During 1988 and 1989, a regional cohort of 81 infants with birth weights less than 1501 g were treated with oxygen only (n = 11), early continuous positive airway pressure (CPAP) (n = 68) or mechanical ventilation from birth (n = 2). We used an easily applicable lightweight CPAP system with nasal prongs and a gas jet supplemented with ventilator treatment if necessary, but with conservative criteria for ventilator treatment with tolerance of high PCO2. A total of 65 infants (80%) survived to discharge, 61 of whom were supported solely with CPAP or oxygen. Nineteen infants (26%) developed periventricular-intraventricular haemorrhage, but only 4 survivors (6%) developed prognostically significant bleedings grade 2-4. No survivors had bronchopulmonary dysplasia. Follow-up at 12-39 months of age revealed definite disabilities in 6 (10%) and suspected disabilities in 2 of 62 long-term survivors. The results suggest that treatment by early CPAP with nasal prongs with tolerance of high PCO2 may be effective and lenient in most infants more than 25 weeks' gestation.

The Scandinavian approach is an effective combined treatment for respiratory distress syndrome (RDS) and prevention of bronchopulmonary dysplasia (BPD). It is composed of many individual parts.Of significant importance is the early treatment with nasal continuous positive airway pressure (nCPAP) and surfactant treatment. The approach may be supplemented with caffeine citrate and non-invasive positive pressure ventilation for apnoea. The low incidence of BPD seen as a consequence of the treatment strategy is mainly due to a reduced need for mechanical ventilation (MV).Conclusion: Early-postnatal treatment with nCPAP and surfactant decreases the severity and mortality of RDS and BPD. This is mainly due to a diminished use of MV in the first days of life.

Aim: To describe and analyse neonatal care, short and long‐term morbidity with special reference to ventilatory support and chronic lung disease (CLD) in a population‐based study. Methods: During 1994 and 1995 a prospective, nation‐wide, multicentre study was conducted, comprising 477 liveborn infants with gestational age (GA) >28 wk and/or birthweight >1000 g. Of these, 407 infants received active treatment. The ventilatory treatment was based on the principle of permissive hypercapnia and early nasal continuous positive airway pressure (NCPAP) supplemented with surfactant and ventilator therapy in case of CPAP failure. Results: Among actively treated infants 85% received CPAP and 23% mechanical ventilation from the first day of life. A total of 269 infants (56%) survived to discharge. Of these, 195 had a GA >28wk. One‐hundred and five survivors with GA >28 wk survived with NCPAP as sole respiratory support. In surviving infants, periventricular leucomalacia/intraventricular haemorrhage grade 3–4 was found in 10%, retinopathy of prematurity grade >2 in 4%, and oxygen requirement at 36 and 40 wk of postmenstrual age (CLD) in 16 and 5%, respectively. Three infants either died of CLD (n= 1) or required oxygen therapy beyond 43 wk of postmenstrual age. Logistic regression analysis showed significant associations between oxygen requirement at 40 wk and GA, septicaemia, mechanical ventilation, symptomatic patent ductus arteriosus and Clinical Risk Index for Babies score. Only the two last‐mentioned factors proved significant in infants with GA >28 wk. No infant died after discharge and 253 (94%) were followed up at 2 y of corrected age; one or more moderate to severe impairments were found in 66 (26%) of the examined children. Conclusion: Ventilatory treatment in extremely premature and extremely low‐birthweight infants based on early NCPAP and permissive hypercapnia may result in comparable survival rates and sensorineural outcome; however, the incidence of CLD seems lower than that reported on conventional treatment.

Continuous positive airway pressure (CPAP) was introduced in 1971 and at that time welcomed as ‘the missing link’ between oxygen and ventilator treatment of premature infants. Originally CPAP was administered by tracheal tube (or head box) which because of the inherent risk of complications necessitated a cautious approach. New, more simple and less risky methods of application, such as nasal CPAP (N-CPAP), permitted earlier treatment which in randomized trials showed a reduction in inspired oxygen concentration, reduced need for mechanical ventilation and a reduction in the rate of death. Early N-CPAP/minimal handling today is an established first-line treatment in a number of centers in Denmark and Sweden, while N-CPAP outside Scandinavia apparently is used less often. However, recently the method has gained new interest as more publications have demonstrated that N-CPAP/minimal handling is both feasible and effective in most very-low-birth-weight infants. Early rescue treatment with fast-acting surfactant, given during a brief intubation, has increased the effectiveness of N-CPAP further. Descriptive studies on N-CPAP suggest that the risk of bronchopulmonary dysplasia may be lower than in conventional intensive treatment because of the relatively low need for mechanical ventilation. This question is at the present time being addressed in a randomized controlled trial in England.

During a 3-year period (1979-81) 85 premature infants with idiopathic respiratory distress (IRDS) were treated early with an easily applicable light-weight CPAP-system with a binasal tube and a gas jet. We used conservative criteria for ventilator treatment. The treatment proved sufficient in 18 out of 25 infants with a birth weight less than or equal to 1500 g and in 53 out of 60 infants with a birth weight greater than 1500 g. Seven infants developed pneumothorax during CPAP treatment. Seventy-four infants survived, all without bronchopulmonary dysplasia. At the age of 1.5-4.5 years the incidence of respiratory tract infections did not differ from that in a group of siblings; and the incidence of lower respiratory tract infections was low compared to previous studies. With the criteria used, early CPAP proved effective in the majority of infants with IRDS.

Pedersen O, Herskind AM, Kamper J, Nielsen JP, Kristensen K. Rehospitalization for respiratory syncytial virus infection in infants with extremely low gestational age or birthweight in Denmark. Acta Paediatr 2003; 92: 240-242. Stockholm. ISSN 0803-5253 Aim: To determine the risk of rehospitalization for respiratory syncytial virus (RSV) infection during the first 2 y of life in extremely preterm infants. Methods: Records on all rehospitalizations during the first 2 living years of all infants born with gestational age <28 wk or birthweight <1000 g during 1994 and 1995 in Denmark were retrospectively reviewed. Results: Among 240 eligible infants, 43 (18%) had been rehospitalized 48 times owing to RSV. In infants (n = 210) without CLD the risk of rehospitalization for RSV was 16%, whereas in infants with CLD (n = 30) it was 30% ( p = 0.065). Eighteen infants (38%) required respiratory support (supplemental oxygen only 3, continuous positive airway pressure 14, mechanical ventilation 1). Apart from CLD the only factor that could be associated with increased risk of hospitalization for RSV was discharge during autumn ( p = 0.05). No infant died from RSV infection. Conclusion:The high rate of rehospitalization for RSV in extremely preterm infants in Denmark, especially in infants with CLD, should lead to considerations concerning more widespread use of prophylaxis against RSV in these infants.

Portal hypertension is a rarely encountered late complication of umbilical vein catheterization. A survey of the 38 cases previously published is presented together with an additional case report. It is concluded that catheterization for more than 2 days carries an increased risk of thrombosis, and that umbilical artery catheterization should be preferred in the majority of cases due to a reduced risk of complications. The correct position of the catheter tip must always be controlled by fluoroscopy or X-ray. Infusion of hypertonic solutions with unphysiological pH should be restricted and umbilical vessel catheterization should only be carried out in severe cases. Pretreatment of the catheters with heparin possibly reduces the hazards.

In this study of infants treated with a regimen of early NCPAP/minimal handling, we found a relatively low incidence of handicaps and impairments. Nearly 90% attended ordinary schools, with near-average performances in mathematics and reading/spelling, which were not statistically different to their siblings. The overall results indicate that these infants fare at least as well as survivors after conventional treatment.