Exploring variation in quality of care and clinical outcomes between neonatal units: a novel use for the UK National Neonatal Audit Programme (NNAP).

Neonatology is a relatively new specialty, in which much of the practice remains non-evidence based. Variation in the quality of care delivered is recognised but measuring this is challenging. One possible indicator of this is variation in practice. For more than a decade, the National Neonatal Audit Project (NNAP) has described variation in practice between UK neonatal units in relation to its annually reviewed audit measures. These are based on evidence based national standards or developed by a consensus method and have become de facto measures defining good quality of neonatal healthcare within the UK. In this article we explore the practicality of using the NNAP to look for associations between quality of care and outcomes. This would not be to validate the measures but could help towards a better understanding of the reasons underlying recognised variation in outcomes, even between neonatal units of the same designation.

The impact of level of neonatal care provision on outcomes for preterm babies born between 27 and 31 weeks of gestation, or with a birth weight between 1000 and 1500 g: a review of the literature.

OBJECTIVE: There is evidence that birth and care in a maternity service associated with a neonatal intensive care unit (NICU) is associated with improved survival in preterm babies born at <27 weeks of gestation. We conducted a systematic review to address whether similar gains manifested in babies born between 27+0 and 31+6 weeks (hereafter 27 and 31 weeks) of gestation, or in those with a birth weight between 1000 and 1500 g. METHODS: We searched Embase, Medline and CINAHL databases for studies comparing outcomes for babies born between 27 and 31 weeks or between 1000 and 1500 g birth weight, based on designation of the neonatal unit where the baby was born or subsequently cared for (NICU vs non-NICU setting). A modified QUIPS (QUality In Prognostic Studies) tool was used to assess quality. RESULTS: Nine studies compared outcomes for babies born between 27 and 31 weeks of gestation and 11 studies compared outcomes for babies born between 1000 and 1500 g birth weight. Heterogeneity in comparator groups, birth locations, gestational age ranges, timescale for mortality reporting, and description of morbidities facilitated a narrative review as opposed to a meta-analysis. CONCLUSION: Due to paucity of evidence, significant heterogeneity and potential for bias, we were not able to answer our question-does place of birth or care affect outcomes for babies born between 27 and 31 weeks? This supports the need for large-scale research to investigate place of birth and care for babies born in this gestational age range.

Optimising neonatal service provision for preterm babies born between 27 and 31 weeks gestation in England (OPTI-PREM), using national data, qualitative research and economic analysis: a study protocol.

INTRODUCTION: In England, for babies born at 23-26 weeks gestation, care in a neonatal intensive care unit (NICU) as opposed to a local neonatal unit (LNU) improves survival to discharge. This evidence is shaping neonatal health services. In contrast, there is no evidence to guide location of care for the next most vulnerable group (born at 27-31 weeks gestation) whose care is currently spread between 45 NICU and 84 LNU in England. This group represents 12% of preterm births in England and over onr-third of all neonatal unit care days. Compared with those born at 23-26 weeks gestation, they account for four times more admissions and twice as many National Health Service bed days/year. METHODS: In this mixed-methods study, our primary objective is to assess, for babies born at 27-31 weeks gestation and admitted to a neonatal unit in England, whether care in an NICU vs an LNU impacts on survival and key morbidities (up to age 1 year), at each gestational age in weeks. Routinely recorded data extracted from real-time, point-of-care patient management systems held in the National Neonatal Research Database, Hospital Episode Statistics and Office for National Statistics, for January 2014 to December 2018, will be analysed. Secondary objectives are to assess (1) whether differences in care provided, rather than a focus on LNU/NICU designation, drives gestation-specific outcomes, (2) where care is most cost-effective and (3) what parents' and clinicians' perspectives are on place of care, and how these could guide clinical decision-making. Our findings will be used to develop recommendations, in collaboration with national bodies, to inform clinical practice, commissioning and policy-making. The project is supported by a parent advisory panel and a study steering committee. ETHICS AND DISSEMINATION: Research ethics approval has been obtained (IRAS 212304). Dissemination will be through publication of findings and development of recommendations for care. TRIAL REGISTRATION NUMBER: NCT02994849 and ISRCTN74230187.

Does placental MDSC-mediated modulation of arginine levels help protect the foetus from auxotrophic pathogens?

Myeloid-derived suppressor cells (MDSCs) are immunosuppressive precursors of dendritic cells, macrophages and granulocytes. MDSCs normally quickly differentiate, but have elevated levels in chronic infection and cancer, where they help tumours evade the immune system through induction of T-cell dysfunction. MDSC levels are also raised in pregnancy, and in the neonate. During pregnancy they may help to prevent maternal rejection of the semiallogenic foetus. In the immediate postnatal period they may aid in allowing tolerance of gut microbiological colonisation and non-pathological environmental antigens. MDSC immunosuppression involves reduction of arginine levels, which leads to downregulation of T-cell receptor (TCR) and cell proliferation. Arginine is also involved in replication, and virulence of a variety of viruses and bacteria, including Hepatitis D, HIV-1, Herpes simplex, Adenovirus, Staphylococci, Neisseria gonorrhoea, Escherichia coli, and Streptococci. Given the above it could be hypothesised that MDSC-mediated reduction in levels during pregnancy and the perinatal period is not just a by-product of T-cell immunosuppression, but potentially a primitive part of the innate immune system. Increased arginase activity would therefore serve a dual purpose, inhibiting the adaptive immune system whilst also providing a degree of protection against infection by arginine auxotrophic pathogens.

Newborn pulse oximetry screening in practice.

The concept of using pulse oximetry (PO) as a screening test to identify newborn babies with critical congenital heart defects (CCHD) before life-threatening collapse occurs has been debated for some time now. Several recent large studies have consistently shown that PO screening adds value to existing screening techniques with over 90% of CCHDs detected. It can also help identify newborn babies with low oxygen saturations due to infection, respiratory disease and non-critical CCHD. Many countries have now introduced PO screening as routine practice, and as screening gains more widespread acceptance in the UK, we have focused more on the practical aspects of screening in this article. This includes case reports to demonstrate how the different screening modalities for CCHD work together and the experience of hospitals that have already introduced PO screening programmes (Birmingham Women's Hospital and others). Issues discussed include how and when to screen babies in hospital, what to do with a positive screen and how to screen babies born at home. The UK National Screening Committee is currently investigating the potential feasibility of routine PO screening in the UK, and so it is perhaps a suitable time for individual hospitals to consider the possibility of introducing such screening in their maternity units.

Using CRP in neonatal practice.

OBJECTIVE: C-reactive protein (CRP) is the most widely used infection marker in neonatal practice. Combined with difficulty in early recognition of neonatal sepsis, the number of infants with risk factors for infection, and postnatal maladaptation of non-infectious origin; CRP is often used as a decision making tool for antibiotic therapy. We wished to examine practice regarding neonatal infection and use of CRP. METHODS: We designed an online multiple choice questionnaire, asking senior clinicians for their response to realistic postnatal ward scenarios. RESULTS: We had 91 replies, showing a great degree of variation, with no pattern emerging for experience, region, or even individual neonatal units. This was true even for situations covered by the guidelines that have an evidence basis. CONCLUSIONS: A recurring theme was duration of antibiotic therapy for an elevated CRP, and once levels are falling, when it is safe to stop treatment. Given a lack of good quality evidence, the National Institute of Clinical Excellence (NICE) guidelines are purposefully non-specific. Further research is required, and if incorporated in future national guidelines, should help promote more widespread use and so reduce potential over- and under-treatment of this patient subset. However, this also requires a greater willingness on the part of pediatricians to ensure practice is evidence based.

Strangulated diaphragmatic hernia presenting at 7 weeks of life as intractable shock.

A 7-week-old infant presented to hospital pale and floppy, with 5 s capillary refill time. Blood gas showed severe acidosis (pH 6.86, partial pressure of carbondioxide 10.55 kPa, base excess 21.1). Hypotension persisted despite several fluid boluses so she was intubated and started on inotropic support. A chest X-ray revealed a congenital diaphragmatic hernia (CDH). Despite steroids and blood transfusions she remained unstable, and could not be resuscitated following cardiac arrest. Postmortem revealed 39 cm of herniated, necrotic colon. 5-25% of CDH presents after the neonatal period, and while not associated with pulmonary hypoplasia is primarily still a diaphragmatic defect. In late presenting cases, herniation occurs shortly prior to developing symptoms; therefore, an antenatal ultrasound (US) cannot pick it up. If we could diagnose the isolated diaphragmatic defect antenatally, this would allow elective postnatal surgical closure. This is not feasible currently; however, with the advent of antenatal three-dimensional US scans it may be possible in the future.

Management of prelabour rupture of membranes (PROM) at term.

Over a 20-month period we identified several cases of neonatal pneumonia associated with prelabour rupture of membranes (PROM) at term. PROM complicates 8%-10% of all pregnancies, yet 60% of cases occur at term. Ascending infection is a contributing factor and the incidence of chorioamnionitis in these patients is relatively high, especially with prolonged membrane rupture. The signs and symptoms NICE recommends patients look out for are not always present as the majority of infections are subclinical, yet associated maternal and neonatal morbidity of chorioamnionitis is potentially devastating. A survey of maternity units in the West Midlands reveals significant variance in management of these cases. Given the lack of consensus and clear evidence on optimal management of PROM at term, we believe early detection of developing infections could be enhanced by using a combination of investigations (at presentation, 12 and 24 h), as well as current advice to self-monitor temperature and vaginal loss.

A neonatal case of congenital coronary artery fistula.

Coronary artery fistulae (CAF) are rare forms of congenital heart disease with an incidence of one in 50 000 live births. The authors present the case of an asymptomatic neonate with a precordial murmur. Pre and postductal saturations, blood pressure and ECG were normal. Echocardiography revealed a large right coronary artery fistula to the right ventricle (4.5 mm). At 11 months, transcatheter occlusion of the fistula with a vascular plug was performed. A year on, the child was thriving, ECG and echocardiogram remained normal. CAF complications and symptoms (including aneurysm, myocardial ischaemia, angina, heart failure and dyspnoea) are commoner in older patients, so traditionally we intervene early. With increasing case reports of spontaneous closure of even large and symptomatic fistulae, management of especially asymptomatic children is unclear. Long-term complications of intervention also remain largely unknown. As such more information is required on the conditions natural history to better manage patients and counsel parents.

Cross-over training in neonatology and obstetrics.

Neonatology is a relatively new subspeciality of paediatrics, and before this, newborn babies were often managed by obstetricians. The two fields are closely related in the continuity of care that is being provided, and both specialities involve difficult and critical decisions. From personal experience, training in both specialities, even at a junior level, allows a greater understanding of the complexities surrounding these choices and their implications. As such, I propose a short period of mandatory training in both specialities for anyone considering a career in either.

Intractable neonatal jaundice due to hereditary spherocytosis and Gilbert's syndrome.

In this article the authors present a case of pathological neonatal jaundice resistant to phototherapy in a baby with a family history of Gilbert's syndrome and hereditary spherocytosis. Her presentation was ultimately explained with a diagnosis of both conditions, and required treatment with phenobarbitone. The authors discuss the mechanism by which Gilbert's syndrome results in hyperbilirubinaemia and its similarities with Crigler-Najjar syndrome. The presentation of hereditary spherocystosis in the neonatal period is also explored, as is the mechanism of exaggerated hyperbilirubinaemia when the two conditions co-exist.