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THE “LOST TRIBE” OF NEAR-TERM BABIES
In the last quarter-century the seriously preterm babies—those <32 weeks, originally, but now those <30 weeks—have been the main focus of attention for obstetricians delivering women, and neonatologists caring for the babies. Even though near-term babies actually account for far more admissions to special care facilities, and seldom require intensive care, there’s a general feeling that they mostly do OK. The research literature confirms that it is generally the very preterm, or the baby <1500 g, that commands clinical focus and research funding. So it is most welcome that Escobar et al, examining the fortunes of babies 30 to 34 weeks in California and Massachusetts, can begin to tell us something about the lost tribe of more mature babies, and shake our complacency with figures such as an 11% readmission rate after discharge home.
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AND HOW QUICKLY DOES THE “LOST TRIBE” GET HOME?
What is it about California and Massachusetts? In this study, Profit et al compared the postmenstrual age at which near-term babies—30 to 34 weeks again—get home in California (Kaiser Permanente Medical Care (KPMC) program), Massachusetts, and the UK. Interestingly, and in spite of the universal community care provision for infants in the UK, the Californian babies got home youngest, the Massachusetts babies next, and the British trailed 4 days later than the Californians. Easy to make the observations; far more difficult to construe an accurate explanation for them. The authors finger the nature of the KPMC program, but other unmeasured factors must also play some part in this variation.
See page 245
SOME GOOD NEWS ABOUT HEARING
It is quite fashionable to knock neonatal intensive care by focusing on the less desirable outcomes, and we do not always do ourselves a service by seeking, and generally finding, something to take the shine off impressive survival figures. So it is particularly good to read the paper by Roth et al who looked at the prevalence of sensorineural hearing loss in a cohort of 346 babies <1500 g, and found just one baby. Not surprisingly, conductive hearing loss was much more common. There seems to be good evidence now that with improvements in many aspects of neonatal care, the prevalence of sensorineural deafness among “high risk” babies is genuinely lower than in the past. We should welcome this.
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PATTERNS OF PALLIATION
Palliative, end-of-life care remains a feature of neonatal intensive care practice, but as Wilkinson et al show, things change. At the level of descriptive epidemiology, this change has been evident for a long time, but at the cot side the pattern of palliative care that families, nurses and doctors experience has changed too. These authors found less chromosome abnormality and fewer babies with neural tube defects, probably as a result of the choices made available to parents early in pregnancy by anomaly scanning. But readers will be surprised that the death rate from “complications of prematurity” was unchanged, since <30 weeks of gestation, survival has improved greatly and along with this, death has become significantly less common than in the past. I suspect that this finding simply reflects the unusual and highly specialised referral base to which the authors refer. It would be interesting to see more work like this, in different settings: Wilkinson et al only cite two similar studies, one from the USA and one from Norway.
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MECONIUM: THE HIDDEN DEPTHS
Substance misuse by mothers in pregnancy is becoming more and more of an issue for neonatal care, but in the nature of the situation, it is likely that many substance-misusing women remain undetected. Equally, the babies may not show withdrawal symptoms until their mothers have got home. It is important that we obtain some knowledge of the hidden burden of fetal exposure to illicit substances, so using anonymised direct measurements from the newborn is an attractive possibility. Meconium and hair are the obvious targets for analyses that can reveal substance exposure weeks or even months before birth, and Williamson et al present some interesting pilot data on the feasibility of this approach. How many mothers use stuff where you work?
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THIS MONTH IN ARCHIVES
Intersex states have an important neonatal dimension, and Archives carries a new consensus statement on their management (see page 554 of Arch Dis Child).