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The objectives of this paper are to examine (a) the survival of extremely low-gestational-age (ELGA) infants born at 23-28 weeks' gestational age (GA) and (b) the neurodevelopmental outcome at 18 months corrected age for those born at 23-25 weeks' GA during 1991-1993, when antenatal steroids, surfactant, and dexamethasone for bronchopulmonary dysplasia had become accepted treatments; and to compare with an earlier (1983-1989), previously published large cohort (in a presurfactant era) from our institution. Perinatal and neonatal data on all births delivered at 23-28 weeks' GA at British Columbia's tertiary perinatal center were analyzed for survival rates by GA. Survivors of those born at 23-25 weeks' GA underwent neurodevelopmental assessment at a corrected chronological age of 18 months. The recent cohort (n = 333) of live birth infants, compared to the earlier cohort (n = 911 ) showed a trend toward an overall improved survival to discharge (72 vs. 65%, p = 0.06). Further analysis showed that improved survival was seen only in 26- to 28-week GA infants (86 vs. 76%, p = 0.01), but not in 23- to 25-week GA infants (44 vs. 44%, p = 0.9), even when adjusted for gender or twin births. In addition, the incidence of major impairment at 18 months (36% in both periods) remained high. Reanalysis of 24- to 25-week GA infants again showed no evidence of improved survival (53 vs. 50%) or improved outcome at 18 months (major handicap rate 32%; vs. 34%). Survival rates improved for 26- to 28-week GA infants, but the survival rate and incidence of major impairment had not improved for of 23- to 25-week GA infants.

The antinuclear antibody test (ANA) is a much overused test in pediatrics. The ANA does have a role in serologic testing but it should be a very limited one. It is often ordered as a screening test for rheumatic illnesses in a primary care setting. However, since it has low specificity and sensitivity for most rheumatic and musculoskeletal illnesses in children, it should not be ordered as a screening test for non-specific complaints such as musculoskeletal pain. It should only be used as a diagnostic test for children with probable Systemic Lupus Erythematosus (SLE) or Mixed Connective Tissue Disease, (MCTD) and other possible overlap-like illnesses. Such children should have developed definite signs and symptoms of a disease before the ANA is ordered. This review presents data supporting these conclusions and a review of the ANA literature in adults and children.By limiting ANA testing, primary care providers can avoid needless venipuncture pain, unnecessary referrals, extra medical expenses, and most importantly, significant parental anxieties. It is best not to do the ANA test in most children but if it ordered and is positive in a low titer (<1:640), the results can be ignored if the child is otherwise well and does not have other features of a systemic illness.

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