Michael Watkinson

Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial

Background: Screening is necessary for infants at risk of retinopathy of prematurity. Despite local anaesthetic drops, infants find eye examinations distressing, displaying behavioural and physiological changes indicating acute pain. Oral sucrose and non-nutritive sucking reduce pain responses associated with invasive procedures. Objective: To evaluate the use of oral sucrose and/or pacifier for reducing pain responses during eye examinations. Methods: Forty infants <32 weeks gestation or <1500 g birth weight, in two neonatal units, were randomised to one of four interventions administered two minutes before their first screening examination: 1 ml sterile water as placebo (group 1, n  =  10), 1 ml 33% sucrose solution (group 2, n  =  10), 1 ml sterile water with pacifier (group 3, n  =  9), or 1 ml 33% sucrose solution with pacifier (group 4, n  =  11). Examinations were videotaped. Two observers, blind to the intervention, assessed recordings. Pain responses were scored using the premature infant pain profile (PIPP). Results: The groups were similar in gestation, birth weight, and age at examination. Mean PIPP scores were 15.3, 14.3, 12.3, and 12.1 for groups 1, 2, 3, and 4 respectively. Analysis of variance showed a significant difference in PIPP score between groups (p  =  0.023). Infants randomised to pacifiers scored lower than those without pacifiers (p  =  0.003). There was no difference between groups receiving sucrose and those receiving water (p  =  0.321). Conclusions: Non-nutritive sucking reduced distress responses in infants undergoing screening for retinopathy of prematurity. The difference in response was large enough to be detected by a validated assessment tool. No synergistic effect of sucrose and pacifier was apparent in this group.

Babies born before arrival at hospital

Objective— To establish the prevalence of babies born before arrival at two local hospitals. To identify women at risk of giving birth before arrival, and the morbidity and mortality associated with such births.

Classifying perinatal death: experience from a regional survey

Objective To examine problems encountered in classifying perinatal death using the systems proposed by Hey et al. (1986) and Cole et al. (1986) .

Outcome of neonatal intensive care: obstetric implications for a regional service

Summary. Data from 634 newborn babies with birthweights ≤2000 g admitted to the South West Thames Regional Neonatal Unit in St Georges Hospital since its opening in 1980 were analysed. Only 271 (43%) of the pregnancies were booked there; 200 (32%) of the babies were transferred in utero and 162 (26%) after delivery. Weight-specific neonatal survival rates, calculated after exclusion of lethal abnormalities showed that between 1001 and 1500 g, 79 (96%) of the 82 babies transferred in utero survived in 1981–1984, compared with only 57 (79%) of the 72 postnatal transfers (P<0.02). Under 1000 g, no such differences were found, possibly because paediatricians transferred only the fitter babies in this weight range. The birth of very-low-birthweight babies of short gestation in units unable to provide immediate resuscitation, adequate stabilization and full neonatal intensive care is a major risk factor for increased neonatal mortality. These findings support the role of regional perinatal centres as service units for antenatal transfer and neonatal intensive care, and as teaching centres.Summary. Data from 634 newborn babies with birthweights ≤2000 g admitted to the South West Thames Regional Neonatal Unit in St Georges Hospital since its opening in 1980 were analysed. Only 271 (43%) of the pregnancies were booked there; 200 (32%) of the babies were transferred in utero and 162 (26%) after delivery. Weight‐specific neonatal survival rates, calculated after exclusion of lethal abnormalities showed that between 1001 and 1500 g, 79 (96%) of the 82 babies transferred in utero survived in 1981–1984, compared with only 57 (79%) of the 72 postnatal transfers (P<0.02). Under 1000 g, no such differences were found, possibly because paediatricians transferred only the fitter babies in this weight range. The birth of very‐low‐birthweight babies of short gestation in units unable to provide immediate resuscitation, adequate stabilization and full neonatal intensive care is a major risk factor for increased neonatal mortality. These findings support the role of regional perinatal centres as service units for antenatal transfer and neonatal intensive care, and as teaching centres.

Suxamethonium is safe in safe hands; mivacurium should also be considered

Editor—We thank Whyte et al 1 for detailing the premedication policies for intubation in United Kingdom neonatal units. There is a wide disparity in both the type and dosage of drugs. Whyte et al 1 mention that, as a muscle relaxant, suxamethonium, has important safety benefits. It has a very rapid onset and offset of action, …

Extracorporeal Membrane Oxygenation

Purpose of review Extracorporeal membrane oxygenation (ECMO) has become a more or less accepted standard in the algorithm of advanced acute respiratory distress syndrome therapy in adult patients when all other treatment options have failed. This article reviews the current status of ECMO therapy with particular focus on new technical developments and their potential implications for performance and indications for ECMO therapy. Recent findings A recently published review on a single-center experience in 255 adult ECMO patients identified using multivariate logistic regression analysis age, sex, initial pH 7.10 or lower and PaO2/FiO2 ratio, and days of mechanical ventilation before ECMO as a significant predictors of survival. Additionally, a careful cost-effectiveness study for neonatal ECMO relating a 4-year base to the UK neonatal ECMO trial has clearly demonstrated cost-effectiveness. Summary Over the years, the technique for ECMO therapy underwent substantial changes in indications and the materials used. Impressive technical progress has been made in pumps, oxygenators, and coating of artificial surfaces, leading to a higher biocompatibility and to a lower rate of procedure-related complications. The potential of new inline pumps in combination with a decreasing rate of procedure-related complications might lead to a re-evaluation of the role of extracorporeal lung support in acute respiratory distress syndrome therapy. A very recent development is the use of spontaneous arteriovenous devices for carbon dioxide removal, allowing significant reduction of ventilator settings at decreased carbon dioxide partial pressures and at increased pH values. Ongoing studies are looking at the potential of this approach to reduce side effects of mechanical ventilation further.

HIV and AIDS

DATA SYN11IESIS: DR in patientswith HlV infectionis an AIDSdefiningopportunistic infectioncausedby Histoplasma capsulatum. It is most frequently observedin HlV-infectedpatientslivingin or travelingto endemicregions. The clinicalpresentation most often includesfever and weightloss, but may be complicatedby comorbidillnesssuch as other opportunistic infections. Diagnosisis best established by histologic examination of peripheral blood smear or bone marrowaspirate, or isolation of the organismin culturesof blood,bone marrow,and respiratory secretions. Serologic examinations may providesupportive diagnostic information. Detectionof histoplasmapolysaccharide antigen(HPA) in serumor urine may proveto be a promisingapproachfor the rapiddiagnosis and therapeutic monitoring of DR in AIDS patients. In contrastto immunocompetent hosts,high relapserates are reportedafter

Babies Born Before Arrival at Hospital

OBJECTIVE To establish the prevalence of babies born before arrival at two local hospitals. To identify women at risk of giving birth before arrival, and the morbidity and mortality associated with such births. DESIGN A case control study. Each baby born before arrival and its mother were compared with the next born in the hospital (random control), and one matched for gestation and birthweight, together with their mothers. SETTING Two maternity units serving East Birmingham and Solihull. SUBJECTS All babies (and their mothers) born before arrival at these hospitals from January 1983 to December 1987. MAIN OUTCOME MEASURES Perinatal mortality rates, patterns of perinatal morbidity, demographic, social and obstetric features of the mothers. RESULTS 137 (0.44%) of 31,140 consecutive births were before arrival at hospital (BBA group). The perinatal mortality rate in the BBA group was 58.4/1000 (8 deaths) compared with 10.1/1000 for all inborn babies (relative risk 5.8, 95% confidence interval 2.9-11.4). In the BBA group the mean birthweight of 3008 g was 212 g (95% CI 50-374 g) less than that in the random control group; the mean gestation of 266 days was 10 days less (95% CI 5.9-14.1 days) than in the random control group. Hypothermia was the commonest morbidity. Women delivered before arrival tended to be either multigravid inner city Asians living a long way from the hospital or unmarried unbooked younger white Europeans. CONCLUSIONS The high perinatal mortality was related to immaturity and low birthweight, rather than to birth before arrival itself. Although groups of mothers at risk of delivery before arrival can be identified more information is needed to establish whether additional antenatal care would be beneficial for these women and their babies.