PEDIATRICS Vol. 114 No. 5 November 2004, pp. 1374-1375 (doi:10.1542/10.1542/peds.2004-1639)
Effectiveness of Neonatal Intensive Care for Extremely Low Birth Weight Infants: In Reply
Lex W. Doyle, MD, FRACPDepartment of Obstetrics and Gynaecology
Royal Women's Hospital
Carlton, Victoria 3053, Australia
Dr Kilbride is concerned that we have overinterpreted the data in our reports of the effectiveness1 and efficiency2 of neonatal intensive care and particularly that we have overlooked the contribution of obstetric interventions. What we have done is to quantitate the overall effectiveness of neonatal intensive care, without trying to measure the individual contributors, including obstetric interventions, to the outcomes. We also incorporated postneonatal care by including any hospitalizations beyond 28 days up to 5 years of age (2 years of age for the 1997 era).
We agree with Dr Kilbride in that obstetric care has changed over the 2 decades of our study and that obstetric decision-making for extremely low birth weight (ELBW; birth weight: 500–999 g) infants is important to their outcome. The overall contribution of obstetric care might be best quantitated in the changes in availability of neonatal intensive care for ELBW infants, the final step in the overall evaluation of neonatal intensive care.3 Availability addresses the issue of whether intensive care is reaching those who need it. We have reported elsewhere on the changing availability of neonatal intensive care for ELBW infants in Victoria, Australia.4 As measures of availability, we determined the changes in both the proportion of ELBW infants who were offered intensive care as well as the place of birth of these infants. Over time, the proportions offered intensive care rose substantially from 58% in 1979–1980 to 90% in 1997. At the same time, 30% of infants were born outside a tertiary perinatal center in 1979–1980, falling to 9% by 1997. Because the decisions about offering intensive care and especially about place of birth are in large part determined after discussion between obstetricians, pediatricians, and families, it is clear that obstetrics has indeed contributed to the improvements we have observed in the overall outcome of ELBW infants born in Victoria over almost 2 decades.
To assess the overall effectiveness of obstetric care, we would need inception cohorts starting in the uterus rather than at birth, as we have done for evaluating neonatal care. Such a study would be possible but would probably need to be based on gestational age rather than birth weight, because there is no method accurate enough for estimating weight in the uterus to determine who will ultimately be ELBW.
REFERENCES
- Doyle LW; Victorian Infant Collaborative Study Group. Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: I. Effectiveness.
Pediatrics. 2004;113
:505
–509
[Abstract/Free Full Text] - Doyle LW; Victorian Infant Collaborative Study Group. Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: II. Efficiency.
Pediatrics. 2004;113
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[Abstract/Free Full Text] - Sinclair JC, Torrance GW, Boyle MH, Horwood SP, Saigal S, Sackett DL. Evaluation of neonatal-intensive-care programs. N Engl J Med. 1981;305 :489 –494[Abstract]
- Doyle LW; Victorian Infant Collaborative Study Group. Changing availability of neonatal intensive care for extremely low birthweight infants in Victoria over two decades. Med J Aust. 2004;181 :136 –139[Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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Related articles in Pediatrics:
- Effectiveness of Neonatal Intensive Care for Extremely Low Birth Weight Infants
- Howard W. Kilbride
Pediatrics 2004 114: 1374.[Extract] [Full Text]
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