George A. Little

Special Report - Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1). They apply primarily to newly born infants undergoing transition from intrauterine to extrauterine life, but the recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. For the purposes of these guidelines, the terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures.2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation. Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics: If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing. If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in …

Helping Babies Breathe: global neonatal resuscitation program development and formative educational evaluation.

OBJECTIVES To develop an educational program designed to train health care providers in resource limited settings to carry out neonatal resuscitation. We analyzed facilitator and learner perceptions about the course, examined skill performance, and assessed the quality of instruments used for learner evaluation as part of the formative evaluation of the educational program Helping Babies Breathe. METHODS Multiple stakeholders and a Delphi panel contributed to program development. Training of facilitators and learners occurred in global field test sites. Course evaluations and focus groups provided data on facilitator and learner perceptions. Knowledge and skill assessments included pre/post scores from multiple choice questions (MCQ) and post-training assessment of bag and mask skills, as well as 2 objective structured clinical evaluations (OSCE). RESULTS Two sites (Kenya and Pakistan) trained 31 facilitators and 102 learners. Participants expressed high satisfaction with the program and high self-efficacy with respect to neonatal resuscitation. Assessment of participant knowledge and skills pre/post-program demonstrated significant gains; however, the majority of participants could not demonstrate mastery of bag and mask ventilation on the post-training assessment without additional practice. CONCLUSIONS Participants in a program for neonatal resuscitation in resource-limited settings demonstrated high satisfaction, high self-efficacy and gains in knowledge and skills. Mastery of ventilation skills and integration of skills into case management may not be achievable in the classroom setting without additional practice, continued learning, and active mentoring in the workplace. These findings were used to revise program structure, materials and assessment tools.

Candles in the Snow: Ritual and Memory for Siblings of Infants Who Died in the Intensive Care Nursery

OBJECTIVE To assess the developmental impact of surviving a sibling who dies in the neonatal intensive care unit (NICU). STUDY DESIGN Fourteen (13 adults, 1 adolescent) siblings of infants who died in Dartmouth-Hitchcock Medical Centers NICU between 1980 and 1990 were interviewed. The interviews were recorded and transcribed verbatim, and prominent themes were coded. RESULTS Six siblings rated family communication as veiled or a family secret; 7 reported unresolved parental mourning. Eleven siblings were rated high on anxiety themes, including concerns over future pregnancy or anxiety about their mothers health. Photos and family rituals were helpful to siblings in grieving and remembering the infant. CONCLUSIONS Although death in the NICU often has a brief course, consequences for survivor siblings can be life-long. Siblings born both before and after the death of an infant may be at risk and in need of psychological support. Family rituals and photos are important vehicles of communication, grieving, and memory for siblings and parents alike. Clinicians should allow siblings to be active participants in the infants brief life and death.

Neonatal Resuscitation: A Global Challenge

Two studies of neonatal care appear in this issue of Pediatrics : “Newborn Care Training for Midwives and Neonatal and Perinatal Mortality Rates in a Developing Country”1 and “High Mortality Rates of Very Low Birth Weight Infants in Developing Countries Despite Training.”2 Results of the first study of 71 689 infants born in a hospital setting in Zambia indicates that an education program focused on cleanliness, thermal protection, neonatal resuscitation, early breastfeeding, skin-to-skin care with the mother, care of the small infant, recognition of infant danger signs, and initial management effectively lowered the early neonatal mortality rate from 11.5 in 1000 to 6.8 in 1000 live births. The addition of enhanced neonatal resuscitation training was associated with further reduction of the 7-day neonatal mortality rate but required substantial statistical modeling to account for changing follow-up rates throughout the course of this facility-based study.1 In the second article, Carlo et al2 report on the outcome of 500- to 1499-g infants in a 6-country, 7-site study of the same educational intervention conducted in rural communities in which most deliveries occurred at home or in first-level facilities. Neither the simple newborn care package with resuscitation nor the additional neonatal resuscitation training was associated with a decrease in the 7-day mortality rate. … Address correspondence to William Keenan, MD, Department of Pediatrics, Saint Louis University, 1465 S Grand Blvd, St Louis, MO 63119. E-mail: keenanwj{at}slu.edu

Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time?

BackgroundThe first minutes after birth are critical to reducing neonatal mortality. Helping Babies Breathe (HBB) is a simulation-based neonatal resuscitation program for low resource settings. We studied the impact of initial HBB training followed by refresher training on the knowledge and skills of the birth attendants in facilities.MethodsWe conducted HBB trainings in 71 facilities in the NICHD Global Network research sites (Nagpur and Belgaum, India and Eldoret, Kenya), with a 6:1 ratio of facility trainees to Master Trainers (MT). Because of staff turnover, some birth attendants (BA) were trained as they joined the delivery room staff, after the initial training was completed (catch-up initial training). We compared pass rates for skills and knowledge pre- and post- initial HBB training and following refresher training among active BAs. An Objective Structured Clinical Examination (OSCE) B tested resuscitation skill retention by comparing post-initial training performance with pre-refresher training performance. We identified factors associated with loss of skills in pre-refresher training performance using multivariable logistic regression analysis. Daily bag and mask ventilation practice, equipment checks and supportive supervision were stressed as part of training.ResultsOne hundred five MT (1.6 MT per facility) conducted initial and refresher HBB trainings for 835 BAs; 76% had no prior resuscitation training. Initial training improved knowledge and skills: the pass percentage for knowledge tests improved from 74 to 99% (p < 0.001). Only 5% could ventilate a newborn mannequin correctly before initial training but 97% passed the post-initial ventilation training test (p < 0.0001) and 99% passed the OSCE B resuscitation evaluation. During pre-refresher training evaluation, a mean of 6.7 (SD 2.49) months after the initial training, 99% passed the knowledge test, but the successful completion rate fell to 81% for the OSCE B resuscitation skills test. Characteristics associated with deterioration of resuscitation skills were BAs from tertiary care facilities, no prior resuscitation training, and the timing of training (initial vs. catch-up training).ConclusionsHBB training significantly improved neonatal resuscitation knowledge and skills. However, skills declined more than knowledge over time. Ongoing skills practice and monitoring, more frequent retesting, and refresher trainings are needed to maintain neonatal resuscitation skills.Trial registrationClinicalTrials.gov Identifier: NCT01681017; 04 September 2012, retrospectively registered.

The New Hampshire Perinatal Program: twenty years of perinatal outreach education.

OBJECTIVE:To describe 20 years of regional outreach education by the New Hampshire Perinatal Program, its interaction with all 26 community hospitals in the state with maternity services and an additional four in adjoining Vermont.STUDY DESIGN:This paper describes educational initiatives responsive to the needs of perinatal physicians and nurses. The core of the program is the transport conference held annually at each referring hospital in which maternal–fetal and infant referrals are discussed. There are additional community hospital-based programs, programs at convenient locations in the region and medical center conferences and skills programs.RESULTS:The program annually awards 10,000 continuing medical education credits (CME) and nursing contact hours. Evaluation and feedback from all participants is encouraged. New Hampshire has one of the lowest perinatal mortality rates in the county, which reflects in part the accomplishments of the program.CONCLUSION:Perinatal outreach education is a shared responsibility of providers in both the academic center and community hospitals and is necessary to ensure optimal care for mothers and infants.

1287 SYNDROMES ASSOCIATED WITH POLYDACTYLY AND HYPOPITUITARISM

We report two female infants with postaxial polydactyly and hypopituitarism of differing etiologies. The first infant was born at term to a 26-year-old gravida 6 para 2 abortus 4 woman who noted markedly decreased fetal movement and intrauterine growth retardation. She was delivered from a breech presentation with posteriorly rotated simplified auricles, short nose, flat nasal bridge, microglossia, micrognathia, cleft posterior palate, short limbs with dislocated hips, postaxial polydactyly of hands and feet, bilateral simian creases, and 2-3 syndactyly of the toes. She died at 21 hours of age and autopsy revealed hypothalamic hamartoblastoma, bilateral hypoplastic renal ectopia, bilateral pulmonary hypoplasia, and a bifid epiglottis. Family history revealed that the mothers sister had died at 17 hours of age with remarkably similar dysmorphic features (no autopsy done), and this is the first report of apparent familial recurrence for Hall-Pallister syndrome. The second infant was born by cesarean section at 42 weeks with postaxial polydactyly of the left hand and primary panhypopituitarism. This pregnancy in a 21-year-old gravida 2, abortus 1 woman was complicated by extremely low maternal estriols. Size at birth and a cranial CT scan were normal, and the family history was negative for other individuals with hypopituitarism or polydactyly. Postaxial polydactyly may be associated with hypopituitarism, especially when associated with cleft palate, choanal atresia, congenital heart disease, and basal brain anomalies.

529 ARE WE PRODUCING MORE LONG TERM PATIENTS IN NEONATAL INTENSIVE CARE

There is concern that neonatal intensive care practice has resulted in an increased census of chronically ill infants. These infants may limit available acute tertiary care beds and cause staffing problems.We used our computer database to analyze epidemiologic characteristics of ICN admissions from 1976 through 1983. With well-established regionalized perinatal care, admission characteristics have remained relatively constant: 344 ± 45(S.D.)admissions/year, 54.2 ± 6.3% infant referrals, 31.8 ± 3.2% maternal-fetal referrals. There was no trend in the yearly distribution of admissions by birth weight or gestational age. There was no trend to increasing average length of stay (LOS) by year (14.7 days, range 13.4-17.1). Mortality and discharges to community hospitals have varied only slightly (10.7 ± 2.4%, 37.7 ± 3.2% respectively). Discharges directly home decreased from 44.6% to 22.8% while discharges to the pediatric ward increased 3.6% to 11.3% (1976 vs. 1983).Infants with LOS>28 days or to> 38 weeks corrected gestational age accounted for 6.1 ± 1.7% of admissions and 33 ± 9.8% of hospital days. Infants with LOS>12 weeks accounted for 2.3 ± 1.1% and 19.4 ± 10.1% of admissions and hospital days, respectively. While the percentages of hospital days represented by long term infants in 1983 were at the upper end of the ′76-′83 range, there was no trend even if pediatric ward LOS was included. We cannot show an increase in long term babies.

AN ANALYSIS OF THE NEONATAL NURSE CLINICIAN (NNC)

84 NNCs from 28 randomly selected NICUs were interviewed via telephone between Jan-Mar 82. The interview included 7 open-ended, 21 fixed-alternative and 5 scaled-item questions. Sequence and wording were predetermined to delineate the group biographic profile, professional education, lines of responsibility,skills utilized and psychosocial aspects. 81(96%) were female, 80(95%) Caucasian, 38(45%) married and 9(11%) divorced. Educational preparation varied:18(22%) held a masters degree, 35(41%) a bachelors, 23(28%) a diploma and 8 (9%) an associates. 66(79%) completed formal NNC programs; others completed inhouse NNC programs. 62(75%) remained in their 1st employment position since beginning their career; leaving time ranged from 6 mo-6 yr with 50% leaving after the 2nd employment year. Of 22 who left 15 remained in the NNC role. A trend was noted towards NNCs with associates degrees performing more invasive tasks than those with masters degrees. Absence of a defined role was the primary factor felt to be responsible for nurse-physician conflict. The study documents the wide range of NNC education, demonstrates the group stability, points out the low crude turnover rate, and indicates the need for the NNC role to be more specifically defined.

477 DAILY AND MONTHLY PATTERNS OF INTENSIVE CARE NURSERY ADMISSIONS

Analysis of temporal patterns of birth and intensive care nursery (ICN) admissions facilitates investigation of perinatal practice and administration of service units. 2,758 consecutive admissions between 1/1/76 and 12/31/79 to the two tertiary ICNs in Vermont and New Hampshire were classified by month and weekday of admission. Mean birth weight and gestational age were similar by month and day. No monthly pattern other than chance distribution for admissions and mortality was detected. However, admissions were distributed by day of the week in a pattern which differed significantly (p=0.004) from chance. Inborns (local and maternal-fetal transports) also differed significantly (p=0.012); outborns (infant transports) did not.Mortality rate by day of admission (not day of occurrence) does not differ significantly over the week (p=0.36). Length of stay was similar by weekday of admission. We speculate that these findings indicate that perinatal medical management is influencing day of birth of babies at risk for ICN admission without producing a negative effect on mortality.