Richard Nicholl

What is the normal range of blood glucose concentrations in healthy term newborns

You are the attending neonatal consultant. It is 6 pm on a Friday after a busy week on the unit. A rather flustered midwife appears from the postnatal ward with a baby and two anxious parents. The baby is full term and appropriately grown, following a normal vaginal delivery and just 8 hours old. Mum has been attempting to breast feed but the baby is reported to have been “not feeding well” and “jittery”. There are no prenatal risk factors for sepsis. Your examination of the baby is normal—he is now not “jittery”.nnA capillary heel prick blood test (Medisense) done on the postnatal ward has given a blood glucose reading of 2.6 mmol.nnBecause this result is perceived to be abnormal (low), one of the neonatal trainees has suggested to …

How good is clinical examination at detecting a significant patent ductus arteriosus in the preterm neonate

A 25 week gestation infant aged 30 days has a continuous murmur and easily palpable pulses. He has already received a course of indomethacin for a “clinically diagnosed” patent ductus arteriosus (PDA). The baby is ventilator dependent. How good (or bad) is clinical examination at diagnosing a clinically important PDA?nnIn a ventilator dependent neonate of very low birth weight (<1000 g) [patient], how good is clinical examination [intervention] at detecting patent ductus arteriosus [outcome]?nnA search string of [patent arterial duct] AND [diagnostic test] was used.nn### Search resultsnnPubMed—three papers.nnCochrane database—nil.nnSUMSearch—nil other than PubMed articles.nnSearch done independently by DU and RN retrieved same three articles. See table 3. …

Association between infant correlates of impulsivity--surgency (extraversion)--and early infant growth.

Increasing evidence suggests that rapid postnatal weight gain is associated with increased risks of being overweight or obese later in life and of co-morbidities, such as diabetes, the metabolic syndrome and cardiovascular disease. In children as young as two years of age, as well as in adults, an appetitive system-linked impulsivity trait has been demonstrated to be linked with increased overweight, and postulated to act via increased food intake, through greater responsiveness to food and lower self-inhibitory control skills. In this study, we hypothesized that growth in infancy, a critical window for metabolic programming, would be predicted by measures of infant surgency/extraversion, assessed using the Rothbart Infant Behaviour Questionnaire (revised version). Anthropometry was measured at birth and at 3, 6 and 12 months, and weight gains expressed as increases in standardized scores, allowing for adjustment for gender and age, including gestational age. We used conditional weight (CW), a residual of current weight regressed on prior weights, to represent deviations from expected weight gains, from 0 to 3, 3 to 6 and 6 to 12 months. Controlling for significant sociodemographic correlations, multiple regression analyses showed significant prediction of CWs at 3 months but not of CWs at 6 or 12 months by surgency/extraversion. These pilot findings of association between infant growth, during a critical period, and surgency/extraversion, early correlates of impulsivity, warrant further investigation, to ascertain implications for childhood and later weight and body composition.

Guidance for withdrawal and withholding of intensive care as part of neonatal end-of-life care

INTRODUCTIONnAdvances in foetal medicine and neonatology have enabled increased antenatal diagnosis of life-limiting conditions and improved preterm survival, escalating the debate surrounding the ethics of neonatal end-of-life care and withholding or withdrawing intensive care.nnnSOURCES OF DATAnLiterature search of MEDLINE and the Cochrane library databases using the search terms [neonatal palliative care] AND [neonatal AND withdrawal of intensive care and treatment]. Review of consensus statements and guidelines.nnnAREAS OF AGREEMENTnUK practice is aided by Grade 3-4 evidence, consensus statements and practice frameworks. There is limited systematic evidence.nnnAREAS OF CONTROVERSYnWe illustrate UK practice with clinical cases and describe worldwide variations.nnnGROWING POINTSnNeonatal end-of-life care incorporating withholding and withdrawing intensive care is not uncommon. The childs best interests take precedent and clinical guidance has been published to support the joint decision-making partnership of clinicians and families. Withholding and withdrawing intensive care should be part of an overall end-of-life care plan incorporating the principles and standards of palliative care.nnnAREAS TIMELY FOR DEVELOPING RESEARCHnFurther guidance on standards and staff training with regard to communicating and delivering neonatal end-of-life care is required to ensure consistent practice of staff and choices for families. The recommended establishment of neonatal outcome databases should aid UK preterm decision-making (NHS and Department of Health Neonatal Taskforce, Toolkit for high-quality neonatal services, London, Department of Health 2009).

Infant feeding bottle design, growth and behaviour: results from a randomised trial

BackgroundWhether the design of an anti-vacuum infant feeding bottle influences infant milk intake, growth or behavior is unknown, and was the subject of this randomized trial.MethodsSubjects: 63 (36 male) healthy, exclusively formula-fed term infants.Intervention: Randomisation to use Bottle A (n = 31), one-way air valve: Philips Avent) versus Bottle B (n = 32), internal venting system: Dr Browns). 74 breast-fed reference infants were recruited, with randomisation (n = 24) to bottle A (n = 11) or B (n = 13) if bottle-feeding was subsequently introduced.Randomisationstratified by gender and parity; computer-based telephone randomisation by independent clinical trials unit.SettingInfant home.Primary outcome measureinfant weight gain to 4 weeks.Secondary outcomes(i) milk intake (ii) infant behaviour measured at 2 weeks (validated 3-day diary); (iii) risk of infection; (iv) continuation of breastfeeding following introduction of mixed feeding.ResultsNumber analysed for primary outcome Bottle A n = 29, Bottle B n = 25.Primary outcomeThere was no significant difference in weight gain between randomised groups (0-4 weeks Bottle A 0.74 (SD 1.2) SDS versus bottle B 0.51 (0.39), mean difference 0.23 (95% CI -0.31 to 0.77).Secondary outcomesInfants using bottle A had significantly less reported fussing (mean 46 versus 74 minutes/day, p < 0.05) than those using bottle B. There was no significant difference in any other outcome measure.Breast-fed reference groupThere were no significant differences in primary or secondary outcomes between breast-fed and formula fed infants. The likelyhood of breastfeeding at 3 months was not significantly different in infants subsequently randomised to bottle A or B.ConclusionBottle design may have short-term effects on infant behaviour which merit further investigation. No significant effects were seen on milk intake or growth; confidence in these findings is limited by the small sample size and this needs confirmation in a larger study.Trial registrationClinical Trials.gov NCT00325208.

Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant

Background An understanding of predictors of breast milk production may enable the provision of better advice and support to mothers with preterm infants who may need to express milk for long periods. Objective To investigate factors predicting the amount of milk expressed by mothers for their preterm infant (1) during the first 10u2005days and (2) during the infants whole hospital stay. Methods 62 mothers with preterm infants <34u2005weeks who participated in a randomised trial comparing two breast pumps completed 10-day diaries including weight of milk expressed and questionnaires giving their opinion of the breast pump; 47 mothers provided data on milk expression up to the infants hospital discharge. Results Significant predictors of 10-day milk weight in multivariate models were the number of episodes of ‘breast feeding’ (17 g (95% CI 8 to 26, p=0.001) increase per episode), the use of double versus single pumping (109 (31–186, p=0.007) g/day more) and the number of complete daily records (17 (1–33, p=0.04) g increase/day). Significant multivariate predictors of total milk production were double versus single pumping (491 (55) mL/day vs 266 (44) mL/day), expressing 500u2005mL/day by day 10 (525 (53) mL/day vs 232 (43) mL/day) and a higher score for breast pump ‘comfort’ (best=489 (39) mL/day, middle=335 (57) mL/day, worst=311 (78) mL/day). Conclusions These results suggest that relatively simple, modifiable factors can favourably impact milk production in the neonatal intensive care unit setting and emphasise the importance of double pumping, early establishment of milk production and design features of the breast pump that promote comfort. Trial registration number NCT00887991.

Randomized Trial Comparing the Effectiveness of 2 Electric Breast Pumps in the NICU.

Background: Mothers with preterm infants may need to express milk for considerable periods. Research to improve breast pump design has focused on compression stimuli, frequencies, and vacuums. Objective: This study aimed to compare the effectiveness of 2 electric pumps: Medela Symphony (pump S) and a novel pump (Philips AVENT Twin electronic pump; pump A). Both offer flexibility of rate and suction; pump A also incorporates petal compression cushions. Primary outcomes were (1) milk weight expressed during 10-day study period and (2) weight of milk expressed in a 15-minute test. Methods: Seventy-one mothers with preterm infants < 34 weeks were randomized. Mothers completed 10-day diaries including weight of milk expressed. Milk weight expressed during a single 15-minute test period and data on pumping mode, skin-to-skin contact, breastfeeding at infant discharge, and mothers’ opinions of the pump were recorded. Results: There was no significant difference in milk expressed during the first 10 days between groups. Pump S mothers expressed significantly more milk during a fixed 15-minute period. Mothers using pump A awarded higher scores for certain characteristics of the pump, notably location of control button and ease of use. Similar proportions of infants received breast milk at discharge, but pump A mothers were more likely to be directly breastfeeding (odds ratio, 4.27 [95% confidence interval, 1.29, 14.1]). Conclusion: The breast pumps showed similar effectiveness in terms of milk expression and maternal opinions. The finding that breast pump design may influence breastfeeding at infant discharge merits further investigation.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study

Background Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis. Objectives To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit. Design Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention). Setting Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London. Participants Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital. Methods Women were screened for GBS at 35–37u2005weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0–6u2005days of birth. Main outcome Incidence of early-onset GBS infections. Results 6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05). Conclusions Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

The impact and efficacy of routine pulse oximetry screening for CHD in a local hospital

OBJECTIVESnThe objective of this study was to evaluate the impact and efficacy of pulse oximetry screening for CHD in a level-two neonatal unit without on-site access to paediatric echocardiography.nnnMETHODSnAll neonatal unit admissions between 1 September, 2011 and 31 August, 2013 were reviewed to determine the outcomes of newborns identified by pulse oximetry screening. Record linkage with the National Congenital Heart Disease Audit allowed follow-up of newborns with a negative screening result.nnnRESULTSnThere were 11,233 live births during the study period, with 973 neonatal unit admissions unrelated to pulse oximetry screening. From the remaining screening population of 10,260 newborns, 23 were admitted on the basis of a screen-positive result; three of the 23 patients went on to have urgent echocardiograms, and two were found to have critical CHD. In the 21 newborns without critical CHD, an alternative diagnosis was made in 16 cases. Record linkage with the National Congenital Heart Disease Audit indicated that no newborns born in the hospital during the study period received surgery for critical CHD following negative screening. The estimated sensitivity of screening was 100% (95% confidence interval 15.81-100%) and specificity was 99.80% (95% confidence interval 99.69-99.87%), with a false-positive rate of 0.20% (95% confidence interval 0.13-0.31%).nnnCONCLUSIONnThe introduction of pulse oximetry screening to a hospital where paediatric echocardiography services are not available is practical, results in very few referrals to the regional paediatric cardiology centre, and detects cases of CHD that would otherwise go undiagnosed. Record linkage with a national CHD database provides a straightforward method for tracking cases of CHD that may have been missed by screening.

Question 1 Is delayed clamping of the umbilical cord in moderately preterm babies beneficial

You are the admitting neonatal registrar. A baby delivered at 32 weeks’ gestation by caesarean section because of pregnancy induced hypertension has a haemoglobin of 17 g/dl and haematocrit (HCt) of 62. The senior house officer comments that the obstetrician had delayed clamping of the umbilical cord prior to handing the baby over “as it would be good for the baby”.nnThe baby is well on admission, requiring only special care and has an uneventful stay prior to hospital discharge.nnIs there any evidence that in preterm babies [patient] delayed cord clamping [intervention] versus immediate cord clamping [comparison] confers benefit [outcome]?nnThe keywords “umbilical cord” and “clamp” were used. We searched for randomised control trials which looked at early (ECC) versus delayed cord clamping (DCC) in preterm babies.nn### Primary sourcesnnPubMed (January 1993 to March 2008) and Embase databases (January 1993 to March 2008).nn### Secondary sourcesnnThe Cochrane Library.nnFour randomised controlled trials (RCTs) and one systematic review were identified for further appraisal. See table 1.nnView this table:nnTable 1 nIs delayed …