Atlas 2018 - 1. Neonatal and paediatric health

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Key findings and recommendations

Early planned caesarean section without medical or obstetric indication

Planned early birth is an important intervention in maternity care, but the timing of birth should be carefully considered to optimise the outcome. There is a growing body of evidence that planned caesarean section before 39 weeks’ gestation can increase:

  • Short-term risks, including neonatal respiratory problems and the risk of hospitalisation for infections in the first five years of life1-4
  • Long-term developmental problems, poorer school performance and attention deficit hyperactivity disorder (ADHD).5-8

Waiting until 39 weeks’ gestation for a planned caesarean section, if there are no medical reasons for earlier birth, is now recommended by several international organisations and some Australian states.

The Atlas found that, in 2015, between 42% and 60% of planned caesarean sections performed before 39 weeks’ gestation did not have a medical or obstetric indication, and between 10% and 22% of caesarean sections performed before 37 weeks did not have a medical or obstetric indication. These data have recently begun to be collected routinely in Australia; four states and territories with sufficient data have been reported. Rates were generally higher for privately funded patients than for publicly funded patients.

Antibiotics in children

The rate of antibiotic use in children in Australia is high compared with other similar countries. For example, Australia’s use in children aged 0–9 years is three times higher than in Norway and the Netherlands.9 In many cases, antibiotics are not needed; for example, most upper respiratory tract infections in children are due to viruses, and antibiotics are ineffective for these. Overuse of antibiotics contributes to bacterial resistance, meaning that antibiotics may be less effective in the future for the child and others in the community.10,11 Emerging research also suggests that changes to the normal gut bacteria caused by antibiotics may increase the risk of chronic disease in children, such as asthma and Crohn’s disease.12-16

The Atlas found high rates of antibiotic use in children, with more than 3 million antibiotic prescriptions dispensed for children aged 0–9 years in 2016–17.

Inappropriate use of proton pump inhibitor medicines in infants

Proton pump inhibitor (PPI) medicines are sometimes used to treat infants with simple reflux or colicky symptoms, such as irritability or crying17,18, even though there is evidence that they are not effective in these situations.19 These medicines reduce the level of stomach acid, and children taking them are more likely to get infections such as gastroenteritis and pneumonia.20 PPI medicines can also change the gut microbiome, which may increase the child’s risk of developing allergies.13,21

The Atlas found about a four-fold difference between the lowest and highest state and territory rates in Pharmaceutical Benefits Scheme (PBS) dispensing of PPI medicines for infants aged 1 year and under in Australia.

Recommendations

Early planned caesarean section without medical or obstetric indication

1a. Local Hospital Networks, health service organisations and clinicians to have systems in place to obtain fully informed patient consent for planned caesarean section by providing prospective parents with comparative information on the short- and long-term risks of planned early‑term caesarean section without a medical or obstetric indication.

1b. The Medicare Benefits Schedule (MBS) Review Taskforce to review item 16519 (Management of labour and birth by any means including caesarean section), and ensure that item descriptors align with current clinical evidence and support a gestation period of at least 39 weeks unless there are medical or obstetric indications.

1c. Relevant colleges to initiate a joint project to develop evidence-based guidance, education and consumer information on early planned caesarean section without a medical or obstetric indication. This guidance should emphasise the need to ensure that potential risks for both mother and baby are discussed with the prospective parents.

1d. Local Hospital Networks and health service organisations to have systems in place, as part of their clinical governance processes, for regular review and reporting of rates of early planned caesarean section without a medical or obstetric indication, and for addressing unwarranted variation.

1e. All states and territories to ensure consistent, routine collection and reporting of data on gestational age for planned caesarean section without a medical or obstetric indication to improve the quality of data collections. This should include reporting of gestational age in days to allow more in-depth understanding of the distribution of births occurring before 39 weeks.

1f. The National Health and Medical Research Council to consider funding research to identify the effects of gestational age and delivery method on childhood development.

1g. The Commission to investigate the potential to include early planned caesarean section without a medical or obstetric indication in the national list of hospital-acquired complications, given the evidence about potential short- and long‑term risks.

Inappropriate use of proton pump inhibitor medicines and antibiotics in children

1h. The Pharmaceutical Benefit Advisory Committee to recommend PBS streamlined authority required listings for PPI medicines that have Therapeutic Goods Administration-approved indications in infants and children, such as gastro‑oesophageal reflux disease.

1i. NPS MedicineWise to ensure that its public education campaigns highlight the potential harms of inappropriate antibiotic use in children, and provide advice for parents on managing coughs, colds, earaches and sore throats without the use of antibiotics.

1j. The Commission, as part of the Antimicrobial Use and Resistance in Australia Surveillance System, to monitor antibiotic use in children in hospitals and the community.

1k. The National Health and Medical Research Council to consider funding research into approaches to reduce antibiotic overuse in children, particularly in acute respiratory infections when antibiotics are most commonly prescribed.

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Note:

Data for Early planned caesarean section without medical or obstetric indication
The national data collection for this indicator is relatively new in Australia, and many states and territories do not yet collect all elements consistent with the national specification. For this reason, the data used for the Atlas for individual states are not available for publication.