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Background: While the use of supplemental oxygen has a long history in neonatal care, resulting in both significant health care benefits and harms, uncertainty remains as to the most appropriate range to target blood oxygen levels in preterm and low birth weight infants. Potential benefits of higher oxygen targeting may include more stable sleep patterns and improved long-term growth and development. However, there may be significant deleterious pulmonary effects and health service use implications resulting from such a policy., Objectives: To determine whether targeting ambient oxygen concentration to achieve a lower vs. higher blood oxygen range, or administering restricted vs. liberal supplemental oxygen, effects mortality, retinopathy of prematurity, lung function, growth or development in preterm or low birth weight infants., Search Strategy: The standard search strategy of the Neonatal Review Group was used. An additional literature search was conducted of the MEDLINE and CINAHL databases in order to locate any trials in addition to those provided by the Cochrane Controlled Trials Register (CENTRAL/CCTR). Search updated to week two July 2008., Selection Criteria: All trials in preterm or low birth weight infants utilising random or quasi-random patient allocation in which ambient oxygen concentrations were targeted to achieve a lower vs. higher blood oxygen range, or restricted vs. liberal oxygen was administered were eligible for inclusion., Data Collection and Analysis: The methodological quality of the eligible trials was assessed independently by each review author for the degree of selection, performance, attrition and detection bias. Data were extracted and reviewed independently by the each author. Data analysis was conducted according to the standards of the Cochrane Neonatal Review Group., Main Results: In the meta-analysis of the five trials included in this review, the restriction of oxygen significantly reduced the incidence and severity of retinopathy of prematurity without unduly increasing death rates The one prospective, multicenter, double-blind, randomized trial investigating lower vs. higher blood oxygen levels from 32 weeks postmenstrual age showed no significant differences in the rates of ROP, mortality or growth and development between the two groups. However, this study did show increased rates of chronic lung disease and home oxygen use., Authors' Conclusions: The results of this systematic review confirm that (the now historical) policy of unrestricted, unmonitored oxygen therapy has potential harms without clear benefits. However, the question of what is the optimal target range for maintaining blood oxygen levels in preterm/LBW infants was not answered by the data available for inclusion in this review.

Objective: To identify prenatal risk factors for chronic lung disease (CLD) at 36 weeks postmenstrual age in very preterm infants., Population: Data were collected prospectively as part of the ongoing audit of the Australian and New Zealand Neonatal Network (ANZNN) of all infants born at less than 32 weeks gestation admitted to all tertiary neonatal intensive care units in Australia and New Zealand., Methods: Prenatal factors up to 1 minute of age were examined in the subset of infants born at gestational ages 22-31 weeks during 1998-2001, and who survived to 36 weeks postmenstrual age (n = 11 453). Factors that were significantly associated with CLD at 36 weeks were entered into a multivariate logistic regression model., Results: After adjustment, low gestational age was the dominant risk factor, with an approximate doubling of the odds with each week of decreasing gestational age from 31 to less than 25 weeks (trend p<0.0001). Birth weight for gestational age also had a dose-response effect: the lower the birth weight for gestational age, the greater the risk, with infants below the third centile having 5.67 times greater odds of CLD than those between the 25th and 75th centile (trend p<0.0001). There was also a significantly increased risk for male infants (odds ratio 1.51 (95% confidence interval 1.36 to 1.68), p<0.0001)., Conclusions: These population based data show that the prenatal factors low gestational age, low birth weight for gestational age, and male sex significantly predict the development of chronic respiratory insufficiency in very preterm infants and may assist clinical decision about delivery.

Objective: To examine trends in preterm births, especially those less than 33 weeks gestation, occurring in perinatal centres in New South Wales (NSW) from 1992 to 2001., Methods: Population data were obtained from the NSW Midwives' Data Collection. Trends in the proportion of births in perinatal centres by gestation and by type of preterm birth (spontaneous or elective), and in Apgar scores and neonatal mortality were determined., Results: The preterm birth rate increased from 6.1% in 1992 to 6.7% in 2001. Factors contributing to the increase in preterm births were multiple births and elective preterm deliveries. Births less than 33 weeks gestation in perinatal centres increased from 76% to 83% and for multiple births from 77% to 87%. This coincided with a decrease in 1-minute Apgar scores less than 4 but no significant change in 5-minute Apgar scores or neonatal mortality., Conclusions: Progress has been made towards the National Health and Medical Research Council guideline that births less than 33 weeks gestation occur in perinatal centres. Preterm births are increasing, creating greater demands for neonatal intensive care unit care and ventilation services.

Background: Physiological studies have shown that chronic hypoxemia may occur in preterm infants who require supplemental oxygen for extended periods and that this hypoxemia may contribute to poor growth and development. Anecdotal reports and uncontrolled observational studies have suggested that a higher oxygen-saturation range may be beneficial in terms of growth and development., Methods: We conducted a multicenter, double-blind, randomized, controlled trial involving 358 infants born at less than 30 weeks of gestation who remained dependent on supplemental oxygen at 32 weeks of postmenstrual age. They were randomly assigned to a target functional oxygen-saturation range of either 91 to 94 percent (standard-saturation group) or 95 to 98 percent (high-saturation group); this target was maintained for the duration of supplemental-oxygen therapy. The primary outcomes were growth and neurodevelopmental measures at a corrected age of 12 months., Results: There were no significant differences between the groups in weight, length, or head circumference at a corrected age of 12 months. The frequency of major developmental abnormalities also did not differ significantly between the standard-saturation group and the high-saturation group (24 percent and 23 percent, respectively, P=0.85). There were six deaths due to pulmonary causes in the high-saturation group and one such death in the standard-saturation group (P=0.12). The high-saturation group received oxygen for a longer period after randomization (median, 40 days vs. 18 days; P<0.001) and had a significantly higher rate of dependence on supplemental oxygen at 36 weeks of postmenstrual age and a significantly higher frequency of home-based oxygen therapy., Conclusions: Targeting a higher oxygen-saturation range in extremely preterm infants who were dependent on supplemental oxygen conferred no significant benefit with respect to growth and development and resulted in an increased burden on health services., (Copyright 2003 Massachusetts Medical Society)

Objectives: To determine antenatal factors associated with the need for ventilatory support in babies born between 30 and 36 weeks gestational age and use this information to help referring obstetricians decide which mothers need antenatal transfer., Methods: Babies born at Royal Prince Alfred Hospital at 30-36 weeks' gestation inclusive between January 1992 to December 1999 were identified in the obstetric and neonatal databases. Information for a wide range of antenatal factors and respiratory outcomes was extracted. Babies with major congenital anomalies were excluded. Statistical analysis using spss for Windows was then undertaken., Results: Data were available for 3102 babies. On univariate analysis, seven factors were significant. Lower gestational age, absence of labour, Caesarean section, antepartum haemorrhage, breech presentation and hypertensive disease of pregnancy were associated with increased risk, while threatened premature labour was protective. On logistic regression analysis, gestational age and absence of labour dominated the model. Other significant factors in the model had a relatively minor impact., Conclusions: The risk of needing ventilatory support according to antenatal risk factors is described for infants born between 30 and 36 weeks. Gestational age and absence of labour were found to be the major determinants of risk. Delivery without labour increased the risk by the equivalent of about 2 weeks of gestation. For example, to avoid a risk > 20%, the cut off is 33 weeks for mothers who labour, but is increased to 35 weeks when there is no labour. Our results should be interpreted with caution, as the patients in a tertiary obstetric unit may not be typical of the wider community.

Objective: To examine trends in the maternal characteristics and delivery of singleton preterm infants in an Australian population., Design: Population-based descriptive study., Setting: New South Wales (NSW), Australia., Population: The population included 37 500 singleton preterm births from 1 January 1990 to 31 December 1997., Methods: Data were obtained from the NSW Midwives' Data Collection (MDC) and rates over time were calculated. Preterm birth by Caesarean section before the onset of labour or where labour was induced were considered to be medically indicated., Main Outcome Measures: Preterm rates, medically indicated preterm birth rates, mode of delivery andneonatal outcomes, and trends over time., Results: Among singleton infants, there was no significant change over time in the rate of preterm birth (annual average 5.5%), preterm births that were medically indicated (annual average 29.3%) or neonatal outcomes of preterm births. The rate of indicated preterm birth varied by gestational age and was highest (39.7%) at 29-32 weeks' gestation. Instrumental preterm births declined over time from 9.5 to 7.8% with a shift from forceps to vacuum use and episiotomy rates declined from 19.7 to 14.8%., Conclusions: Increases in the reported overall preterm rate (singletons and multiples) were not due to increased delivery of singleton infants. Changes in the management of singleton preterm births were similar to changes observed in term births such as decreasing forceps and episiotomy usage. It may be to time to reassess whether Australian clinicians would be willing to randomise patients to clinical trials of the best method of delivery for preterm infants.

Objectives: To review neuro-developmental outcome at 1 and 2 years of age following randomized controlled trials (RCT) of neonatal surfactant therapy., Methods: A systematic review of the MEDLINE, Embase and Cochrane Controlled Trial Register databases, searching for RCT of surfactant replacement therapy with follow-up outcomes, was carried out. The main outcome measures were severe and mild disability at 1 and 2 years plus composite adverse outcome of death and/or severe disability., Results: A meta-analysis using odds ratios was carried out on 13 RCT. There were a total of 2218 treated and 2090 control infants who underwent follow up at 1 year of age. There were 303 treated and 292 control infants with follow up at between 18 months and 2 years of age. Surfactant therapy was associated with a lower rate of mild disability at 1 year (OR 0.79; 95% CI 0.66-0.95). There was a reduction in the combined adverse outcome (death or severe disability rate) at 1 year (OR 0.8; 95% CI 0.72-0.89). Neither the 1 year nor the 2 year follow-up examination showed a statistical difference in the severe disability rate between the control and treated group., Conclusion: Surfactant therapy increases survival without an increase in subsequent morbidity at 1 and 2 years of age.

Background: The application of a continuous distending pressure (CDP) has been shown to have some benefits in the treatment of pre-term infants with respiratory distress syndrome (RDS). CDP has the potential to reduce lung damage, particularly if applied early before atelectasis has occurred. Early application of CDP may better conserve an infant's own surfactant stores and consequently be more effective than CDP applied later in the course of RDS., Objectives: In pre-term infants with RDS to determine if early compared with delayed initiation of CDP results in lower mortality and reduced need for intermittent positive pressure ventilation., Search Strategy: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register (Issue 1, 2002), MEDLINE (1966-2001), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language., Selection Criteria: Trials among pre-term infants with respiratory distress syndrome spontaneously breathing at trial entry, which used random or quasi-random allocation to either early or delayed CDP., Data Collection and Analysis: Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used, including independent assessment of trial quality and extraction of data by two authors., Main Results: In six studies on a total of 165 infants, early CDP was associated with a significant reduction in subsequent use of intermittent positive pressure ventilation, typical RR 0.55, RD -0.16, NNT 6, but there was no evidence of effect on overall mortality. There was no evidence of effect on the rates of pneumothorax (five studies) or bronchopulmonary dysplasia (one study). Early CDP resulted in a reduction in duration of oxygen therapy in the single study reporting this outcome., Reviewer's Conclusions: Early application of CDP has a clinical benefit in the treatment of RDS in that it reduces subsequent use of IPPV and thus may be useful in preventing the adverse effects of this treatment. However, many of the trials were done in the 1970s and 1980s and re-evaluation of the strategy of early CDP in the era of antenatal steroid use and early surfactant administration is indicated.

Background: Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease., Objectives: In spontaneously breathing preterm infants with RDS, to determine if continuous distending pressure (CDP) reduces the need for IPPV and associated morbidity without adverse effects., Search Strategy: The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002), MEDLINE (1966-January 2002), and EMBASE (1980-January 2002), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language., Selection Criteria: All trials using random or quasi-random allocation of preterm infants with RDS were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube, or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body, compared with standard care., Data Collection and Analysis: Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used, including independent assessment of trial quality and extraction of data by each author., Main Results: CDP is associated with a lower rate of failed treatment (death or use of assisted ventilation) [summary RR 0.70 (0.55, 0.88), RD -0.22 (-0.35, -0.09), NNT 5 (3, 11)], overall mortality [summary RR 0.52 (0.32, 0.87), RD -0.15 (-0.26, -0.04), NNT 7 (4, 25)], and mortality in infants with birthweights above 1500 g [summary RR 0.24 (0.07, 0.84), RD -0.281 (-0.483, -0.078), NNT 4 (2, 13)]. The use of CDP is associated with an increased rate of pneumothorax [summary RR 2.36 (1.25, 5.54), RD 0.14 (0.04, 0.23), NNH 7 (4, 24)]., Reviewer's Conclusions: In preterm infants with RDS the application of CDP either as CPAP or CNP is associated with benefits in terms of reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. The applicability of these results to current practice is difficult to assess, given the intensive care setting of the 1970s when four out of five of these trials were done. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings

Background: The issue of whether to abruptly or gradually discontinue supplemental oxygen is a contentious one. There have been mixed results in studies of both humans and animal models on the effects of either method of oxygen cessation on important infant outcomes., Objectives: In preterm or low birth weight infants, does gradual versus abrupt discontinuation of supplemental oxygen influence mortality, retinopathy of prematurity, lung function, growth or development?, Search Strategy: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language. An additional literature search of the MEDLINE and CINAHL databases was conducted in order to locate any trials in addition to those provided by the Cochrane Controlled Trials Register (CENTRAL/CCTR)., Selection Criteria: All trials utilising random or quasi-random patient allocation, in which gradual weaning was compared with abrupt discontinuation of supplemental oxygen in preterm or low birth weight infants, were eligible for inclusion., Data Collection and Analysis: The methodological quality of the eligible trial was assessed independently by each author for the degree selection, performance, attrition and detection bias. Data were extracted and reviewed independently by the each author. Results were compared and differences resolved as required. Data analysis was conducted according to the standards of the Cochrane Neonatal Review Group., Main Results: The results of the one small trial of 51 infants included in this systematic review indicate a significant reduction in vascular retrolental fibroplasia (i.e. severe ROP) for infants weaned gradually from high oxygen concentrations compared with abrupt discontinuation (RR 0.22, 95% CI 0.07-0.68). This finding was independent of the duration of oxygen therapy., Reviewer's Conclusions: The results of this systematic review provide additional evidence linking routine exposure to high ambient oxygen in the early neonatal period to the development of ROP in preterm/LBW infants. However, due to small numbers and historical oxygen monitoring techniques, they provide little assistance to clinicians with regard to the most appropriate method of oxygen weaning, gradual or abrupt, in modern neonatal care settings.

Background: Whilst the use of supplemental oxygen has a long history in neonatal care, resulting in both significant health care benefits and harms, uncertainty remains as to the most appropriate range to target blood oxygen levels in preterm and low birth weight infants. Potential benefits of higher oxygen targeting include more stable sleep patterns and improved long term growth and development. However, there may be significant deleterious pulmonary effects and health service use implications resulting from such a policy., Objectives: In preterm or low birth weight infants, does targeting ambient oxygen concentration to achieve a lower versus higher blood oxygen range, or administering restricted versus liberal supplemental oxygen, influence mortality, retinopathy of prematurity, lung function, growth or development?, Search Strategy: The standard search strategy of the Neonatal Review Group was used. An additional literature search was conducted of the MEDLINE and CINAHL databases in order to locate any trials in addition to those provided by the Cochrane Controlled Trials Register (CENTRAL/CCTR)., Selection Criteria: All trials in preterm or low birth weight infants utilising random or quasi-random patient allocation, in which ambient oxygen concentrations were targeted to achieve a lower versus higher blood oxygen range, or restricted versus liberal oxygen was administered, were eligible for inclusion., Data Collection and Analysis: The methodological quality of the eligible trials was assessed independently by each author for the degree selection, performance, attrition and detection bias. Data were extracted and reviewed independently by the each author. Data analysis was conducted according to the standards of the Cochrane Neonatal Review Group., Main Results: The restriction of oxygen significantly reduced the incidence and severity of retinopathy of prematurity without unduly increasing death rates in the meta-analysis of the five trials included in this review. The one trial that specifically addressed the question of lower versus higher PaO2 found no effect on death, but did not report (in sufficient detail to warrant inclusion) the effect of this intervention on eye or other outcomes. The effects of either of these oxygen administration policies on other clinically meaningful outcomes including chronic lung disease and long term growth, neurodevelopment, lung or visual function were not reported in any of the available trials., Reviewer's Conclusions: The results of this systematic review confirm the commonly held view of today's clinicians that a policy of unrestricted, unmonitored oxygen therapy has potential harms, without clear benefits. However, the question of what is the optimal target range for maintaining blood oxygen levels in preterm/LBW infants was not answered by the data available for inclusion in this review.

Background: When preterm infants have been given intermittent positive pressure ventilation (IPPV) for respiratory failure, weaning from support and tracheal extubation may be difficult. A significant contributing factor is thought to be the relatively poor respiratory effort and tendency to develop hypoventilation and apnea, particularly in very preterm infants. Doxapram stimulates breathing and appears to act via stimulation of both the peripheral chemoreceptors and the central nervous system. This effect might increase the chance of successful tracheal extubation., Objectives: In preterm infants being weaned from IPPV and in whom endotracheal extubation is planned, does treatment with doxapram reduce the use of intubation and IPPV, or reduce other morbidity, without clinically important side effects? In this regard, how does doxapram compare with standard treatment or with an alternative treatment such as methylxanthine or CPAP? Subgroup analyses were prespecified according to birth weight and/or gestational age, use of co-interventions (methylxanthines or nasal CPAP), and route of administration (intravenous or oral)., Search Strategy: The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE and EMBASE., Selection Criteria: Eligible studies included published trials utilising random or quasi-random patient allocation in which preterm or low birth weight infants being weaned from IPPV were given doxapram compared with standard care or other treatments, to facilitate weaning from IPPV and endotracheal extubation. Trials were independently assessed by the authors before inclusion., Data Collection and Analysis: The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. Each author extracted data separately; the results were compared and any differences resolved. The data were synthesized using the standard method of Neonatal Review Group with use of relative risk and risk difference., Main Results: Two trials involving a total of 85 infants compared doxapram and placebo. In both the individual trials and the meta-analyses there were no significant differences between the doxapram and placebo groups in any of the outcomes (failed extubation, death before discharge, respiratory failure, duration of IPPV, side effects, oxygen at 28 days or oxygen at discharge). There was a trend towards an increase in side effects (hypertension or irritability leading to cessation of treatment) in the doxapram group [summary RR 3.21 (0.53, 19.43). In one of these two trials (Huon 1998) an 'alarming rise in blood pressure' occurred in five infants in the doxapram group and none of the controls, although in only one was treatment withdrawn. One additional trial involving only eight infants compared doxapram with aminophylline, but there were insufficient data for meaningful analysis., Reviewer's Conclusions: The evidence does not support the routine use of doxapram to assist endotracheal extubation in preterm infants who are eligible for methylxanthine and/or CPAP. The results should be interpreted with caution because the small number of infants studied does not allow reliable assessment of the benefits and harms of doxapram. Further trials are required to evaluate the benefits and harms of doxapram compared with no treatment or with other treatments, such as methylxanthines or CPAP, to evaluate whether it is more effective in infants not responding to these other treatments, and to assess whether the drug is effective when given orally.

Background: Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease., Objectives: In spontaneously breathing preterm infants with RDS, to determine if continuous distending airway pressure (CDAP) reduces the need for IPPV and associated morbidity without adverse effects., Search Strategy: The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language., Selection Criteria: All trials using random or quasi-random patient allocation of newborn infants with RDS were eligible. Interventions were continuous distending airway pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharnygeal tube, or endotracheal tube, or continuous negative pressure (CNDP) via a chamber enclosing the thorax and lower body, compared with standard care., Data Collection and Analysis: Standard methods of the Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each author, were used., Main Results: CDAP is associated with a lower rate of failed treatment (death or use of assisted ventilation), overall mortality, and mortality in infants with birthweights above 1500 g. The use of CDAP is associated with an increased rate of pneumothorax., Reviewer's Conclusions: In preterm infants with RDS the application of CDAP either as CPAP or CNDP is associated with some benefits, particularly in infants with birthweights over 1500 gms. The extent of this benefit is difficult to assess given the outdated methods to administer CDAP, low use of antenatal corticosteroids, non-availability of surfactant and the intensive care setting of the 1970's in which these trials were done. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings

Background: This section is under preparation and will be included in the next issue., Objectives: In preterm or low birth weight infants, does targeting ambient oxygen concentration to achieve a lower versus higher blood oxygen range, or administering restricted versus liberal supplemental oxygen, influence mortality, retinopathy of prematurity, lung function, growth or development?, Search Strategy: The standard search strategy of the Neonatal Review Group was used. An additional literature search was conducted of the MEDLINE, EMBASE, and CINAHL databases in order to locate any trials in addition to those provided by the Cochrane Controlled Trials Register (CENTRAL/CCTR)., Selection Criteria: All trials in preterm or low birth weight infants utilising random or quasi-random patient allocation, in which ambient oxygen concentrations were targeted to achieve a lower versus higher blood oxygen range, or restricted versus liberal oxygen was administered, were eligible for inclusion., Data Collection and Analysis: The methodological quality of the eligible trials was assessed independently by each author for the degree selection, performance, attrition and detection bias. Data were extracted and reviewed independently by the each author. Data analysis was conducted according to the standards of the Cochrane Neonatal Review Group., Main Results: The restriction of oxygen significantly reduced the incidence and severity of retinopathy of prematurity without unduly increasing death rates in the meta-analysis of the five trials included in this review. The one trial that specifically addressed the question of lower versus higher PaO2 found no effect on death, but did not report (in sufficient detail to warrant inclusion) the effect of this intervention on eye or other outcomes. The effects of either of these oxygen administration policies on other clinically meaningful outcomes including chronic lung disease and long term growth, neurodevelopment, lung or visual function were not reported in any of the available trials., Reviewer's Conclusions: The results of this meta-analysis confirm the commonly held view of today's clinicians that a policy of unrestricted, unmonitored oxygen therapy has potential harms, without clear benefits. However, the question of what is the optimal target range for maintaining blood oxygen levels in preterm/LBW infants was not answered by the data available for inclusion in this review.

Background: Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease., Objectives: In spontaneously breathing preterm infants with RDS, to determine if continuous distending pressure (CDP) reduces the need for IPPV and associated morbidity without adverse effects., Search Strategy: The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE (1966-Jan. 2000), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language., Selection Criteria: All trials using random or quasi-random patient allocation of newborn infants with RDS were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube, or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body, compared with standard care., Data Collection and Analysis: Standard methods of the Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each author, were used., Main Results: CDP is associated with a lower rate of failed treatment (death or use of assisted ventilation), overall mortality, and mortality in infants with birthweights above 1500 g. The use of CDP is associated with an increased rate of pneumothorax., Reviewer's Conclusions: In preterm infants with RDS the application of CDP either as CPAP or CNP is associated with some benefits in terms of reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. The applicability of these results to current practice is difficult to assess, given the outdated methods to administer CDP, low use of antenatal corticosteroids, non-availability of surfactant and the intensive care setting of the 1970s when these trials were done. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings

One hundred and fifty-three infants were assessed by a method specific to preterm infants and appropriate to the intensive-care nursery environment. The presence or absence of six atypical features (coarse jitters, dominant asymmetrical tonic neck reflex, paucity of movement, 'contradictory' development, hypotonia, or hypertonia) resulted in neonatal classification. There were 116 'usual' (an absence of atypical features with progressive development), 26 'unusual' (a transient occurrence of any atypical feature), and 11 'suspect' (dominance of one or more atypical features). At 6 years of age the motor subsystems of balance, coordination, fine and gross motor, and associated movements were assessed. Nine of 11 children with cerebral palsy had neonatal categories of 'suspect' (7) and 'unusual' (2), of the remaining four other 'suspect' children, two failed two motor subsystems and two failed motor items. A 'usual' neonatal assessment predicted normal motor outcome for 72 of 116 (62%) whereas a 'suspect' assessment predicted major motor dysfunction for seven of 11 of the children.

Objectives: To assess: (i) the size of placental transfusion following a 30 s delay in cord clamping following vaginal and Caesarean births; and (ii) the feasibility of delaying cord clamping in the labour ward and particularly in the operating theatre., Methods: Fourty-six infants born at 26-33 weeks gestation were randomized to having the umbilical cord clamped either immediately or 30 s after birth. The venous haematocrit was measured at 1 and at 4 h of age., Results: There were trends towards higher mean haematocrits in the infants following delayed clamping, but these were not significant either at 1 h (55 +/- 7.7 vs 52.9 +/- 7) or at 4 h of age (55 +/- 7 vs 52.5 +/- 7). The trends were more marked in the infants born by Caesarean section, and in those born at 26-29 weeks gestation., Conclusions: A 30 s delay in cord clamping is feasible at both vaginal and Caesarean births, but does not lead to the predicted difference in infant haematocrit. Although physiological studies suggest that a placental transfusion of 15-20 mL/kg occurs within 30 s of delivery, these data suggest that future trials should either delay cord clamping for more than 30 s, or should alter the position of the infant in relation to the uterus in order to facilitate the transfusion. Delayed cord clamping is feasible at Caesarean section.

Objective: The Neonatal Early Discharge and Family Support Programme (NEDP) was an initiative aimed at providing extended care for families whose infants had required neonatal special care, thereby allowing earlier discharge., Methodology: Two groups of families were examined; one before and one after the instigation of the NEDP. Hospital and community service usage and psychosocial effects were examined., Results: Families who received support were able to be discharged earlier and rooming-in was unnecessary as support was provided at home. Visits to family doctors for mothercraft issues were less frequent. Transport of babies from the Level 3 nursery to other nurseries in order to be closer to home was also provided by the nursing team, saving on ambulance costs and freeing their time for emergencies. There was no increase in maternal anxiety and infants were less difficult in the patient group., Conclusions: NEDP and family support programme is a worthwhile extension of neonatal intensive care.

Compared with term infants, little information is available about the usefulness of the umbilical artery pH in relation to outcome in extremely preterm infants. This prospective study evaluates the relation between umbilical artery pH (UapH), Apgar scores, perinatal events, and outcome in infants born at less than 32 weeks' gestation. Six hundred and twenty three infants of < 32 weeks' gestation were studied. The median UapH was 7.25, with a range of 6.78-7.49. A low UapH was significantly associated with male sex, hyaline membrane disease, grade 3 or 4 intraventricular haemorrhage, and neonatal death. It was also associated with lower birth weight and lower birthweight centile. The relations between the UapH and outcomes of neonatal death, cerebral palsy, and developmental quotient at 1 year, and other perinatal risk factors were then examined using multiple logistic regression. After adjusting for other risk factors, UapH was not significantly associated with any outcome. In contrast, a low one minute Apgar (< 4) remained a significant risk factor, with odds ratios of 2.7 (95% confidence interval (CI) 1.5 to 5.2) for neonatal death and 3.8 (95% CI 1.4 to 10.4) for cerebral palsy.

The prone and supine resting postures of the pelvis and legs of 106 preterm infants (25 to 34 weeks gestation) were studied longitudinally between 30 and 38 weeks post-menstrual age. All the infants subsequently had normal motor development. Posture was graded in relation to three items: the angle of elevation of the pelvis and the weight-bearing surface of the knee in prone, and the angle of rotation of the leg in supine. Although no grade was found to be exclusive to a particular postmenstrual age, all three items showed a statistically significant progressive trend. Only less than 6 per cent of the infants regressed in grade during the study. Infants dependent on oxygen for more than 28 days had significantly lower grades for leg posture in both prone and supine. Posture was not significantly altered by time ex utero or by intra-uterine growth retardation. The results show that these observation items are suitable measures of the progressive development of antigravity postures of preterm infants.

Submental electromyorgams (SM EMG) were recorded from 20 preterm babies (gestational age 30 +/- 2 wk, postmenstrual age at study 35 +/- 2 wk) (mean +/- SD) and 3 full-term infants (7-14 days old). SM EMG was evaluated during eupnea and brief experimental airway occlusion. Phasic inspiratory SM EMG was rarely seen during eupnea. SM EMG tended to increase on the first occluded effort, although this increase was not statistically significant in most babies. All infants showed progressive breath-by-breath augmentation of phasic SM EMG during occlusions in rapid-eye-movement (REM) as well as quiet (QS) sleep; phasic increases in SM EMG were similar during REM and QS occlusions in the majority (16/22) of babies. Periods of airway closure were detected during 24 occlusions in 5 infants; phasic SM EMG was reduced on these occasions. The results are consistent with the idea that recruitment of upper airway muscles contributes to the stability of the airway of the preterm human.

A case control study of neonates was performed to determine those factors contributing to the development of chronic lung disease (CLD). During the 5 years 1981-84 there were 487 neonatal survivors at gestations of 25-32 weeks; 391 of these developed respiratory failure (oxygen therapy required for more than 6 h). Fifty-six of the latter developed CLD (oxygen therapy required for more than 28 days and a coarse reticular pattern on chest X-ray). These neonates were predominantly of the shortest gestational ages, regardless of the initial chest X-ray diagnosis. Forty-three of these infants with CLD were matched for gestation and initial chest X-ray appearance (respiratory distress syndrome, n = 20; normal, n = 15; non-specific, n = 8) with 42 control infants. The mean duration of oxygen therapy (P less than 0.001), maximum FiO2 (P less than 0.001), incidence (P less than 0.01) and duration of intermittent positive pressure respiration (IPPR; P less than 0.05) and peak IPPR (P less than 0.05) were significantly greater in the CLD group. Mean birthweight (P less than 0.001), arterial cord pH (P less than 0.05) and base excess (P less than 0.05) were significantly lower in the CLD group. Factors that were not statistically significant in the development of CLD included antenatal fetal heart rate abnormality, hypertensive disease of pregnancy, acute intrauterine infection (chorioamnionitis or umbilical vasculitis), administration of antenatal steroids, sex, patent ductus arteriosus and pneumothorax. The association between CLD and ventilator/oxygen therapy is confirmed. Contrary to other reports, male sex, clinical patent ductus arteriosus and pneumothorax were not associated with CLD.

This study documents the longitudinal development of head control in 104 infants born at 25-33 weeks gestation. Protective side turning of the head was found to have a developmental sequence of reducing spinal extension. In the 93 infants with normal motor outcome, individual differences in the rate of development correlated with caudo-cephalic muscle development (P less than 0.001, r = 0.5) but not with the length of extra-uterine experience. As a group, the 11 infants with later motor handicap showed a persistence of the early form of movement at 35-39 weeks post-menstrual age, without a significant correlation with the ratio of upper-lower limb muscle development. Head control, supine to sitting, in the infants with normal motor outcome showed variations in the rate of preterm development. The infants born at less than 31 weeks showed significantly higher scores at 33-35 weeks post-menstrual age than those born at 31-33 weeks (P less than 0.01). There was no difference at later ages. The spinal extension movement accompanying protective side turning of the head is age specific to the preterm infant. Individual rates of normal preterm development can be evaluated by longitudinal standardised examination. As a group, the infants with subsequent abnormal motor development showed delay at preterm age but this was not individually significant.