2.67] p=0.028). The whole group: males (OR 1.68 [1.12,2.51] p=0.012). Uncooperative –
Cases: unemployed father (OR 8.79 [2.12, 36.46] p=0.003), male (OR 4.63 [1.05,20.34] p=0.043).
Arrhythmic – Cases: mother who had not completed the higher school certificate (OR 8.00
[1.75,36.62] p=0.007), Asian (OR 7.00 [1.65,29.72] p=0.008).
Conclusions: The demographic associations with difficult temperament and its various
dimensions in this cohort are comparable with those of the original normative sample. Admission to
hospital and longterm medication in the first year of life, were associated with difficult temperament
in the control children. It is encouraging that cases are not perceived as being more difficult than
controls. Most of the children in this cohort with CP had a severe functional disability, and were
perceived as withdrawn. These results will be compared with temperament outcomes at 3 years.
This study was supported by The Financial Markets Foundation for Children, NSW Health Department, APEX Foundation for Research
into Intellectual Disability
283
P151
NUTRITIONAL CONSEQUENCES OF INDOMETHACIN (INDO) THERAPY FOR PATENT
DUCTUS ARTERIOSUS (PDA) IN 750-1250GM PREMATURE INFANTS – A CASE-CONTROL
STUDY
Dodd G, McPhee A
Dept Neonatal Medicine, Women’s and Children’s Hospital, North Adelaide 5006
E-mail: mcphee@wch.sa.gov.au
Study Aims: INDO therapy for the treatment of PDA in premature infants <1250gms is frequently
associated with protracted renal dysfunction requiring fluid (and nutrient) restriction. We assessed,
via a case-control study, the impact of INDO therapy on nutrient intake and weight gain in the first
month of life in premature infants of 750-1250 gms birth weight.
Methods: Case-control study of babies managed in the NICU at the WCH between 1994 and
1998; two weight cohorts, 750-999gms and 1000-1250gms were studied. Infants with PDA treated
with INDO (INDO group) were matched for birth weight (+/-100gms), gestational age (+/-1 wk) and
sex with infants without PDA, (NO INDO group). Case note audit was used to determine clinical
profiles, together with detailed fluid and nutritional intakes (enteral and parenteral) on days 4, 8, 12,
16, 20, 24 and 28. Comparisons between INDO and NO-INDO groups within each birth weight
cohort were made using ANOVA with repeated measures; a calorie intake of 90-100 cals/kg/day
was considered a desirable target intake for growth.
Results: By design, the groups were well matched for birth weight, gestational age and sex; their
clinical profiles were also comparable. Calorie intake (a) and weight gain (b) for each birth weight
cohort are shown. INDO infants had lower calorie intakes on days 8 and 12 in the 750-999gm
cohort and on days 8-20 in the 1000-1250gm cohort. In both cohorts INDO infants achieved target
calorie intakes later than NO-INDO infants, and showed lower bodyweights at 20-28 days.
a. Calorie Intake For Babies 750-999 g
a. Calorie Intake For Babies 1000 - 1250 g
Mean Calories / kg / day
Mean Calories /kg /day
140
120
100
80
60
40
20
0
4
8
PDA
12
16
20
24
Post Natal Day
120
100
80
60
40
20
0
4
28
1200
1450
1150
1400
1100
1350
Weight (grams)
Weight (grams)
12
16
20
24
Post Natal Days
28
N=22/group
b. Weight During First 28 Days (1000-1249 g)
b. Weight During First 28 Days (750-999 g)
1050
1000
950
900
1300
1250
1200
1150
1100
850
1050
4
indomethacin
800
4
indomethacin
8
PDA
No PDA
N=15/group
No PDA
140
8
12
16
20
24
28
Post Natal Day
8
12
16
20
24
28
Post Natal Day
no indomethacin
no indomethacin
Conclusions: INDO therapy is associated with significant calorie restriction and diminished
weight gain in the first month of life in infants with birth weight 750-1250gms (these adverse
nutritional consequences of INDO may have long term implications).
284
P152
RESISTIVE INDEX FROM RENAL ARTERIAL DOPPLER IN THE DIAGNOSIS OF SIGNIFICANT
PATENT DUCTUS ARTERIOSUS IN PRETERM INFANTS
Armstrong DL, Harding JE, Teele RL
National Women’s Hospital, Auckland, New Zealand
E-mail: damiena@ahsl.co.nz
Background: Up to 50% of preterm, extremely low birth weight neonates will have a patent ductus
arteriosus (PDA). Because a PDA is associated with problems such as cardiac failure,
intraventricular haemorrhage and necrotising enterocolitis, prompt diagnosis and treatment is
important. Clinical examination and radiographs of the chest are known to be unreliable in the
diagnosis of PDA. Although the “gold standard” investigation is direct visualisation of the PDA by
echocardiography, this procedure is not always available in every neonatal unit. It is known that
renal arterial waveforms are altered by the presence of a PDA but a prospective study comparing
echocardiography with renal Doppler investigation, within minutes of each other, has not been
performed. We undertook such a study.
Aims: This study compares the findings from echocardiography and renal arterial Doppler
examination in preterm infants suspected of having PDA.
Methods: In preterm infants at risk for PDA, renal ultrasonograms, including Doppler study, were
performed immediately before or after echocardiography. Echocardiograms were performed by
one of three investigators. A single investigator, who was not involved in the infant’s care,
performed the renal scans.
The ductus arteriosus was identified using colour Doppler, images were frozen on screen and the
ductus arteriosus was measured using electronic callipers. A PDA >1.5mm diameter was
considered significant. Other information obtained included left atrial/aortic ratio, size of foramen
ovale, presence of a left to right shunt and flow pattern in the descending thoracic aorta.
Immediately before or after echocardiograms, both renal arteries were identified on
ultrasonography and a pulsed wave Doppler display was acquired. Resistive index (RI), using
measurements of the peak systolic and end diastolic renal arterial velocities was obtained for each
renal artery.
Findings: Forty-one scans were performed on 27 babies. Mean gestational age was 26.8 weeks
(SEM  0.4), mean birthweight was 915g  55 and mean postnatal age was 12.2 days  2. A
receiver operator curve was plotted and used to determine optimal cut off values for the RI. When
the renal artery RI was >1.1 the likelihood ratio for having a significant duct was 13.7 (sensitivity
82%, specificity 94%). When the renal RI was < 0.9 the likelihood ratio for having a significant PDA
was 0.2 (sensitivity 45%, specificity 100%).
Conclusions: Resistive index obtained from renal arterial Doppler represents a simple
investigation that can be used to predict a significant PDA.
285
P153
HAEMOLYSIS AFTER INFUSION OF PACKED RED CELLS THROUGH PERCUTANEOUS
CENTRAL VENOUS CATHETER-AN IN VITRO STUDY
Tuladhar R, Porter D, Patole SK, *Muller R, Whitehall JS
Kirwan Hospital for Women, *James Cook University, Townsville, Qld
Background: Percutaneous central venous catheters (PCVC) are often used in neonates needing
long term venous access. Data on haemolysis after infusion of packed red cells (PRBC) through
PCVC is not available.
Aim: To compare occurrence / extent of haemolysis after PRBC transfusion through PCVC with
that after infusion through peripheral intravenous cannula in an in vitro study.
Methods: 20 mls of PRBC ready for use in neonates, were transfused at 5ml / hour over 4 hours
through either a 23 G silicone PCVC [Vygon, Germany, (n=9)] or 24 G cannula [Insyte, Becton,
USA, (n=9)]. PRBC packets were assigned to “PCVC” or “Cannula” group according to computer
generated random numbers contained in 18 sealed coded envelopes. Transfusion equipment [30
ml syringes (Terumo, USA), syringe pump (Atom 1235,USA), 3 way tap (Connecta TH, Sweden),
extension set (B. Brauwn, Malaysia)] and environmental temperature (24+20C) were similar for all
experiments. Significant haemolysis was defined prospectively as rise in free haemoglobin (FHb)
by>0.15% midway through and/or at the end of transfusion. For each experiment 5 blood samples
were collected- (1) From PRBC packets before starting transfusion. From the tip of cannula /
PCVC –(2) at commencement of transfusion (3) midway through the transfusion (4) at end of
transfusion &(5) from residual blood in the syringe at end of transfusion. The samples were
immediately centrifuged at 100g for 5 minutes & the supernatant plasma was analyzed for FHb by
a Coulter MAXM Hematology analyzer.
Statistics: Non parametric tests were used due to skewed distributions.
Results: Median (25%-75%) FHb in PRBC packets, were 10 (3-10) gram % and 4 (3-10) gram %
for PCVC and Cannula group respectively. Median (25%-75%) FHb levels in samples 2-5 are
shown below
Table1
PCVC (Vygon) n=9
Cannula (Insyte) n=9
Sample number
FHb: median(25%-75%)
FHb: median(25%-75%)
2 start of Transfusion (Tx)
2.5 (2-8.2)
2.0 (2-7.5)
3 Midway through Tx
3.5 (2-9)
3.0 (2-7.5)
4 End of Tx
3.5 (2.2-9)
3.0 (2-8)
5 Residual blood in syringe
3.5 (2-8.2)
3.0.(2-8)
Median (range) differences in FHb for samples 3 Vs2, 4Vs2 &5Vs2 were not significantly different
for PCVC and Cannula (Wilcoxon rank sum test: all p>0.5)
Conclusion: PCVC may be used for PRBC transfusions.
(Acknowledgements: Queensland Surgical)
286
P154
EFFECT OF EARLY TARGETED INDOMETHACIN ON THE DUCTUS ARTERIOSUS AND
UPPER BODY BLOOD FLOW IN THE PRETERM INFANT
Osborn DA, Kluckow M, Evans N
Departments of Neonatal Medicine, Royal Prince Alfred and Royal North Shore Hospitals, and
Department of Obstetrics and Gynaecology, University of Sydney, Sydney, NSW
E-mail: davido@peri.rpa.cs.nsw.gov.au
Aim: To determine the short term effect of indomethacin on ductus arteriosus (PDA) constriction
and blood flow to the upper body and brain in the early postnatal period.
Background: Early low superior vena cava (SVC) flow is associated with large diameter PDA and
subsequent intraventricular haemorrhage when SVC flow improves. We hypothesised that ductal
constriction induced by indomethacin would increase SVC flow when the infant's spontaneous
postnatal ductal constriction had failed.
Methods: The study was a randomised, double blind, crossover trial of indomethacin (Indo) versus
placebo. 111 infants born before 30 weeks had echocardiograms at 3 and/or 10 hours. Trial packs
had 2 identical vials (labelled A and B) randomly allocated to contain Indo 0.2 mg/kg or placebo.
Infants were eligible if the colour Doppler PDA diameter was >1.6mm. All infants received vial A
first. Echocardiogram was repeated 1 hour after vial A. Crossover to vial B occurred if the PDA was
still >1.6mm and constriction was <30%. Further echocardiograms were done 1 and 2 hours post
intervention. Primary outcomes were SVC flow (mls/kg/min) and ductal constriction.
Results: 70/111 (63%) infants had a ductus > 1.6mm and were randomised at mean age 4 hours.
35 had Indo first and 35 placebo first. The 2 groups were well matched. One hour after the first vial,
there was no difference between the two groups in degree of ductal constriction (placebo: -15% vs
Indo: -20%), change in SVC flow (placebo: -9% vs Indo: -1%) or right ventricular output (placebo:
+2% vs Indo: -5%).
53 infants given Indo (either as vial A or vial B) had blinded but non-placebo controlled measures
at 2 hours. At this time, there was a significant PDA constriction (mean 2.4 to 1.5mm, p<0.001), no
change in SVC flow (mean 71.9 to 70.5 mls/kg/min) and a small but significant reduction in RVO
(mean 198 to 180 mls/kg/min; p = 0.001). After Indo, babies born before 27 weeks showed greater
falls in RVO and SVC flow than those born after 26 weeks. (Change RVO: -17% vs -2%, p = 0.001;
and change SVC flow: -11% vs +14%, p = 0.07).
Conclusions: Indomethacin had minimal effect on PDA constriction at 1 hour and no consistently
positive or negative effects on blood flow. Significant ductal constriction had occurred 2 hours after
indomethacin and flow measures tended to fall in less mature babies while being maintained in the
more mature.
287
P155
COULD ILEUS DURING PHOTOTHERAPY IN NEONATES BE A DIRECT EFFECT OF LIGHT?
Kadalraja R, Patole SK, *Muller R, Whitehall JS
Kirwan Hospital for Women, *James Cook University, Townsville, Australia
Background: Phototherapy (PT) is shown to cause vascular smooth muscle relaxation in animal
experiments. Association of PDA with PT is reported in neonates <1.5 kg.
Abdominal distension, Ileus & bile stained aspirates are common in neonates under PT.
Direct photorelaxation of gut smooth muscle or gut ischemia due to stealing of mesenteric flow by
peripheral vasodilatation may be responsible for ileus during PT. In term neonates, postprandial
increase in velocity of blood flow to gut is reported to be significantly less after PT. Data on gut flow
(in absence of associated risk factors for ileus) after commencing PT in preterm neonates is not
available.
Objective: To compare mesenteric flow before & after commencing PT in stable, preterm
neonates with no associated risk factors for ileus
Design / Methods: Superior mesenteric artery blood flow (maximum, minimum velocity & resistive
index) was measured by ultrasound pulsed-Doppler method in 6 consecutive neonates before and
8-12 hours after commencing continuous PT. At the time of study they did not have associated risk
factors for ileus (PDA, indomethacin /aminophylline /morphine /pancuronium therapy,
polycythemia, sepsis, electrolyte imbalance, umbilical vascular catheters & enteral feeds) their
ventilatory/ oxygen needs were minimal & cardiovascular support was not required.
Results: Birth weight, gestational age & postnatal age of enrolled neonates at study ranged from
885-1410 grams, 27-29 weeks & 2-4 days respectively. Mean +(Sd) level of serum bilirubin before
starting PT & at flow recording was 130+ 52 & 165+ 40 mmol/litre respectively.
Table: Mesenteric flow (m/sec) before and after PT
V max
V min
RI
Cases
Pre
Post
Pre
Post
Pre
Post
1
0.38
0.38
0.10
0.10
0.74
0.74
2
0.51
0.39
0.02
0.15
0.62
0.62
3
0.51
0.47
0.08
0.08
0.80
0.85
4
0.49
0.64
0.03
0.18
0.79
0.72
5
0.14
0.61
0.03
0.21
0.79
0.66
6
0.35
0.55
0.12
0.21
0.66
0.62
Mean + (Sd) Maximum (V max) velocity, & resistive index (RI) before (Pre) and after (Post)
commencing PT were not significantly different. [Pre Max: 0.39+0.14 Vs Post Max: 0.15 +0.05,
p=0.26] [Pre RI: 0.73 +0.07 Vs Post RI: 0.7 +0.08, P=0.27] Minimum (V min) velocity Post RI was
significantly increased. [Pre Min: 0.06 +0.04 Vs Post Min: 0.15 + 0.05, p=0.03]
Conclusion: Overall, mesenteric flow did not change significantly post PT. Increased diastolic flow
post PT flow may possibly be due to photorelaxation of mesenteric vessels. Development of ileus
in absence of associated risk factors may be due to direct effect of light on gut smooth muscle if
mesenteric flow is unchanged.
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