Neonates with tongue-based airway obstruction: a systematic review.

OBJECTIVE: In this systematic review, the authors summarize the current evidence in the literature regarding diagnosis, treatment, and long-term outcomes in neonates with tongue-based airway obstruction (TBAO) and assess the level of evidence of included studies. DATA SOURCES: The terms Pierre Robin syndrome/sequence, micrognathia, retrognathia, and cleft palate were combined with airway obstruction, treatment, tongue-lip plication, and osteogenesis distraction to perform an Ovid literature search, yielding 341 references. The authors excluded references containing patients with isolated choanal/nasal obstruction, patients older than 12 months, and expert opinion papers, yielding 126 articles. REVIEW METHODS: The authors searched 3 electronic databases and reference lists of existing reviews from 1980 to October 2010 for articles pertaining to the diagnosis, treatment, and outcomes of TBAO. Reviewers assigned a level of evidence score based on Oxford's Centre for Evidence Based Medicine scoring system and recorded relevant information. RESULTS: Most studies were case studies and single-center findings. The lack of standardization of diagnostic and treatment protocols and the heterogeneity of cohorts both within and between studies precluded a meta-analysis. There was little evidence beyond expert opinion and single-center evaluation regarding diagnosis, treatment, and long-term outcomes of neonates with TBAO. CONCLUSIONS: The variability in the phenotype of the cohorts studied and the absence of standardized indications for intervention preclude deriving any definitive conclusions regarding diagnostic tools to evaluate this patient population, treatment choices, or long-term outcomes. A coordinated multicenter study with a standardized diagnostic and treatment algorithm is recommended to develop evidence for the diagnosis and treatment of neonates with TBAO.

Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement.

OBJECTIVE: To reduce maternal and neonatal death at a large regional hospital through the use of quality improvement methodologies. METHODS: In 2007, Kybele and the Ghana Health Service formed a partnership to analyze systems and patient care processes at a regional hospital in Accra, Ghana. A model encompassing continuous assessment, implementation, advocacy, outputs, and outcomes was designed. Key areas for improvement were grouped into "bundles" based on personnel, systems management, and service quality. Primary outcomes included maternal and perinatal mortality, and case fatality rates for hemorrhage and hypertensive disorders. Implementation and outcomes were evaluated tri-annually between 2007 and 2009. RESULTS: During the study period, there was a 34% decrease in maternal mortality despite a 36% increase in patient admission. Case fatality rates for pre-eclampsia and hemorrhage decreased from 3.1% to 1.1% (P<0.05) and from 14.8% to 1.9% (P<0.001), respectively. Stillbirths were reduced by 36% (P<0.05). Overall, the maternal mortality ratio decreased from 496 per 100000 live births in 2007 to 328 per 100,000 in 2009. CONCLUSION: Maternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.

Educational impact of a hospital-based neonatal resuscitation program in Ghana.

AIM OF THE STUDY: To assess midwives' baseline cognitive knowledge of evidence-based neonatal resuscitation practices, and short- and long-term educational effects of teaching a neonatal resuscitation program in a hospital setting in West Africa. METHODS: All midwives (n=14) on the labor ward at Ridge Hospital in Ghana were trained using materials modified from the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP). This training program included didactic and practical teaching and was assessed by direct observation within delivery rooms and written pre- and post-test evaluations. Written and practical modules 9-12 months after the initial training session were also conducted to assess retention of NRP knowledge and skills. RESULTS: Fourteen midwives received NRP training on the labor ward. Both written and practical evaluation of neonatal resuscitation skills increased after training. The percentage of items answered correctly on the written examination increased from 56% pre-training to 71% post-training (p<0.01). The percentage of items performed correctly on the practical evaluation of skills increased from 58% pre-training to 81% (p<0.01). These results were sustained 9-12 months after the initial training session. CONCLUSION: After receiving NRP training, neonatal resuscitation knowledge and skills increased among midwives in a hospital in West Africa and were sustained over a 9-month period. This finding demonstrates the sustained effectiveness of a modified neonatal resuscitation training program in a resource constrained setting.

Using quality-improvement methods to reduce variation in surfactant administration.

BACKGROUND: Respiratory distress syndrome and chronic lung disease are prevalent disorders in extremely low-birth-weight infants. Evidence demonstrates that timely surfactant administration improves respiratory outcomes. OBJECTIVE: To assess whether basic quality-improvement methods can reduce the time to initial surfactant dose for premature infants. DESIGN/METHODS: The study was conducted in a 48-bed neonatal intensive care unit (NICU) within a midsize academic centre. The authors included infants less than 27 weeks born from May 2007 to November 2007. Prior to the intervention, we obtained baseline data on the timing of initial surfactant dose. The intervention was designed using a series of Plan-Do-Study-Act cycles. The authors changed the process of surfactant administration to include administration of surfactant in the delivery room and a respiratory therapist on the delivery room team. The primary outcome measures were percentage of eligible infants who received surfactant in the delivery room and minutes after delivery at which the initial dose of surfactant was administered. RESULTS: After the authors changed the surfactant administration process, 20/21 (95%) of eligible infants received surfactant in the delivery room. The authors decreased the time after delivery of initial surfactant dose from a mean of 26 min to 10.2 min (p=0.0004). The variation in timing of the initial surfactant dose also decreased. CONCLUSIONS: The authors demonstrated that quality-improvement methods can be used to improve the timeliness and reduce variation in timing of surfactant administration within a NICU. Future studies should assess whether these results can be replicated in a variety of NICU settings.

Mild fetal cerebral ventriculomegaly: diagnosis, clinical associations, and outcomes.

The normal fetal lateral ventricular diameter remains stable at 10 mm over gestation. Mild ventriculomegaly, defined as a lateral ventricular diameter of >or=10 mm but or=3 mm but