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Some perinatal care practices can optimize or worsen the condition of very premature newborns

Perinatal care and delivery room management by hospital personnel can substantially improve or worsen the immediate condition of premature newborns, says a study supported by the Agency for Health Care Policy and Research (HS07015). In a comparison of six neonatal intensive care units (NICUs), the researchers found that worse neonatal outcomes at two NICUs were associated with lower use of beneficial antenatal corticosteroid treatment and poorer stabilization and resuscitation after delivery.

Douglas K. Richardson, M.D., M.B.A., of Harvard Medical School, and his colleagues abstracted medical record data on 1,476 babies born at a gestational age of less than 32 weeks at six perinatal centers. They measured newborn illness severity with the Score for Neonatal Acute Physiology (SNAP; higher scores indicate greater severity of illness) and constructed models to predict SNAP scores as a function of perinatal risk factors.

Advancing gestational age had a powerful impact on neonatal stability, with a drop of more than 1 SNAP point for each additional week of gestation. Presence of a life-threatening congenital anomaly added 4 SNAP points. Antenatal corticosteroids (which improve respiration and cardiovascular systems and improve neonatal stability) lowered SNAP an average of 2.1 points. Low 1- and 5-minute Apgar scores were associated with higher SNAP (2.4 and 2.2 points, respectively) at 12 hours of age. Hypothermia on arrival to the NICU added 2.3 points to the SNAP score.

On the other hand, higher SNAP scores at two perinatal centers could not be explained by such neonatal characteristics. Instead, they were associated with lower use of antenatal corticosteroids, low Apgar scores (which usually reflect delivery room resuscitation and mode of delivery), and neonatal hypothermia at NICU admission (reflecting poorer stabilization following delivery). Babies of similar gestational age at one site were nearly three times more apt to have a low Apgar score and had two to nine times more delivery room deaths than babies at other sites. The higher rate of poor 5-minute Apgar scores at this site suggested a pattern of suboptimal resuscitation or greater antecedent fetal sedation or compromise.

See "Perinatal risk and severity of illness in newborns at 6 neonatal intensive care units," by Dr. Richardson, Bhavesh L. Shah, M.D., Ivan D. Frantz III, M.D., and others, in the April 1999 American Journal of Public Health 89(4), pp. 511-516.

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