Improving the quality of survival for infants of birthweight < 1000 g born in non-level-III centres in Victoria. The Victorian Infant Collaborative Study Group.
OBJECTIVE
To compare between eras the early care of extremely low birthweight (birthweight < 1000 g) infants born in non-level-III centres, that is, centres without a neonatal intensive care nursery, in Victoria, to identify changes associated with the improved quality of survival over time.


METHODS
The early care and outcome for infants of birthweight 500 to 999 g born in a non-level-III centre in Victoria were compared between two distinct eras, 1979-1980 and 1985-1987. PATIENTS AND OUTCOMES: Mortality data to two years of age were available for all infants liveborn in non-level-III centres in the two eras (1979-1980, n = 106; 1985-1987, n = 129). In 1979-1980, 47 of 52 infants transferred to a level-III centre were transported by the Newborn Emergency Transport Service (NETS); in 1985-1987, all 49 infants transferred were transported by NETS. Data concerning the immediate care after birth and during transport to a level-III centre were available for all infants transferred by NETS. All survivors were assessed for sensorineural impairments and disabilities at two years of age, corrected for prematurity.


RESULTS
In both eras, 18 children born outside and transferred to a level-III centre survived to two years of age. Survivors in both eras had almost identical mean birthweights and gestational ages. There were trends for more survivors to be referred by paediatricians--1979-1980, 61%; 1985-1987, 83%; odds ratio (OR), 2.94; 95% confidence interval (CI), 0.7-12.4--and for quicker referral times to NETS in 1985-1987 (1979-1980, median 34.5 minutes after birth; 1985-1987, median 21.5 minutes after birth; z = 1.91, P = 0.056). It was possible only during 1985-1987 to monitor transcutaneous PO2 during transport. Durations of transport were similar in both eras. However, only in 1985-1987 was it possible in survivors to reduce significantly the inspired oxygen concentration during transport (median reductions in inspired oxygen, 1979-1980 3.5%; 1985-1987 20%; P = 0.028). Neurological impairment rates were substantially lower in survivors transported in the latter era (1979-1980 72% impaired; 1985-1987 22% impaired; OR 0.14, 95% CI 0.04-0.52). Of the neurological impairments, fewer had severe developmental delay alone (1979-1980 22%; 1985-1987 0%; OR 0.09, 95% CI 0.018-0.46), and the rate of blindness was lower, but the latter difference was not quite statistically significant (1979-1980 28%; 1985-1987 6%; OR 0.21, 95% CI 0.037-1.19). Over all, neurological disabilities were significantly reduced in the latter era (z = 2.93, P < 0.005).


CONCLUSIONS
More active management of extremely low birthweight infants before transfer to a level-III centre, including prompt referral and transcutaneous PO2 monitoring during transport, may be important in improving the sensorineural outcome of survivors.
D001785:Blood Gas Monitoring, Transcutaneous; D002675:Child, Preschool; D002658:Developmental Disabilities / Q000453:epidemiology / Q000209:etiology; D006233:Persons with Disabilities; D006801:Humans; D007224:Infant Care / Q000592:standards / Q000706:statistics & numerical data*; D007226:Infant Mortality; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data; D009725:Nurseries, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D010360:Patient Transfer; D012017:Referral and Consultation / Q000639:trends; D013997:Time Factors; D014187:Transportation of Patients; D016896:Treatment Outcome; D014739:Victoria