Nursing workload in UK tertiary neonatal units.

BACKGROUND: Neonatal intensive care requires adequate numbers of trained neonatal nurses to provide safe, effective care, but existing research into the relationship between nurse numbers and the care needs of babies is over 10 years old. Since then, the preterm population and treatment practices have changed considerably. AIMS: To validate the dependency categories of the British Association of Perinatal Medicine (BAPM, 2001) and to revalidate the Northern Region categories (NR, 1993) in relation to contemporary nursing workload. SETTING: Three tertiary neonatal intensive care services in England. METHODS: Nursing activity around each baby was captured every 10 min by direct observations by trained observers. Time spent on each nursing activity was related to the baby's dependency category and the nurse's grade. RESULTS: Both scales detected differences between categories. Discrimination between individual categories was improved when nasal continuous positive airway pressure (nCPAP) was distinguished from ventilation and combined with BAPM2/NRA. On this revised four-point scale, babies in BAPM1/NRA occupied nursing time for a median of 56 min per hour (IQR 48-70), those on nCPAP or in BAPM2/NRB for 36 min, (27-42), those in BAPM3/NRC for 20-22 min (15-33) and those in BAPM4/NRD for 31-32 min (24-36). The NR scale was easier to apply and had greater interobserver agreement (98.5%) than the BAPM scale (93%). All categories attracted more time compared to 1993. CONCLUSIONS: Both scales predict average nursing workload. A revised categorisation which separates nCPAP from ventilation is more robust and practical. Nursing time attracted in all categories has increased since 1993.

The contribution of late termination of pregnancy to stillbirth rates in Northern England, 1994-2005.

The impact of late terminations (> or = 24 weeks) on the overall stillbirth rate was determined for the 12-year period from 1994 to 2005 using data collected by the Regional Maternity Survey Office in the north of England. It is a legal requirement to register late terminations, and this may lead to an overestimation of the true stillbirth rate. In our region, terminations resulting in stillbirth increased the registered stillbirth rate by nearly 10%. The impact remained stable for the period 1998-2005. This suggests that the failure of the national (and regional) stillbirth rate to decline in recent years is not due to an increase in late terminations.

Repeat testing for congenital hypothyroidism in preterm infants is unnecessary with an appropriate thyroid stimulating hormone threshold.

BACKGROUND: Revised UK neonatal screening guidelines recommend that a second blood sample for assay of thyroid stimulating hormone (TSH) be taken when preterm infants reach a postmenstrual age of 36 weeks. OBJECTIVE: To examine the results of a regional screening programme to see whether a rise in TSH concentration was observed in some preterm infants between the first sample taken around 5 days after delivery and the second sample taken at around 36 weeks. METHODS: Whole-blood TSH concentrations in preterm infants born over a 2-year period (April 2005 to March 2007) were assessed, and the number of infants in whom there was a fall or rise to values below or above the local screening threshold (6 mU/l) was determined. RESULTS: Baseline TSH samples were obtained from 2238 preterm infants (median gestational age 32 weeks, range 21-35) with second samples obtained from 2039 (median gestational 32 weeks, range 23-35). In 19 infants, TSH concentrations fell from above to below the screening threshold, and in five infants values rose from below the screening threshold to 6-10 mU/l. However, TSH concentrations fell to <6 mU/l on a further blood spot in four of these infants, and the remaining infant had a serum TSH of 6.8 mU/l. Three infants had raised TSH concentrations on both occasions with unequivocal hypothyroidism (serum TSH >80 mU/l). The initial TSH concentration in one of these infants was 6-10 mU/l. CONCLUSIONS: No infant with a normal TSH concentration on first sampling had a TSH concentration that rose above 10 mU/l on second sampling, and no infants with a normal TSH concentration on first screening are receiving long-term thyroxine treatment. This study suggests that a second sample may not be necessary with a screening threshold of 6 mU/l.

Randomised trial of infant sleep location on the postnatal ward.

OBJECTIVE: To determine whether postnatal mother-infant sleep proximity affects breastfeeding initiation and infant safety. DESIGN: Randomised non-blinded trial analysed by intention to treat. SETTING: Postnatal wards of the Royal Victoria Hospital (RVI), Newcastle upon Tyne, UK. PARTICIPANTS: 64 newly delivered mother-infant dyads with a prenatal intention to breastfeed (vaginal deliveries, no intramuscular or intravenous opiate analgesics taken in the preceding 24 h). INTERVENTION: Infants were randomly allocated to one of three sleep conditions: baby in mother's bed with cot-side; baby in side-car crib attached to mother's bed; and baby in stand-alone cot adjacent to mother's bed. MAIN OUTCOME MEASURES: Breastfeeding frequency and infant safety observed via night-time video recordings. RESULTS: During standardised 4-h observation periods, bed and side-car crib infants breastfed more frequently than stand-alone cot infants (mean difference (95% confidence interval (CI)): bed v stand-alone cot = 2.56 (0.72 to 4.41); side-car crib v stand-alone cot = 2.52 (0.87 to 4.17); bed v side-car crib = 0.04 (-2.10 to 2.18)). No infant experienced adverse events; however, bed infants were more frequently considered to be in potentially adverse situations (mean difference (95% CI): bed v stand-alone cot = 0.13 (0.03 to 0.23); side-car crib v stand-alone cot = 0.04 (-0.03 to 0.12); bed v side-car crib = 0.09 (-0.03-0.21)). No differences were observed in duration of maternal or infant sleep, frequency or duration of assistance provided by staff, or maternal rating of postnatal satisfaction. CONCLUSION: Suckling frequency in the early postpartum period is a well-known predictor of successful breastfeeding initiation. Newborn babies sleeping in close proximity to their mothers (bedding-in) facilitates frequent feeding in comparison with rooming-in. None of the three sleep conditions was associated with adverse events, although infrequent, potential risks may have occurred in the bed group. Side-car cribs are effective in enhancing breastfeeding initiation and preserving infant safety in the postnatal ward.

Evaluation of advanced neonatal nurse practitioners: confidential enquiry into the management of sentinel cases.

OBJECTIVE: To evaluate the quality of the neonatal care delivered by an advanced neonatal nurse practitioner led service at Ashington Hospital, Northumberland. SETTING: Maternity service with no resident paediatric medical input. DESIGN: Comparison of quality measures on sentinel cases with five comparator hospitals using modified confidential enquiry. RESULTS: On six out of seven dimensions, the neonatal nurse practitioner service performed better than the average of the five comparator hospitals, and overall ranked second. CONCLUSION: Good quality neonatal care can be delivered by advanced neonatal nurse practitioners alone, without the support of resident junior paediatricians.

Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds.

The definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology. In this article, some of the reasons for these contentions are discussed. Pragmatic recommendations for operational thresholds, ie, blood glucose levels at which clinical interventions should be considered, are offered in light of current knowledge to aid health care providers in neonatal medicine. Future areas of research to resolve some of these issues are also presented.

Pumactant and poractant alfa for treatment of respiratory distress syndrome in neonates born at 25-29 weeks' gestation: a randomised trial.

BACKGROUND: Exogenous surfactant preparations vary in their constitution and biophysical properties. Synthetic and animal-derived preparations lower the rate of death compared with controls. No significant differences in mortality or important long-term clinical outcomes have been shown between them in randomised trials. We did a randomised controlled trial to compare pumactant, a synthetic surfactant, with poractant alfa, an animal-derived surfactant, both of which are widely used in the UK. METHODS: We enrolled 212 neonates born between 25 weeks' and 29 weeks and 6 days' gestation who were intubated for presumed surfactant deficiency and were free from life-threatening malformations. We randomly assigned 105 neonates poractant alfa, and 107 pumactant. The primary outcome was duration of high-dependency care and mortality was a secondary outcome. Analysis was by intention to treat. FINDINGS: Outcome data were analysed for 199 babies. The trial was stopped on the recommendation of the data and safety monitoring committee because mortality assumed a greater importance than the primary outcome. Predischarge mortality differed significantly between groups, in favour of poractant alfa (14.1 vs 31.0%, p=0.006; odds ratio 0.37 [95% CI 0.18-0.76). This difference was sustained after adjustment for centre, gestation, birthweight, sex, plurality, and use of antenatal steroids. INTERPRETATION: Mortality was unexpectedly lower among neonates who received poractant alfa than among those who received pumactant, and was independent of all the variables we investigated. Stopping the trial early may have widened the difference between the treatment groups.

Prospective population based survey of outcome of pregnancy in diabetic women: results of the Northern Diabetic Pregnancy Audit, 1994.

OBJECTIVE: To determine whether the St Vincent declaration (1989) target of diabetic pregnancy outcome approximating non-diabetic pregnancy outcome in near to being achieved. DESIGN: Prospective collection of population based information on pregnancies in women with diabetes from all participating hospitals. SETTING: District general and teaching hospitals of the former Northern region. SUBJECTS: 111 diabetic women booking with pregnancy during 1 January to 31 December 1994. MAIN OUTCOME MEASURES: Diabetic control, perinatal mortality rate, fetal abnormality rate. RESULTS: The perinatal mortality rate was 48/1000 for diabetic pregnancies compared with 8.9/1000 for the background population (odds ratio 5.38; 95% confidence interval 2.27 to 12.70) and the neonatal mortality rate was 59/1000 compared with 3.9/1000 (15.0; 6.77 to 33.10). Two late neonatal deaths were due to congenital heart defects. Six per cent of all fetal losses (6/109 cases) were due to major malformations. The congenital malformation rate was 83/1000 compared with 21.3/1000 (3.76; 2.00 to 7.06) in the background population. CONCLUSIONS: Diabetic pregnancy remains a high risk state with perinatal mortality and fetal malformation rates much higher than in the background population.

A double-blind comparison of morphine infusion and patient controlled analgesia in children.

The analgesia provided after major abdominal surgery in 30 children by continuous morphine infusion and patient controlled analgesia, also using morphine, was compared using a double-blind, double-dummy design. The groups of children were comparable in age, weight, duration of operation and sex ratio. Pain assessment was carried out by a single observer using a visual analogue scale and the Poker Chip Tool. Assessments took place during two four-hour periods, one on the day of operation and one the following day. Children aged between nine and 15 years achieved better pain relief with patient controlled analgesia. No difference could be shown in children aged between five and eight years.

Impaired ketogenesis in fructose-1,6-bisphosphatase deficiency: a pitfall in the investigation of hypoglycaemia.

Intermediary metabolite concentrations were measured in blood during fasting in two patients with fructose-1,6-bisphosphatase deficiency. Hypoglycaemia was accompanied by markedly raised levels of plasma free fatty acids, without the expected degree of ketosis. This suggests that there is secondary impairment of ketogenesis in this condition, and could lead to diagnostic confusion.

Neonatal blood glucose concentrations: metabolic effects of intravenous glucagon and intragastric medium chain triglyceride.

Neonatal hypoglycaemia is a common clinical problem and the traditional treatment for the condition is intravenous glucose administration. The glycaemic effects of two additional treatments were investigated, in a randomised trial, in 23 neonates who were receiving intravenous glucose as treatment for hypoglycaemia. Eleven infants received an intravenous bolus dose of glucagon (200 micrograms/kg) and 12 infants received intragastric medium chain triglyceride (MCT) (5 ml/kg). Blood concentrations of glucose and intermediary metabolites were measured before and one hour after treatment, and, using stable isotope infusion, glucose production rates were calculated. After glucagon, there was a mean rise in blood glucose concentration of 1.6 mmol/l and in the glucose production rate of 2.6 mg/kg/min. After MCT, there was a small mean rise in blood glucose concentration of 0.4 mmol/l, but the effect of MCT on glucose production rate was variable. Intravenous bolus glucagon administration exerted a glycaemic effect which was associated with an increase in glucose production rate. The use of glucagon, as an alternative treatment to intravenous glucose, should be investigated further.

Metabolic adaptation in small for gestational age infants.

Hypoglycaemia has long been recognised as a feature of the failure of metabolic adaptation in infants who are small for gestational age (SGA). This study examined the process of metabolic adaptation by measuring, longitudinally, the concentrations of metabolic fuels and substrates in 33 SGA infants in the first postnatal week, and relating these to cross sectional data in 218 infants of appropriate weight for gestational age (AGA). SGA term infants had higher mean blood lactate concentrations than AGA term infants at delivery (2.98 v 2.10 mmol/l) and in the first few postnatal hours (3.05 v 1.91 mmol/l). Subsequently, although there were no differences in blood glucose concentrations, SGA term infants had lower mean ketone body concentrations (for example day 2: 0.07 v 0.41 mmol/l), and failed to mount a ketogenic response to low blood glucose concentrations. At birth, SGA preterm infants had lower mean blood glucose concentrations than AGA preterm infants (3.17 v 4.16 mmol/l), but there were few postnatal metabolic differences between the two groups. Mean blood glucose concentrations did not differ between AGA and SGA preterm infants. For variables that differed between the groups, multiple regression analysis suggested that both the degree and asymmetry of growth retardation were related to the severity of the metabolic abnormalities. These data suggest that, although there are early metabolic differences between SGA and AGA infants, it is possible that current clinical management is effective in preventing subsequent hypoglycaemia. This is important because of the failure of SGA infants to mount a ketogenic response.

Hormonal and metabolic response to hypoglycaemia in small for gestational age infants.

Little is known of the ability of hypoglycaemic infants who are small for gestational age (SGA) to mount the coordinated hormonal and metabolic counterregulatory response that is seen in healthy older subjects during glycopenia. This response was studied in 22 SGA infants (birth weight < 10th centile) by measuring the blood concentrations of glucose, intermediary metabolites, and glucoregulatory hormones. Plasma non-esterified fatty acid and blood ketone body concentrations were low, even when blood glucose concentrations were low. Plasma insulin and glucagon varied widely (< 1.0-53.1 mU/l and 16.6-87.1 pmol/l, respectively). Concentrations of noradrenaline and glucagon were raised, but cortisol and adrenaline were lower than those found in hypoglycaemic adults. There was no relationship between the concentration of any hormone and blood glucose concentration. We postulate that hypoglycaemia and the failure to mobilise alternative fuels in some SGA infants is secondary both to a poorly coordinated counterregulatory hormone response and to a peripheral insensitivity to the actions of the hormones. Those infants, who fail to mount a counterregulatory response, should be identified by accurate and reliable blood glucose monitoring, and an adequate exogenous supply of energy, either enteral or parenteral, should be ensured.