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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: Heart rate (HR) is an important clinical parameter in newborn infants, but normal ranges are poorly defined. Our aim was to establish normal reference ranges and individual variations in HR as obtained by auscultation in healthy term-born infants during the first 24 hours of life.Design: Observational study.Setting: Single hospital in Norway.Methods: HR was assessed by auscultation for 30 s at 2, 4, 8, 16 and 24 hours of age. Auscultation was validated against ECG recordings.Subjects: Healthy term-born infants who were asleep or awake in a quiet resting state.Main Outcome Measures: Construction of percentile curves for resting HR.Results: The study included 953 infants. The 50th percentile was 126 beats per minute (bpm) at age 2 hours and thereafter 120-122 bpm. The respective 2nd and 98th percentiles were 102 (thereafter 96-100) bpm and 162 (thereafter 150-156) bpm. The mean HR was 5.6 bpm higher when awake than asleep, 4.9 bpm higher when on the mother's chest than in the cot, 1.6 bpm higher in girls than in boys, and increased by 0.5 bpm per 0.1°C increase in rectal temperature. Mode of delivery, meconium staining, birth weight and maternal smoking during pregnancy were of no significance. For each infant, HR varied considerably during the first 24 hours (intraclass correlation 0.21 (95% CI 0.18 to 0.24), coefficient of variation 9.2%).Conclusions: The HR percentiles allow for a scientifically based use of HR when assessing newborn infants born at term. [ABSTRACT FROM AUTHOR]

Objective: In a previous audit, we demonstrated poor compliance with the neonatal resuscitation algorithm. Training can improve guideline compliance and performance. We aimed to prospectively collect detailed data on delivery room resuscitations to identify needs for educational interventions.Design: Observational study using video recordings of neonatal resuscitations. We analysed episodes where chest compressions (CCs) were provided.Setting: A Norwegian university hospital.Patients: All delivery room resuscitations August 2014 to November 2016.Interventions: The recordings were transcribed using Interact V.9 software (Mangold Int GmbH, Arnstorf, Germany). Supplementary information was collected from the patient electronic records.Main Outcome Measures: Heart rate (HR) assessment, provision of positive pressure ventilation (PPV) and CC, endotracheal intubation and team communication.Results: Twenty-nine CC episodes were analysed. We identified team discordance in the decisions to perform CC and only 6 (21%) were retrospectively judged to be in need for CC: 8 (28%) infants had adequate spontaneous respiration, 18 (62%) infants received ineffective PPV and 5 (17%) had a HR >60 bpm. Only one infant was intubated before CC, and we could not identify a consistent pattern of ventilation corrective actions. One infant received CC without prior HR assessment. In some infants, CC duration was exceedingly short, and 11 (38%) of the infants that received CC were not admitted to the NICU. Six (21%) infants had no documentation of CPR in the delivery record.Conclusions: Education and training should focus on team function and communication, correct and timely HR assessment, effective PPV, and indications for endotracheal intubation. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the variation in neurodevelopmental disability rates between populations persists after adjustment for demographic, maternal and infant characteristics for an international very preterm (VPT) birth cohort using a standardised approach to neurodevelopmental assessment at 2 years of age.Design: Prospective standardised cohort study.Setting: 15 regions in 10 European countries.Patients: VPT births: 22+0-31+6 weeks of gestation.Data Collection: Standardised data collection tools relating to pregnancy, birth and neonatal care and developmental outcomes at 2 years corrected age using a validated parent completed questionnaire.Main Outcome Measures: Crude and standardised prevalence ratios calculated to compare rates of moderate to severe neurodevelopmental impairment between regions grouped by country using fixed effects models.Results: Parent reported rates of moderate or severe neurodevelopmental impairment for the cohort were: 17.3% (ranging 10.2%-26.1% between regions grouped by country) with crude standardised prevalence ratios ranging from 0.60 to 1.53. Adjustment for population, maternal and infant factors resulted in a small reduction in the overall variation (ranging from 0.65 to 1.30).Conclusion: There is wide variation in the rates of moderate to severe neurodevelopmental impairment for VPT cohorts across Europe, much of which persists following adjustment for known population, maternal and infant factors. Further work is needed to investigate whether other factors including quality of care and evidence-based practice have an effect on neurodevelopmental outcomes for these children. [ABSTRACT FROM AUTHOR]

Objective: To compare management recommendations of the National Institute for Health and Care Excellence (NICE) guidelines with the Kaiser Permanente sepsis risk calculator (SRC) for risk of early onset neonatal sepsis (EONS).Design: Multicentre prospective observational projection study.Setting: Eight maternity hospitals in Wales, UK.Patients: All live births ≥34 weeks gestation over a 3-month period (February-April 2018).Methods: Demographics, maternal and infant risk factors, infant's clinical status, antibiotic usage and blood culture results from first 72 hours of birth were collected. Infants were managed using NICE recommendations and decisions compared with that projected by SRC.Main Outcome Measure: Proportion of infants recommended for antibiotics on either tool.Results: Of 4992 eligible infants, complete data were available for 3593 (71.9%). Of these, 576 (16%) were started on antibiotics as per NICE recommendations compared with 156 (4.3%) projected by the SRC, a relative reduction of 74%. Of the 426 infants avoiding antibiotics, SRC assigned 314 (54.6%) to normal care only. There were seven positive blood cultures-three infants were recommended antibiotics by both, three were not identified in the asymptomatic stage by either; one was a contaminant. No EONS-related readmission was reported.Conclusion: The judicious adoption of SRC in UK clinical practice for screening and management of EONS could potentially reduce interventions and antibiotic usage in three out of four term or near-term infants and promote earlier discharge from hospital in >50%. We did not identify any EONS case missed by SRC when compared with NICE. These results have significant implications for healthcare resources. [ABSTRACT FROM AUTHOR]

Objectives: Identify determinants of neurodevelopmental outcome in preterm children.Methods: Prospective national cohort study of children born between 2009 and 2011 at <29 weeks gestational age, admitted to one of 28 Canadian neonatal intensive care units and assessed at a Canadian Neonatal Follow-up Network site at 21 months corrected age for cerebral palsy (CP), visual, hearing and developmental status using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). Stepwise regression analyses evaluated the effect of (1) prenatal and neonatal characteristics, (2) admission severity of illness, (3) major neonatal morbidities, (4) neonatal neuroimaging abnormalities, and (5) site on neurodevelopmental impairment (NDI) (Bayley-III score < 85, any CP, visual or hearing impairment), significant neurodevelopmental impairment (sNDI) (Bayley-III < 70, severe CP, blind or hearing aided and sNDI or death.Results: Of the 3700 admissions without severe congenital anomalies, 84% survived to discharge and of the 2340 admissions, 46% (IQR site variation 38%-51%) had a NDI, 17% (11%-23%) had a sNDI, 6.4% (3.1%-8.6%) had CP, 2.6% (2.5%-13.3%) had hearing aids or cochlear implants and 1.6% (0%-3.1%) had a bilateral visual impairment. Bayley-III composite scores of <70 for cognitive, language and motor domains were 3.3%, 10.9% and 6.7%, respectively. Gestational age, sex, outborn, illness severity, bronchopulmonary dysplasia, necrotising enterocolitis, late-onset sepsis, retinopathy of prematurity, abnormal neuroimaging and site were significantly associated with NDI or sNDI. Site variation ORs for NDI, sNDI and sNDI/death ranged from 0.3-4.3, 0.04-3.5 and 0.12-1.96, respectively.Conclusion: Most preterm survivors are free of sNDI. The risk factors, including site, associated with neurodevelopmental status suggest opportunities for improving outcomes. [ABSTRACT FROM AUTHOR]

Background: Antibiotics used for women in spontaneous preterm labour without overt infection, in contrast to those with preterm rupture of membranes, are associated with altered functional outcomes in their children.Methods: From the National Pupil Database, we used Key Stage 2 scores, national test scores in school year 6 at 11 years of age, to explore the hypothesis that erythromycin and co-amoxiclav were associated with poorer educational outcomes within the ORACLE Children Study.Results: Anonymised scores for 97% of surviving children born to mothers recruited to ORACLE and resident in England were analysed against treatment group adjusting for key available socio-demographic potential confounders. No association with crude or with adjusted scores for English, mathematics or science was observed by maternal antibiotic group in either women with preterm rupture of membranes or spontaneous preterm labour with intact membranes. While the proportion receiving special educational needs was similar in each group (range 31.6-34.4%), it was higher than the national rate of 19%.Conclusions: Despite evidence that antibiotics are associated with increased functional impairment at 7 years, educational test scores and special needs at 11 years of age show no differences between trial groups.Trial Registration Number: ISCRT Number 52995660 (original ORACLE trial number). [ABSTRACT FROM AUTHOR]

The article discusses a study exploring the experience of and need for communication training among trainee neonatologists. Topics discussed include using a short open-ended questionnaire for exploring the involvement of trainee neonatologists in communication skills training, assessment of training using deaneries, and regional training and requirement for improved education for improving the experience of both the healthcare professional and the families involved in neonatal units.

Background: Routine comparable outcome data collection relating to the later health status of babies born very preterm has long been considered important, but has not been achieved in the UK. Aim: To test the potential for a parental questionnaire to provide these data for all eligible babies from a geographical population. Methods: Consent for follow-up by questionnaire (using the Parent Report of Children's Abilities-Revised combined with questions derived from the Oxford minimum dataset) was sought for all babies ≤30 weeks of gestation, discharged from a hospital in the East Midlands and Yorkshire regions of the UK, having been born between 1 January 2007 and 31 December 2011. Results: The rate of consent to participate in follow-up showed a steady increase over time to 83.1% in 2011. However, the response rate in terms of completion and return of the questionnaire at 2 years, as a proportion of those eligible, showed little change over time, varying between 42% and 46%. Among those children where a questionnaire was returned, the rate of disability was broadly consistent over time: lowest in 2009, 21.0% (95% CI 16.8% to 25.6%) and highest in 2011, 25.5% (95% CI 21.5% to 31.2%). The instruments used appeared effective with the capability of discriminating between children with physical and/or cognitive disability. Conclusions: The overall response rate in terms of returned questionnaires was disappointing and inadequate to recommend for implementation. It is possible that response rates would have been higher had clinical follow-up been linked to the data obtained from the questionnaires rather than running as a parallel process. [ABSTRACT FROM AUTHOR]

Background Introducing neonatal screening procedures may not be readily accepted by parents and may increase anxiety. The acceptability of pulse oximetry screening to parents has not been previously reported. Objective To assess maternal acceptability of pulse oximetry screening for congenital heart defects and to identify factors predictive of participation in screening. Design and setting A questionnaire was completed by a cross-sectional sample of mothers whose babies were recruited into the PulseOx Study which investigated the test accuracy of pulse oximetry screening. Participants A total of 119 mothers of babies with false-positive (FP) results, 15 with true-positive and 679 with true-negative results following screening. Main outcome measures Questionnaires included measures of satisfaction with screening, anxiety, depression and perceptions of test results. Results Participants were predominantly satisfied with screening. The anxiety of mothers given FP results was not significantly higher than that of mothers given truenegative results (median score 32.7 vs 30.0, p=0.09). White British/Irish mothers were more likely to participate in screening, with a decline rate of 5%; other ethnic groups were more likely to decline with the largest increase in declining being for Black African mothers (21%, OR 4.6, 95% CI 3.8 to 5.5). White British mothers were also less anxious ( p<0.001) and more satisfied ( p<0.001) than those of other ethnicities Conclusions Pulse oximetry screening was acceptable to mothers and FP results were not found to increase anxiety. Factors leading to differences in participation and satisfaction across ethnic groups need to be identified so that staff can support parents appropriately. [ABSTRACT FROM AUTHOR]

Background: The hip trial aimed to assess clinical effectiveness, economic and psychosocial costs, and benefits of ultrasound imaging (US) compared with conventional clinical assessment alone to guide the management of infants with neonatal hip instability. Objective: To report on psychosocial consequences for mothers and the developing mother-child relationship of US, and associations between abduction splinting and maternal psychosocial distress. Design: Multi centre randomised control led trial. Sewing: Thirty three hospitals in the United Kingdom and Ireland. Participants, interventions: A total of 629 infants with neonatal hip instability randomised to US examination or clinical assessment alone before treatment decision. Questionnaires were completed by 561 (89%) mothers at 8 weeks and 494 (79%) at 1 year. Main outcome measures: Anxiety, postnatal depression, parenting stress assessed by standardised questionnaires. Maternal concerns about hip problems were assessed using the Infant hip worries inventory. Results: At 8 weeks, there were no differences between US and non-US groups of the trial in maternal anxiety (mean difference (MD) -1.2, 95% confidence interval (CI) -3.2 to 0.8), depression (MD 0.0, 95% CI -0.7 to 0.8), parenting stress (MD -1.2, 95% CI -2.8 to 0.4), or other measures. The same pattern was evident at 1 year. In an explanatory analysis, early splinting was associated with increased anxiety at 8 weeks (MD 3.8, 95% CI 1.7 to 5.9) and increased level of hip worries at 8 weeks (MD 6.8, 95% CI 5.6 to 7.9) and 1 year(MD 1.3, 95% CI 0.3 to 2.4). Conclusions: Although early splinting is associated with maternal anxieties, US is not associated with any increase or reduction in psychosocial effects on mothers. Together with the clinical findings, this suggests that the use of US allows reduction in splinting rates without increased risk of adverse clinical or psychosocial outcomes. [ABSTRACT FROM AUTHOR]