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Background: National reporting of adverse incidents has resulted in a number of clinical alerts being issued. Despite a lack of evidence, these alerts are often accompanied by a mandatory requirement to alter practice. There is likely to be clinician resistance to such a method of change management, particularly where evidence of safety is missing. Aim: To determine the level of implementation within neonatal units of an alert requiring the change from litmus to pH paper to test nasogastric tube position. Method: A questionnaire sent to all neonatal units in the United Kingdom with more than 12 cots. Results: From the 207 questionnaires sent, there were 165 (80%) responses. Fifty five percent of units were still using litmus. All continued to use supplementary tests not recommended in best practice statements issued at the time of the alert. There was considerable variation in the pH value at which it was considered safe to feed. Conclusions: Nine months after the alert, more than half the units had not changed to pH paper, and supplementary methods of testing were still being used. The wide range of pH values highlights the uncertainty about the ‘normal’ gastric pH in the newborn. The evidence that, in neonatal units, changing to pH paper is safer than the long established use of litmus is lacking. Recommendations for change in practice must be based on good information and not seen just as a ‘knee jerk’ response to adverse incidents. [ABSTRACT FROM AUTHOR]

Objective: Closed-loop systems have been used to optimise insulin delivery in children with diabetes, but they have not been tested in neonatal intensive care. Extremely preterm infants are prone to hyperglycaemia and hypoglycaemia; both of which have been associated with adverse outcomes. Insulin sensitivity is notoriously variable in these babies and glucose control is time-consuming, with management requiring frequent changes of dextrose-containing fluids and careful monitoring of insulin treatment. We aimed to evaluate the feasibility of closed-loop management of glucose control in these infants.Design and Setting: Single-centre feasibility study with a randomised parallel design in a neonatal intensive care unit. Eligibility criteria included birth weight <1200 g and <48 hours of age. All infants had subcutaneous continuous glucose monitoring for the first week of life, with those in the intervention group receiving closed-loop insulin delivery in a prespecified window, between 48 and 72 hours of age during which time the primary outcome was percentage of time in target (sensor glucose 4-8 mmol/L).Results: The mean (SD) gestational age and birth weight of intervention and control study arms were 27.0 (2.4) weeks, 962 (164) g and 27.5 (2.8) weeks, 823 (282) g, respectively, and were not significantly different. The time in target was dramatically increased from median (IQR) 26% (6-64) with paper guidance to 91% (78-99) during closed loop (p<0.001). There were no serious adverse events and no difference in total insulin infused.Conclusions: Closed-loop glucose control based on subcutaneous glucose measurements appears feasible as a potential method of optimising glucose control in extremely preterm infants. [ABSTRACT FROM AUTHOR]

Objective: Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room resuscitations.Methods: A systematic literature search in MEDLINE was conducted to identify original studies that reported the quality of documentation records during newborn resuscitation in the delivery room. Data extracted from the studies included population characteristics, methodology, documentation protocols, use of gold standard and main results (initial assessment of heart rate and peripheral oxygen saturation, respiratory support and supplementary oxygen).Results: In total, 197 records were screened after initial database search, of which seven studies met the inclusion criteria and were finally included in this review. Four studies were chart reviews and three studies compared conventional documentation methods with video recording. Only one study tested an intervention to improve documentation. Documentation was often inaccurate and important resuscitation events and interventions were poorly recorded. Lack of uniformity among studies preclude pooled analysis, but it seems that complex or advanced procedures were more accurately reported than basic interventions.Conclusions: There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of documentation seems to be unsatisfactory. There is a need for consensus guidelines and innovative solutions in newborn resuscitation documentation. [ABSTRACT FROM AUTHOR]

Objective: To determine whether maternal exposure to iodine or neonatal exposure to topical iodine-containing solutions increases the risk of transient thyroid dysfunction in neonates born <32 weeks' gestation or <1.5 kg. Design: Systematic review. Search strategy: Electronic searches were conducted using Medline and the Cochrane Library. Eligibility criteria: A study was eligible for review if it reported neonatal exposure to topical iodine or maternal iodine exposure. The key outcome measure was neonatal thyroid function. The search had no restrictions on date of publication, type of study or language. Results: 794 papers were identified during the initial search; 15 studies were fully reviewed. The incidence of (transient) hypothyroidism/hyperthyrotropinaemia following exposure to topical iodine ranged from 12 to 33 per 100 infants; the incidence in non-exposed infants was 0. Conclusions: There is evidence that neonatal exposure to iodine-containing disinfectants causes thyroid dysfunction in infants born <32 weeks. None of the studies evaluated neurodevelopment. Larger scale studies are needed to determine definitively the nature of the relationship and the impact of exposure on neurodevelopment. In the meantime, it would seem prudent to restrict exposure of iodine-containing skin disinfectants in preterm infants; chlorhexidine might be a credible alternative. [ABSTRACT FROM AUTHOR]

Objective: Maternal glycaemia and anthropometry-derived newborn adiposity are strongly correlated. The children of mothers with diabetes are at greater risk of adverse metabolic health, and increased adiposity is a plausible mediator. We undertook a systematic review and meta-analysis to compare adiposity in infants of diabetic mothers (IDM) and infants of mothers without diabetes (NIDM).Design: We identified observational studies reporting adiposity in IDM and NIDM. We searched references, traced forward citations and contacted authors for additional data. We considered all body composition techniques and compared fat mass, fat-free mass, body fat % and skinfold thickness. We used random effects meta-analyses and performed subgroup analyses by maternal diabetes type (type 1, type 2 and gestational) and infant sex. We examined the influence of pre-pregnancy body mass index (BMI) and conducted sensitivity analyses.Results: We included data from 35 papers and over 24 000 infants. IDM have greater fat mass than NIDM (mean difference (95% CI)): 83 g (49 to 117). Fat mass is greater in infants of mothers with gestational diabetes: 62 g (29 to 94) and type 1 diabetes: 268 g (139 to 397). Insufficient studies reported data for type 2 diabetes separately. Compared with NIDM, fat mass was greater in IDM boys: 87 g (30 to 145), but not significantly different in IDM girls: 42 g (-33 to 116). There was no attenuation after adjustment for maternal BMI.Conclusions: IDM have significantly greater adiposity in comparison with NIDM. These findings are justification for studies to determine whether measures to reduce infant adiposity will improve later health. [ABSTRACT FROM AUTHOR]

Background: High feed osmolality (or osmolarity) is often suggested to be linked with adverse gastrointestinal events in preterm infants.Aim: To systematically review the literature on milk feed osmolality and adverse gastrointestinal events in newborn and low birthweight infants and animals.Methods: MEDLINE, Embase, CAB Abstracts, Current Contents, BIOSIS Previews and SciSearch were searched from inception to May 2018 to identify potentially relevant studies.Inclusion Criteria: randomised controlled or observational studies of newborn and low birthweight infants or animals investigating the effects of milk-based feeds with different osmolalities. Only full-text, English-language papers were included.Results: Ten human and six animal studies met the inclusion criteria. Of human studies, seven reported no differences in adverse events with varying feed osmolalities; one reported delayed gastric emptying with feed osmolarity of 539 mOsm/L compared with lower levels; one reported higher necrotising enterocolitis (NEC) incidence with feed osmolarity of 650 mOsm/L compared with 359 mOsm/L; one found higher NEC incidence with the lowest feed osmolality (326 mOsm/kg compared with 385 mOsm/kg). Of animal studies, two reported delayed gastric emptying with feed osmolarity >624 mOsm/L, one reported decreased survival due to dehydration with dietary osmolarities ≥765 mOsmol/L and none reported increased NEC incidence with differing feed osmolalities. No clear mechanisms were found, and diet composition differences limited the interpretations regarding the independent impact of osmolality.Conclusions: There is no consistent evidence that differences in feed osmolality in the range 300-500 mOsm/kg are associated with adverse gastrointestinal symptoms in neonates. [ABSTRACT FROM AUTHOR]

Objective: To describe the epidemiology of neonatal infection over the past decade in UK neonatal units.Design: Retrospective analysis of prospectively collected infection surveillance network data from 2005 to 2014.Setting: 30 neonatal units in the UK.Patients: Newborns on participating neonatal units who had a positive blood, cerebrospinal fluid or urine culture and were treated with at least 5 days of appropriate antibiotics.Results: 2171 episodes of neonatal infection in 1922 infants were recorded. The incidence of infection was 6.1/1000 live births and 48.8/1000 neonatal admissions (2.9 and 23.5 respectively if coagulase-negative staphylococci (CoNS) cultures excluded). The incidence of infection showed a statistically significant reduction over time with reductions in the rates of both early-onset sepsis (EOS) and late-onset sepsis (LOS).The majority of episodes (76%) represented LOS (diagnosed > 48 hours after birth), and infection was more common in premature (<37 weeks gestation) and low birth weight (<2500 g) neonates (84% and 81%, respectively). Commonly identified pathogens included group B streptococci (43%) and Escherichia coli (18%) for EOS, while E. coli (15%), Staphylococcus aureus (14%) and CoNS were prominent causes of LOS.Conclusions: This paper describes the epidemiology of neonatal infection in the UK over the past decade. These data enable benchmarking of practice and inform areas of future research and guideline development. The results support the hypothesis that the introduction of infection prevention care bundles and antibiotic stewardship programmes in the UK has reduced the burden of LOS. [ABSTRACT FROM AUTHOR]

Objective: Neonatal resuscitation is often retrospectively documented, which can lead to inaccuracy and incomplete recording of delivery room management. In this study, we assessed the accuracy and completeness of neonatal resuscitation documentation in our neonatal intensive care unit. Methods: Recordings of physiological parameters and video data were performed in the delivery room and used to deduct the clinical condition of the infant, the interventions done and their effect on the infant's condition. The data from the recordings were compared with the documentation on neonatal stabilisation in the medical records ( paper or digital). Results: Recordings of 54 infants were compared with the documentation in their medical records. In 93% of the medical records delivery room management was documented. The clinical condition of the infant at birth was documented in 76% and 1 min Apgar scores in 98%. Respiratory support was correctly documented in 83%, heart rate in 37% and oxygen saturation in 13%. In 57% use of supplemental oxygen and its indication were correctly reported. Seven infants were intubated and this was correctly documented in 57%. Apgar scores were compared between the recordings and the medical records. At 1 min, 5 min and 10 min after birth the Apgar score, given by the researcher using the recordings, was similar to the scores in the medical records in 33%, 44% and 53%, respectively. Conclusions: Accurate and complete documentation of neonatal resuscitation continues to be a challenge. Recordings of physiological parameters and video imaging can improve documentation by providing detailed information. [ABSTRACT FROM AUTHOR]

Background: Parents often prefer being present during neonatal resuscitation and benefit from this experience. We aim to determine if parental presence during neonatal resuscitation affects the perceived workload of healthcare providers.Methods: Perceived workload was measured using the multidimensional retrospective National Aeronautics and Space Administration Task Load Index survey. Over 3 months, healthcare providers were asked to complete a paper and pencil survey following their participation in a neonatal resuscitation. Surveys also collected healthcare providers' reports of parental presence during resuscitation.Results: 204 surveys were completed. Of these 183 (90%) had complete information about parental presence. Overall workload of healthcare professionals was significantly lower when at least one parent was present (33; 16-47) compared with when no parents were present (46; 29-57) during the resuscitation (p=0.0004).Conclusion: This work supports the presence of parents during neonatal resuscitation. Parental presence during neonatal resuscitation was associated with decreased overall workload experienced by healthcare providers. [ABSTRACT FROM AUTHOR]

Garcia-Bournissen F, Rokach B, Karaskov T, et al. Methamphetamine detection in maternal and neonatal hair: implications for fetal safety (Arch Dis Child Fetal Neonatal Ed 2007;92:351–5). This paper states that positive results were confirmed by gas chromatography/mass spectrometry. The authors have clarified that some, but not all, samples that were positive by ELISA were confirmed with GC/MS; they further confirm that this fact had no impact on the results of comparing maternal to neonatal hair levels in the paper, so that the paper's conclusions remain the same. [ABSTRACT FROM AUTHOR]

This paper considers some of the changes in practice that have occurred in the last 5 years. There have been significant improvements in parental involvement in care. Not all changes have been based on evidence from research: practice has also been affected by changing technology and pressure by industry and other groups. Among the research-based changes were: an awareness of confidentiality, individualised developmental care, increased use of inhaled nitric oxide, therapeutic hypothermia, less postnatal steroids (although the dosage used is not evidence-based), sucrose as analgesia and permissive hypotension. [ABSTRACT FROM AUTHOR]

This paper reviews the evidence regarding whether a standardised examination in the newborn period can improve infant health. The review considers aspects of delivering such a service from timing and number of examinations through to who should perform examinations, and whether evidence supports current practice. Infants at higher risk of anomaly such as those born preterm are highlighted. Aspects of the examination itself are reviewed, such as detection of congenital heart disease, and the relatively poor detection rate which does not seem to be improving. Potential advantages of additional screening with pulse oximetry are covered. The paper also discusses screening for developmental dysplasia of the hip, which the UK national screening council is unsure of the benefit of, the difficulties of detecting all cases of cleft palate and problems with screening for the very important congenital cataract. The authors draw attention to the relative rarity of some conditions and reflected on how this complicates screening. [ABSTRACT FROM AUTHOR]

Unconjugated hyperbilirubinaemia occurs in almost all premature infants and is potentially neurotoxic. Treatment is based on total serum bilirubin (TSB), but treatment thresholds are not evidence based. Free bilirubin (Bf)—that is, not bound to albumin, seems a better parameter for bilirubin neurotoxicity, but measurements of Bf are not available in clinical practice. The bilirubin/albumin (B/A) ratio is considered a surrogate parameter for Bf and an interesting additional parameter in the management of hyperbilirubinaemia. This paper reviewed the evidence supporting the use of B/A ratios for predicting bilirubin-induced neurological dysfunction (BIND) including neurodevelopmental delay in jaundiced premature infants (gestational age less than 32 weeks). A literature search was performed and six publications reviewed regarding B/A ratios in the management and outcome of jaundiced premature infants. No prospective clinical trials had been undertaken to show whether bilirubin-induced neurotoxicity is reduced or whether unnecessary treatment is avoided by using the B/A ratio in addition to TSB. Recently, a randomised controlled trial evaluating the effect of the additional use of the B/A ratio on neurodevelopmental outcome in jaundiced premature infants has been initiated. Based on the prevailing evidence many authorities suggest that the additional use of the B/A ratio may be valuable when evaluating jaundiced premature infants. [ABSTRACT FROM AUTHOR]

Objectives: (1) To characterise neurodevelopmental outcome of neonates with necrotizing enterocolitis (NEC); (2) to define whether NEC increases risk of neurodevelopmental impairment in very low birth weight neonates; (3) to investigate whether stage of disease or need for surgery increase risk of poor outcome. Design: A systematic review was performed. Searches identified 182 relevant papers. Ten studies compared extremely low birthweight neonates with NEC to infants of similar age and gestation who did not develop NEC. Data are reported as OR (95% Cls, p values for test for overall effect) and compared by χ2. Results: 7843 children (821 with NEC) were included in the meta-analysis. Median follow-up was 20 months (range 12 to 156). Overall, 45% of children who had neonatal NEC were neurodevelopmentally impaired. Infants with NEC were significantly more likely than infants of similar age and gestation who did not develop NEC to be neurodevelopmentally impaired (1.6 (1.3 to 2.0), p<0.0001) including a higher risk of cerebral palsy (1.5 (1.2 to 2.0), p=0.001), visual (2.3 (1.0 to 5.1), p=0.04), cognitive (1.7 (1.4 to 2.2), p<0.0001) and psychomotor impairment (1.7 (1.3 to 2.2), p<0.0001). The odds ratio of neurodevelopmental impairment was also 2.3 times higher in neonates with Bell's stage III disease or requiring surgery ((1.5 to 3.6), p=0.0001). Conclusions: NEC is associated with significantly worse neurodevelopmental outcome than prematurity alone. Presence of advanced NEC and need for surgery increase the risk of neurological impairment. [ABSTRACT FROM AUTHOR]

Objective To evaluate the evidence on the transition process from child to adult services for young people with palliative care needs. Design Systematic review. Setting Child and adult services and interface between healthcare providers. Patients Young people aged 13-24 years with palliative care conditions in the process of transition. Main outcome measures Young people and their families' experiences of transition, the process of transition between services and its impact on continuity of care and models of good practice. Results 92 studies included. Papers on transition services were of variable quality when applied to palliative care contexts. Most focussed on common life-threatening and life-limiting conditions. No standardised transition program identified and most guidelines used to develop transition services were not evidence-based. Most studies on transition programs were predominantly condition-specific (eg, cystic fibrosis (CF), cancer) services. CF services offered high-quality transition with the most robust empirical evaluation. There were differing condition-dependent viewpoints on when transition should occur but agreement on major principles guiding transition planning and probable barriers. There was evidence of poor continuity between child and adult providers with most originating from within child settings. Conclusions Palliative care was not, in itself, a useful concept for locating transition-related evidence. It is not possible to evaluate the merits of the various transition models for palliative care contexts, or their effects on continuity of care, as there are no long-term outcome data to measure their effectiveness. Use of validated outcome measures would facilitate research and service development. [ABSTRACT FROM AUTHOR]

A summary of papers in the April 2010 issue of "Archives of Disease in Childhood: Fetal & Neonatal Edition" is presented. It discusses two papers which explored the outcomes of babies born at the extreme of viability. A paper applied queuing theory to model the intensive care capacity of a neonatal network in line with the individual units within it. A study examined the impact of maternal methadone use on the growth of babies.

Invasive fungal infections in preterm neonates in the neonatal intensive care unit are predominantly caused by Candida spp, and have a high burden of morbidity and mortality. Effective prophylactic strategies have recently become available, but the identification of the best possible strategies to manage high-risk infants is still a priority. Choice and use of appropriate antifungal drugs needs careful assessment of neonatal characteristics, the epidemiology and drug pharmacokinetics. Ideally, antifungal drugs for preterm neonates should target fungal bio-films, prevent or effectively treat end-organ localisations, be active against fluconazole-resistant Candida species, and have reliable safety and tolerability profiles. The paper reviews the state-of-the-art in the area of neonatal fungal infections, and addresses some open questions related to the best possible prophylactic and therapeutic strategies to be implemented in such unique patients. [ABSTRACT FROM AUTHOR]

Objective There is a paucity of data relating to neurodevelopmental outcomes in infants born late and moderately preterm (LMPT; 32+0-36+6 weeks). This paper present the results of a prospective, population-based study of 2-year outcomes following LMPT birth. Design 1130 LMPT and 1255 term-born children were recruited at birth. At 2 years corrected age, parents completed a questionnaire to assess neurosensory (vision, hearing, motor) impairments and the Parent Report of Children's Abilities-Revised to identify cognitive impairment. Relative risks for adverse outcomes were adjusted for sex, socio-economic status and small for gestational age, and weighted to account for over-sampling of term-born multiples. Risk factors for cognitive impairment were explored using multivariable analyses. Results Parents of 638 (57%) LMPT infants and 765 (62%) controls completed questionnaires. Among LMPT infants, 1.6% had neurosensory impairment compared with 0.3% of controls (RR 4.89, 95% CI 1.07 to 22.25). Cognitive impairments were the most common adverse outcome: LMPT 6.3%; controls 2.4% (RR 2.09, 95% CI 1.19 to 3.64). LMPT infants were at twice the risk for neurodevelopmental disability (RR 2.19, 95% CI 1.27 to 3.75). Independent risk factors for cognitive impairment in LMPT infants were male sex, socio-economic disadvantage, non-white ethnicity, preeclampsia and not receiving breast milk at discharge. Conclusions Compared with term-born peers, LMPT infants are at double the risk for neurodevelopmental disability at 2 years of age, with the majority of impairments observed in the cognitive domain. Male sex, socio-economic disadvantage and preeclampsia are independent predictors of low cognitive scores following LMPT birth. [ABSTRACT FROM AUTHOR]

Aim To produce a simple tool with good transferability to provide a consistent assessment of tongue appearance and function in infants with tongue-tie. Methods The Bristol Tongue Assessment Tool (BTAT) was developed based on clinical practice and with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF). This paper documents 224 tongue assessments using the BTAT. There were 126 tongue assessments recorded using the BTAT and ATLFF tools to facilitate comparisons between them. Paired BTAT assessments were obtained from eight midwives who were using the new assessment tool. Results There was acceptable internal reliability for the four-item BTAT (Cronbach's α=0.708) and the eight midwives who used it showed good correlation in the consistency of its use (ICC=0.760). The BTAT showed a strong and significant correlation (0.89) with the ATLFF, indicating that the simpler BTAT could be used in place of the more detailed assessment tool to score the extent of a tongue-tie. Midwives found it quick and easy to use and felt that it would be easy to teach to others. Conclusions The BTAT provides an objective, clear and simple measure of the severity of a tongue-tie, to inform selection of infants for frenotomy and to monitor the effect of the procedure. [ABSTRACT FROM AUTHOR]

Background and Objectives: Caregivers and clinicians of extremely preterm infants (born before 26 weeks' gestation) depend on long-term follow-up research to inform clinical decision-making. The completeness of outcome reporting in this area is unknown. The objective of this study was to evaluate the reporting of outcome definitions, selection, measurement and analysis in existing cohort studies that report on neurodevelopmental outcomes of children born extremely preterm.Methods: We evaluated the completeness of reporting of 'cognitive function' and 'cerebral palsy' in prospective cohort studies summarised in a meta-analysis that assessed the effect of preterm birth on school-age neurodevelopment. Outcome reporting was evaluated using a checklist of 55 items addressing outcome selection, definition, measurement, analysis, presentation and interpretation. Reporting frequencies were calculated to identify strengths and deficiencies in outcome descriptions.Results: All 14 included studies reported 'cognitive function' as an outcome; nine reported both 'cognitive function' and 'cerebral palsy' as outcomes. Studies reported between 26% and 46% of the 55 outcome reporting items assessed; results were similar for 'cognitive function' and 'cerebral palsy' (on average 34% and 33% of items reported, respectively). Key methodological concepts often omitted included the reporting of masking of outcome assessors, methods used to handle missing data and stakeholder involvement in outcome selection.Conclusions: The reporting of neurodevelopmental outcomes in cohort studies of infants born extremely preterm is variable and often incomplete. This may affect stakeholders' interpretation of study results, impair knowledge synthesis efforts and limit evidence-based decision-making for this population. [ABSTRACT FROM AUTHOR]

Optimal management of the patent ductus arteriosus (PDA) in the premature infant remains controversial. Despite considerable historical and physiological data indicating that a persistent PDA may be harmful, robust evidence of long-term benefits or harms from treatment is lacking. This has been equated to a lack of benefit but is also a reflection of the fact that most clinical trials were designed to assess the effects of short-term (2-8 days) rather than prolonged exposure to a PDA. No clinical trials have been designed to assess the effects of prolonged exposure of persistent PDA on morbidity and mortality of very premature infants in the era of antenatal corticosteroids, surfactant and non-invasive respiratory support. Further research is required, but new insights and novel therapies are evolving, which will allow greater individual patient assessment, understanding of risk and optimisation of treatment. In this paper, we review the current literature, evidence for treatment options, including a non-interventional approach, and research directions for infants <28 weeks' gestational age. [ABSTRACT FROM AUTHOR]

The need for outcome evaluations as part of clinical trials has never been greater. In this paper, issues around the design and data collection of such outcome evaluations are discussed in relation to how they may be best collected and the options available. There is a need for organisation of such evaluations and consistency of measures between trials to optimise efficiency. [ABSTRACT FROM AUTHOR]

Children born very preterm have poorer attainment in all school subjects, and a markedly greater reliance on special educational support than their term-born peers. In particular, difficulties with mathematics are especially common and account for the vast majority of learning difficulties in this population. In this paper, we review research relating to the causes of mathematics learning difficulties in typically developing children, and the impact of very preterm birth on attainment in mathematics. Research is needed to understand the specific nature and origins of mathematics difficulties in very preterm children to target the development of effective intervention strategies. [ABSTRACT FROM AUTHOR]

Objective The purpose of the study was to investigate the trends and causes of regional disparities of infant mortality rate (IMR) in rural China from 1996 to 2008. Design A population-based, longitudinal study. Setting The national child mortality surveillance network. Population Population of the 79 surveillance counties. Main outcome measure IMR, leading causes of infant death and the RR of IMR. Results The IMR in coastal, inland and remote regions declined by 72.4%, 62.9% and 58.2%, respectively, from 1996 to 2008. Compared with the coastal region, the RR of IMR were 1.7 (95% CI 1.6 to 1.9), 1.9 (95% CI 1.7 to 2.0) and 1.8 (95% CI 1.6 to 2.0) for inland region and 2.6 (95% CI 2.4 to 2.7), 3.2 (95% CI 3.0 to 3.5) and 3.1 (95% CI 2.7 to 3.4) for the remote region during 1996-2000, 2001-2005 and 2006-2008, respectively. The regional disparities existed for both male and female IMRs. The postneonatal mortality showed the highest regional disparities. Pneumonia, birth asphyxia, prematurity/ low birth weight, injuries and diarrhoea were the main contributors to the regional disparities. There were significantly more infants who did not seek healthcare services before death in the remote region relative to the inland and coastal regions. Conclusion The results indicated persistent existence of regional disparities in IMR in rural China. It is worth noting that regional disparities in IMR increased in the remote and coastal regions during 2001-2005 in rural China. These disparities remained unchanged during 2006-2008. The results indicate that strategies to reduce mortality caused by pneumonia, birth asphyxia and diarrhoea are keys to reducing IMR. INSETS: What is already known on this subject;What this papers adds. [ABSTRACT FROM AUTHOR]

Objective: Hyperglycaemia is common in very preterm infants and is associated with adverse outcomes. Preventing hyperglycaemia without increasing the risk of hypoglycaemia is difficult. Real time tracking with continuous glucose monitors (CGM) may improve glucose control. We assessed the feasibility and safety of CGM to target glucose control in preterm infants, to inform a randomised controlled trial (RCT).Design: We performed a single centre study in very preterm infants during the first week of life. Accuracy was assessed by comparison of CGM with blood glucose levels (n=20 infants). In a separate pilot study of efficacy (n=20), real-time CGM combined with a paper guideline to target glucose control (2.6-10 mmol/L) was compared with standard neonatal care (masked CGM). Questionnaires were used to assess staff acceptability.Results: No concerns were raised about infection or skin integrity at sensor site. The sensor performed well compared with point-of-care blood glucose measurements, mean bias of -0.27 (95% CI -0.35 to -0.19). Per cent time in target range (sensor glucose 2.6-10 mmol/L) was greater with CGM than POC (77% vs 59%, respectively) and per cent time sensor glucose >10 mmol/L was less with CGM than POC (24% vs 40%, respectively). The CGM also detected clinically unsuspected episodes of hypoglycaemia. Staff reported that the use of the CGM positively improved clinical care.Conclusions: This study suggests that CGM has sufficient accuracy and utility in preterm infants to warrant formal testing in a RCT. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about the use of pH specific paper to test gastric aspirates to reduce harm caused by misplaced nasogastric feeding tubes.