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ObjectivesTo describe characteristics of neonates with severe neonatal hyperbilirubinaemia (SNH) and to gain more insight in improvable factors that may have contributed to the development of SNH.Design and settingDescriptive study, based on national Dutch perinatal audit data on SNH from 2017 to 2019.PatientsNeonates, born ≥35 weeks of gestation and without antenatally known severe blood group incompatibility, who developed hyperbilirubinaemia above the exchange transfusion threshold.Main outcome measuresCharacteristics of neonates having SNH and corresponding improvable factors.ResultsDuring the 3-year period, 109 neonates met the eligibility criteria. ABO antagonism was the most frequent cause (43%). All neonates received intensive phototherapy and 30 neonates (28%) received an exchange transfusion. Improvable factors were mainly related to lack of knowledge, poor adherence to the national hyperbilirubinaemia guideline, and to incomplete documentation and insufficient communication of the a priori hyperbilirubinaemia risk assessment among healthcare providers. A priori risk assessment, a key recommendation in the national hyperbilirubinaemia guideline, was documented in only six neonates (6%).ConclusionsSNH remains a serious threat to neonatal health in the Netherlands. ABO antagonism frequently underlies SNH. Lack of compliance to the national guideline including insufficient a priori hyperbilirubinaemia risk assessment, and communication among healthcare providers are important improvable factors. Implementation of universal bilirubin screening and better documentation of the risk of hyperbilirubinaemia may enhance early recognition of potentially dangerous neonatal jaundice.

Objective: To compare the effect of intervention at low vs high threshold of ventriculomegaly in preterm infants with posthemorrhagic ventricular dilatation on death or severe neurodevelopmental disability. Study design: This multicenter randomized controlled trial reviewed lumbar punctures initiated after either a low threshold (ventricular index of >p97 and anterior horn width of >6 mm) or high threshold (ventricular index of >p97 + 4 mm and anterior horn width of >10 mm). The composite adverse outcome was defined as death or cerebral palsy or Bayley composite cognitive/motor scores

Background and study aims: Infections are a recognized risk of endoscopic retrograde cholangiopancreatography (ERCP). This paper reports on a large outbreak of VIM-2-producing Pseudomonas aeruginosa that was linked to the use of a recently introduced duodenoscope with a specific modified design (Olympus TJF-Q180V). Methods: Epidemiological investigations and molecular typing were executed in order to identify the source of the outbreak. Audits on implementation of infection control measures were performed. Additional infection control strategies were implemented to prevent further transmission. The design and the ability to clean and disinfect the duodenoscope were evaluated, and the distal tip was dismantled. Results: From January to April 2012, 30 patients with a VIM-2-positive P. aeruginosa were identified, of whom 22 had undergone an ERCP using a specific duodenoscope, the TJF-Q180V. This was a significant increase compared with the hospital-wide baseline level of 2 – 3 cases per month. Clonal relatedness of the VIM-2 P. aeruginosa was confirmed for all 22 cases and for the VIM-2 strain isolated from the recess under the forceps elevator of the duodenoscope. An investigational study of the new modified design, including the dismantling of the duodenoscope tip, revealed that the fixed distal cap hampered cleaning and disinfection, and that the O-ring might not seal the forceps elevator axis sufficiently. The high monthly number of cases decreased below the pre-existing baseline level following withdrawal of the TJF-Q180V device from clinical use. Conclusions: Duodenoscope design modifications may compromise microbiological safety as illustrated by this outbreak. Extensive pre-marketing validation of the reprocessability of any new endoscope design and stringent post-marketing surveillance are therefore mandatory.

BACKGROUND: In multi-infusion IV therapy, the actual volume delivered to the neonate can vary over time. To reduce flow rate variability, check valves can be used. A check valve allows flow through the valve in only one direction. OBJECTIVE: To evaluate flow rate variability in a low flow dual-infusion setup with and without check valves. METHODS: The effect of changing the height of and adding syringes to the IV-administration set was tested with and without check valves in an in vitro dual-infusion setup with in-line flow meters. The pre-programmed flow rates were 2.5 and 0.1 ml/h. RESULTS: Twenty-four tests of 90 minutes were performed. Time to reach 75% of the pre-programmed 0.1 ml/h flow rate was >20 minutes. The highest total delivered volume during a test was (mean ± SD) 56 ± 8% of the expected delivery for tests without check valves, and diminished to 12 ± 24% of the expected delivery for check valves with a higher opening pressure. CONCLUSIONS: The actual flows and the total delivered volume in low flow dual-infusion setups are less than expected on the pre-programmed flow-rate. These findings emphasize the need for the development of more accurate delivery systems for drugs and fluids in neonatology. Caregivers should be aware of these findings, and optimise the delivery of IV substances by making use of check valves with low opening pressures and by minimising compliance and volume of the IV-administration set. Furthermore, changes in the relative height between pumps and catheter tip should be minimized.

Aims: This article aims (a) to get insight into intensive care nurses’ most critical work-related incidents, (b) their reactions and coping and

SummaryAim To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for newborns. Methods We conducted a review of the literature from 1980 to 2011 in PubMed and Web of Knowledge. Articles focusing on flow-rate variability and possible complications due to flow-rate variability were included. Results Forty-one articles were selected for this review. IV therapy in (preterm) neonates is prone to significant start-up delays and flow-rate variability. The sudden changes in the volume delivered to (preterm) neonates may have serious consequences. Low preprogrammed flow rates, total compliance, and volume of the IV administration set, the presence or absence of antisiphon valves or inline filters and the vertical displacement of syringe pumps all contribute to flow-rate variability in IV therapy for neonates. Conclusions Flow-rate variability in IV therapy and its clinical relevance are due to the preprogrammed flow rate, the hydrostatic pressure changes, the complete IV administration set compliance and the type of substances supplied to the patient. To improve IV therapy, the internal compliance of the complete IV administration set should be minimized and the highest possible preprogrammed flow rate should be used in combination with small syringes and low-resistance valves.

The aim of this study was to evaluate the performance of "new-generation" pulse oximeters in extremely low-birth-weight ([ELBW]

Aim: To quantify manual fraction of inspired oxygen (FiO2) adjustments performed by caregivers in extremely low birth weight (ELBW; ≤1000 g) infants, in relation to oxygen saturation (SpO) and bedside care. Methods: In a single-centre study, FiO, SpO and alarm limits of ELBW infants were collected for 3 days continuously, while caregivers were filmed. A descriptive analysis, focused on manual FiO adjustments, was performed. Results: Twelve ELWB infants were included. Total recording time was 726 h. FiO was increased 851 times and decreased 1309 times; median (range) step size was 5% (1% to 65%) and -3% (-1% to -65%), respectively. Wide variation of FiO adjustments for equal levels of SpO was observed in all included infants. One hundred and twenty-six of 136 FiO adjustments with a step size âyen 15% and 111 of 171 desaturations 21%, alarm limits for SpO were set according to protocol (88-94%) in 64% of the time. Within these periods, SpO was >94% for 30% and

This meta-analysis reviewed existing data on the impact of work-related critical incidents in hospital-based health care professionals. Work-related critical incidents may induce post-traumatic stress symptoms or even post-traumatic stress disorder (PTSD), anxiety, and depression and may negatively affect health care practitioners’ behaviors toward patients. Nurses and doctors often cope by working part time or switching jobs. Hospital administrators and health care practitioners themselves may underestimate the effects of work-related critical incidents. Relevant online databases were searched for original research published from inception to 2009 and manual searches of the Journal of Traumatic Stress, reference lists, and the European Traumatic Stress Research Database were conducted. Two researchers independently decided on inclusion and study quality. Effect sizes were estimated using standardized mean differences with 95% confidence intervals. Consistency was evaluated, using the I2-statistic. Meta-analysis was performed using the random effects model. Eleven studies, which included 3866 participants, evaluated the relationship between work-related critical incidents and post-traumatic stress symptoms. Six of these studies, which included 1695 participants, also reported on the relationship between work-related critical incidents and symptoms of anxiety and depression. Heterogeneity among studies was high and could not be accounted for by study quality, character of the incident, or timing of data collection. Pooled effect sizes for the impact of work-related critical incidents on post-traumatic stress symptoms, anxiety, and depression were small to medium. Remarkably, the effect was more pronounced in the longer than in the shorter term. In conclusion, this meta-analysis supports the hypothesis that work-related critical incidents are positively related to post-traumatic stress symptoms, anxiety, and depression in hospital-based health care professionals. Health care workers and their supervisors should be aware of the harmful effects of critical incidents and take preventive measures., Highlights ► Critical incidents induce PTSD-symptoms, anxiety, and depression. ► PTSD-symptoms are more pronounced in the longer than the shorter term. ► Health professionals suffer from impaired functioning but relatively few seek help. ► Professionals should be aware of and prevent harmful effects of critical incidents.

Background The VACTERL association is a non-random association of congenital defects with an unknown aetiology in the majority of patients. Methods A male newborn is reported with features of the VACTERL association, including anal atresia, laryngeal and oesophageal atresia with tracheo-oesophageal fistula, dextroposition of the heart with persistent left superior vena cava, and unilateral multicystic kidney. As the clinical picture of this patient overlaps with that of X-linked heterotaxy caused by ZIC3 mutations, the ZIC3 coding region was sequenced. Results In a patient with the VACTERL association a 6-nucleotide insertion was found in the GCC repeat of the ZIC3 gene, which is predicted to expand the amino-terminal polyalanine repeat from 10 to 12 polyalanines. The polyalanine expansion is a novel ZIC3 mutation which was not found in 336 chromosomes from 192 ethnically matched controls. The mutation was also not present in the mother, suggesting it occurred de novo in the patient and is therefore a pathogenetic mutation. Conclusion It is hypothesized that this novel and de novo polyalanine expansion in ZIC3 contributes to the VACTERL association in this patient. A newborn male is described with features of the VACTERL association, including anal atresia, laryngeal and oesophageal atresia with tracheo-oesophageal fistula, dextroposition of the heart with persistent left superior vena cava, and unilateral multicystic kidney. As the clinical picture of the VACTERL association overlaps with X-linked heterotaxy caused by ZIC3 mutations, the ZIC3 coding region was sequenced, and a 6-nucleotide insertion was found that is predicted to expand the amino-terminal polyalanine repeat from 10 to 12 polyalanines. This novel mutation was not present in the mother, nor in 336 chromosomes from 192 ethnically matched controls. It is hypothesised that this novel and de novo polyalanine expansion in the ZIC3 gene contributes to the VACTERL association in this patient.

Objective: To describe policies towards family visiting in Neonatal Intensive Care Units (NICU) and compare findings with those of a survey carried out 10 years earlier. Methods: A questionnaire on early developmental care practices was mailed to 362 units in eight European countries (Sweden, Denmark, the UK, the Netherlands, Belgium, France, Spain and Italy). Of them 78% responded, and among those responded, 175 reported caring for at least 50 very low birth weight infants every year and their responses were analysed further. Results: A majority of all units allowed access at any time for both parents. This was almost universal in northern Europe and the UK, whereas it was the policy of less than one-third of NICU in Spain and Italy, with France in an intermediate position. Restrictions on visiting of grandparents, siblings and friends, as well as restricting parents' presence during medical rounds and procedures followed the same pattern. A composite visiting score was computed using all the variables related to family visiting. Lower median values and larger variability were obtained for the southern countries, indicating more restrictive attitudes and lack of national policy. Conclusions: The presence of parents and other family members in European NICUs has improved over a 10-year period. Several barriers, however, are still in place, particularly in the South European countries.

BACKGROUND: Cocaine exposure during pregnancy has been reported to have detrimental effects on the fetus.OBJECTIVE: To describe the findings on cranial ultrasonography (CUS) as part of a neonatal screening programme for exposed neonates.MATERIALS AND METHODS: The study was a semiprospective analysis of a 12-year cohort of neonates born to mothers who had used cocaine during their pregnancy and who had follow-up according to a strict clinical protocol.RESULTS: In total, 154 neonates (78 boys, 76 girls) were included, of whom 29 (19%) were born preterm, and 125 (81%) were born full-term. Abnormalities on CUS were seen in 37 neonates (24%; 95% CI 18-31%). The abnormalities were classified as minor in 20 (13%; 95% CI 9-19%) and mildly abnormal in 17 (11%; 95% CI 7-17%). None of the infants showed severe abnormalities. The abnormalities were not associated with the duration or maximum amount of cocaine use during pregnancy.CONCLUSION: None of the infants had severe abnormalities. Detected abnormalities were not correlated with the duration or maximum amount of cocaine use. Given these findings, we feel that routine cranial ultrasonography in this population is not warranted.

PURPOSE: For neonates receiving intensive care, nasogastric tube feeding is essential. Since nasogastric tube placement techniques are not well standardized and common verification methods can be unreliable, placement errors may lead to unsafe situations. In mechanically ventilated neonates and neonates on continuous positive airway pressure, malpositioning of the nasogastric tube may prevent excess air within the stomach to escape. In this study, we aimed to relate tube position to amount of air. The hypothesis was: the better the position of the tube, the smaller the amount of air in the stomach. SUBJECTS: A 1-year cohort of neonates in a level IIIc neonatal intensive care unit with a nasogastric tube. DESIGN AND METHODS: We retrospectively reviewed 326 radiographs and classified nasogastric tube position and gastric air. Descriptive statistics were used to describe demographic data. Kendal's τ statistic was applied to explore the relationship between nasogastric tube position and amount of gastric air. A Mann-Whitney U test was performed to confirm the differences in gastric air in neonates with Ch5 and Ch6 gastric tubes and neonates with Ch8 gastric tubes. RESULTS: One or both orifices of nasogastric tubes were in the esophagus in 7.1% of cases, tubes were curled up in the stomach in 35.3% of cases, and tube tips were beyond the pyloric sphincter in 5.5% of cases. Substantial or excessive air was found in 37.7% of cases. Kendal's τ value indicated that there was no significant correlation between nasogastric tube position and gastric air. The Mann-Whitney U value indicated that children with Ch5 and Ch6 gastric tubes had significantly more gastric air than children with Ch8 gastric tubes. CONCLUSION: Nasogastric tubes were malpositioned in nearly half of cases, and substantial or excessive air was found in more than one-third of cases. The hypothesis-the better the position of the tube, the smaller the amount of gastric air-was not confirmed by the data. However, a significant relationship was found between tube size and gastric air. Copyright

Aim: To study development and growth in relation to newborn individualized developmental and assessment program (NIDCAP (R)) for infants born with a gestational age of less than 30 weeks. Methods: Developmental outcome of surviving infants, 25 in the NIDCAP group and 24 in the conventional care group, in a prospective phase-lag cohort study performed in a Dutch level III neonatal intensive care unit (NICU) was compared. Main outcome measure was the Bayley scales of infant development-II (BSID-II) at 24 months corrected age. Secondary outcomes were neurobehavioral and developmental outcome and growth at term, 6, 12 and 24 months. Results: Accounting for group differences and known outcome predictors no significant differences were seen between both care groups in BSID-II at 24 months. At term age NIDCAP infants scored statistically significant lower on neurobehavioral competence; motor system (median [IQR] 4.8 [2.9-5.0] vs. 5.2 [4.3-5.7], p = 0.021) and autonomic stability (median [IQR] 5.7 [4.8-6.7] vs. 7.0 [6.0-7.7], p = 0.001). No differences were seen in other developmental outcomes. After adjustment for background differences, growth parameters were comparable between groups during the first 24 months of life. Conclusion: At present, the strength of conclusions to be drawn about the effect of NIDCAP on developmental outcome or growth at 24 months of age is restricted. Further studies employing standardized assessment approaches including choice of measurement instruments and time points are needed.

Objectives The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality. Study design Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA—28 days after delivery). A standardized procedure to establish the cause of death and substandard care by perinatal audit was developed. The main outcome measures were perinatal mortality rates in ethnic groups, cause of death classified by extended Wigglesworth classification, presence of substandard care (unlikely to be, possibly or likely to be related to perinatal death), and component of care considered to be substandard. Results In Surinamese and other non-Western mothers (mainly from Ghana) perinatal mortality, beyond 16 weeks' gestation, was statistically significantly higher than among native Dutch mothers. (4.01, 2.50, and 1.07%, respectively). In Surinamese and Moroccan mothers, we observed a higher rate of early preterm deliveries. The prevalence of substandard care differed statistically significantly among ethnic groups ( p =0.034), with the highest prevalence among Surinamese mothers. These differences were especially apparent in the prevalence of (more) maternal substandard care factors among Surinamese and Moroccan mothers. These factors consisted of a later start date for antenatal care or a later notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements). Conclusions The higher perinatal mortality in Surinamese and other non-Western groups is mainly due to a higher rate of early preterm deliveries. No differences in care were observed among ethnic groups during labour and delivery. Among Surinamese mothers, however, the results indicate that substandard care with maternal involvement plays a role in explaining their higher perinatal mortality rates.

Purpose: To study the effect of introduction of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) on nursing staff job satisfaction. SUBJECTS: Registered nurses, with specialist neonatal qualifications or in training, in a level III neonatal intensive care unit (NICU) in the Netherlands. DESIGN AND METHODS: A survey was performed before 2001 and 6 months after (2003) the introduction of NIDCAP as the new model of care. Job satisfaction was measured by means of the Index of Work Satisfaction (IWS) instrument. PRINCIPAL RESULTS: From the 74 and 70 nurses on the payroll, who participated in the survey before and after the introduction of NIDCAP, respectively 67.6% and 80% responded. No differences were seen in background variables between both groups. Individual components of the IWS on importance and satisfaction were ranked in the same order before and after the NIDCAP introduction. The results on the IWS demonstrated no change in the overall satisfaction rate, respectively 14.4 and 14.5. Only in 1 component, organizational policies, the mean score increased significantly (3.68 and 4.13, respectively, P = .008). The other component scores did not increase significantly. CONCLUSIONS: Major changes in nursing care practice by means of NIDCAP, on our NICU did not affect overall satisfaction. Scores suggested that nursing staff were persistently satisfied with their job. Copyright

Context: Central congenital hypothyroidism (CH-C) in neonates born to mothers with inadequately treated Graves’ disease usually needs T4 supplementation. The thyroid and its regulatory system have not yet been extensively studied after T4 withdrawal, until we observed disintegrated thyroid glands in some patients. Objective: The aim was to study the occurrence and pathogenesis of disintegrated thyroid glands in CH-C patients. Design, Setting, Patients, Participants: Thyroid function was measured and thyroid ultrasound imaging was performed in 13 children with CH-C due to inadequately treated maternal Graves’ disease after T4-supplementation withdrawal (group Aa). In addition, thyroid ultrasound imaging was performed in six children with CH-C born to inadequately treated mothers with Graves’ disease, in whom T4 supplementation was not withdrawn yet (group Ab) or never initiated (group Ac), in six euthyroid children born to adequately treated mothers with Graves’ disease (group B), and in 10 T4-supplemented children with CH-C as part of multiple pituitary hormone deficiency (group C). Main Outcome Measures: Thyroid function and aspect (volume, echogenicity, echotexture) were measured. Results: In group A, five children had developed thyroidal hypothyroidism characterized by persistently elevated TSH concentrations and exaggerated TSH responses after TRH stimulation. In the majority of patients in groups A and C, thyroid echogenicity and volume were decreased, and echotexture was inhomogeneous. Thyroid ultrasound imaging was normal in group B children. Conclusions: Inadequately treated maternal Graves’ disease not only may lead to CH-C but also carries an, until now, unrecognized risk of thyroid disintegration in the offspring as well. We speculate that insufficient TSH secretion due to excessive maternal-fetal thyroid hormone transfer inhibits physiological growth and development of the child’s thyroid.

We thank Saliou and Baron for their comments. They state that microbial surveillance of endoscopes by antegrade sampling with a sterile 0.9 % saline solution might be insufficient to reveal the microbial contamination. They also suggest the additional use of thiosulfate during sampling. Unfortunately, in the outbreak we described, the use of a thiosulfate-containing buffer would not have been able to detect the microbial contamination. As the manufacturer states, the elevator wire channel of the TJF-Q180V is sealed by an O-ring, which means that separate cleaning is no longer necessary. Moreover, this scope is also designed with a unique distal cap that is fixed, which impairs cleaning and disinfection in the spaces within this cap. Sampling of these spaces is only possible when using an ultrathin swab, as demonstrated in our study, which thereby revealed the VIM-2 producing Pseudomonas aeruginosa. However, we do agree with Saliou and Baron that the optimal sampling method for endoscopes is still under debate. At present, the use of sterile 0.9 % saline solution is recommended by the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates. Although the French guideline recommends the use of a tensioactive solution (e. g. Tween 80) to increase the detection of microorganisms, the use of sodium thiosulfate is not mentioned in this guideline. The combination of the narrow lumina of the endoscope and heavy contamination with blood, secretions, and microorganisms during its use, might promote the growth of biofilms in cases of insufficient (pre)cleaning. Once these biofilms occur, they are very resilient to physical removal by regular cleaning and are less susceptible to biocides. In a recent review, it was concluded that by ensuring prompt device cleaning and reprocessing, either by high-level disinfection or sterilization, and proper drying, biofilms will not have a chance to form [8]. Unfortunately, at present there is no evidence in the literature that a consensus on this matter has been reached. However, in light of recent reports of microbiological outbreaks after endoscopy, a reliable method of investigating microbial safety following high-level disinfection is urgently needed. The utility of sodium thiosulfate or another biofilm dissolver should be investigated in studies, led, ideally, by an international working group consisting of microbiologists and endoscopists. In addition, a consensus statement concerning the interpretation and action required from the data collected should become available and updated regularly. Saliou and Baron also stress the importance of endoscope drying in order to prevent bacterial proliferation. The importance of drying has been emphasized previously by Muscarella. As stated in our manuscript, at the Erasmus MC all endoscopes are dried and stored in a storage cabinet (WASSENBURG DRY 300; Wassenburg Medical Devices BV, Dodewaard, The Netherlands), unless immediate re-use (within 4 hours) is required. Therefore, bacterial proliferation during storage was not considered to be a possible cause of the VIM-2 producing P. aeruginosa outbreak.

OBJECTIVE. The aim of this study was to determine whether thyroxine treatment would improve nerve conduction in infants with Down syndrome. METHODS. A single-center, nationwide, randomized, double-blind, clinical trial was performed. Neonates with Down syndrome were assigned randomly to thyroxine (N = 99) or placebo (N = 97) treatment for 2 years. Daily thyroxine doses were adjusted regularly to maintain plasma thyrotropin levels in the normal range and free thyroxine concentrations in the high-normal range. The outcome measures were nerve conduction velocity and central conduction time, determined through median nerve somatosensory evoked potential recording, at the age of 24 months. RESULTS. At the age of 24 months, somatosensory evoked potential recordings for 81 thyroxine-treated and 84 placebo-treated infants were available for analysis. Nerve conduction velocity and central conduction time did not differ significantly between the 2 treatment groups (nerve conduction velocity: thyroxine: 51.0 m/second; placebo: 50.1 m/second; difference: 0.9 m/second; central conduction time: thyroxine: 8.83 milliseconds; placebo: 8.73 milliseconds; difference: 0.1 milliseconds). CONCLUSIONS. Postnatal thyroxine treatment of infants with Down syndrome did not alter somatosensory evoked potential-measured peripheral or central nerve conduction significantly. The absence of favorable effects suggests that pathologic mechanisms other than mild postnatal hypothyroidism underlie the impaired nerve conduction. The absence of adverse effects suggests that longstanding plasma free thyroxine concentrations in the high-normal range are not harmful to nerve maturation.

The main purpose of implementing the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) in our neonatal intensive care unit from the perspective of quality of care was to bring about an improvement in the satisfaction of parents. This was measured by means of the NICU-Parent Satisfaction Form and the Nurse Parent Support Tool. Parents were significantly more satisfied with care given according to NIDCAP principles than they were with the traditional care for their premature born babies.

A prospective observational study was performed in pregnant women with known thyroid disease. We studied the effect of maternal thyroid function in the first half of pregnancy on the neurologic development of the infant in the first 2 y of life. Clinical and thyroid function data were collected from 20 pregnant women with known thyroid disease and their newborn children. Infants were divided into three groups according to their maternal thyroid function within the first half of pregnancy: Group A (n = 7): maternal subclinical hypothyroidism, Group B (n = 6): maternal euthyroidism, and Group C (n = 7): maternal hyperthyroidism or subclinical hyperthyroidism. Neurophysiologic, i.e. motor nerve conduction velocity and somatosensory evoked potentials and neurologic and developmental (Bayley scales) assessments were done. One infant, born to a mother with Graves' disease, developed transient hyperthyroidism. At the age of 6 and 12 mo, the mean mental developmental index (MDI) score was 16 points lower for infants in Group A than for those in Group B (p = 0.03 and 0.02, respectively). At the age of 24 mo, the mean MDI score was 6 points lower, which was not statistically significant. Neurophysiologic and neurologic assessments and the mean Psychomotor Developmental scores did not differ among the three groups. In conclusion, maternal subclinical hypothyroidism in the first half of pregnancy was associated with a lower mean MDI score in their infants during the first year of life.

Objective : Cross-sectional and longitudinal reference values of cortical N 1 peak latency of the median nerve SEP in very preterm infants. Methods : In infants in a placebo control group within an l-thyroxine supplementation trial, born at less than 30 weeks' gestation, cortical N 1 peak latency was measured at 2 weeks, at term and at 6 months corrected age. Cross-sectional N 1 latency values obtained in 50 infants and complete series of longitudinal values obtained in 15 infants were analyzed in relation to postmenstrual age (PMA). Results : Mean N 1 latency decreased from 66 ms at 2 weeks to 38 ms at term and 20 ms at 6 months corrected age. Possible confounding factors did not have any significant effect on N 1 latency at 2 weeks or at term age except cranial ultrasound abnormalities at 2 weeks of age. Conclusions : Longitudinal N 1 latency values were consistent with cross-sectional N 1 latency values. The observed N 1 latency at term and at 6 months corrected age suggest that extrauterine maturation of the somatosensory pathway in infants born at less than 30 weeks' gestation is delayed by extrauterine life.

Sufficient reference values for motor nerve conduction velocity (MNCV) in very preterm infants are not yet available. In the placebo infants within an L-thyroxine supplementation trial, born at less than 30 weeks' gestation, ulnar and posterior tibial MNCV measurements were performed shortly after birth. Repeated measurements were done at 2 weeks, at term, and at 6 months corrected age. Cross-sectional MNCV values obtained in 50 infants and longitudinal MNCV values obtained in 15 infants were analyzed in relation to postmenstrual age (PMA). Mean ulnar MNCV increased from 13 to 44 m/s and mean tibial MNCV from 11 to 37 m/s. Motor nerve conduction velocity was clearly related to PMA. Longitudinal MNCV values were consistent with cross-sectional MNCV values. Possible confounding factors did not have any significant effect on MNCV. In the ulnar nerve, extrauterine maturation during the first 2 weeks of life was delayed compared with intrauterine maturation.

BACKGROUND: Transient hypothyroxinemia is common in preterm infants and has been associated with neurodevelopmental dysfunction and slow nerve conduction velocity. It is still unknown whether L-thyroxine supplementation is required. During an L-thyroxine supplementation trial, motor nerve conduction velocity was measured to answer the question whether L-thyroxine supplementation improves motor nerve conduction velocity. METHODS: Two hundred infants

Objective. To study the effect ofl-thyroxine supplementation on neurologic maturation in very preterm infants with transient hypothyroxinemia. Design. Randomized, double-blind, placebo-controlled,l-thyroxine supplementation trial. Setting. Level III neonatal intensive care unit. Subjects. A total of 200 infants Intervention. Subjects were randomly assigned to receivel-thyroxine (8 μg/kg birth weight per day) or a placebo during the first 6 weeks of life. Methods. Median nerve somatosensory evoked potentials were recorded, measuring cortical N1 peak latency at 2 weeks of age, at term, and at 6 months (corrected) age. Results. Cortical N1 peak latency was not decreased significantly in the l-thyroxine group compared with the placebo group throughout the study period. Conclusion. l-Thyroxine supplementation during the first 6 weeks of life did not decrease cortical N1 peak latency in infants of

PURPOSE: To prospectively evaluate hazards in the process of supplemental oxygen therapy in very preterm infants hospitalized in a Dutch NICU. METHODS: A Failure Mode and Effects Analysis (FMEA) was conducted by a multidisciplinary team. This team identified, evaluated, and prioritized hazards of supplemental oxygen therapy in preterm infants. After accrediting "hazard scores" for each step in this process, recommendations were formulated for the main hazards. RESULTS: Performing the FMEA took seven meetings of 2 hours. The top 10 hazards could all be categorized into three main topics: incorrect adjustment of the fraction of inspired oxygen (FiO2), incorrect alarm limits for SpO2, and incorrect pulse-oximetry alarm limits on patient monitors for temporary use. The FMEA culminated in recommendations in both educational and technical directions. These included suggestions for (changes in) protocols on alarm limits and manual FiO2 adjustments, education of NICU staff on hazards of supplemental oxygen, and technical improvements in respiratory devices and patient monitors. CONCLUSIONS: The FMEA prioritized flaws in the process of supplemental oxygen therapy in very preterm infants. Thanks to the structured approach of the analysis by a multidisciplinary team, several recommendations were made. These recommendations are currently implemented in the study's center. Copyright

Healthcare professionals are seeing an increasing number of morbidly obese patients. Medical interventions are often difficult to perform in these patients. In acute situations this can lead to major problems.Assistance from a mobile medical team was requested for a 42-year-old male weighing 350 kg with severe respiratory failure. Transporting the patient was problematic due to his build. The hospital to which he was brought after hours of delay lacked the appropriate space and resources for morbidly obese patients. Since the condition of the patient deteriorated, intubation and mechanical ventilation were required. Despite additional equipments for problematic airway access, the procedure failed and the patient died due to respiratory failure.Designating centres for care, also in the acute situations, of morbidly obese patients is recommended, to improve the care of these patients and to prevent disasters.

This article aims (a) to get insight into intensive care nurses' most critical work-related incidents, (b) their reactions and coping and (c) perceived support, in a Dutch intensive care unit.Research about the impact of critical incidents has largely been aimed at ambulance and emergency nurses; knowledge about intensive care nurses in this respect is scarce. Persistent stress reactions after critical incidents may cause symptoms of post-traumatic stress disorder, depression and anxiety. Unresolved problems may also cause poor behaviour towards patients. In response, nurses reduce work hours or even resign. Social support alleviates emotional problems, but little is known about actual support perceived.This study is a qualitative explorative study.Thematic analysis of semi-structured interviews was performed among a purposive sample of 12 intensive care nurses in a university hospital in The Netherlands.Four main themes have been identified in critical incidents: high emotional involvement in patient-related incidents (in contrast to major life-threatening events as such), avoidable incidents, sub-standard patient care and intimidation. Themes discerned in nurses' reactions after critical incidents were physical reactions, emotional reactions and cognitive/behavioural reactions. After critical incidents, nurses talked with colleagues, friends or relatives, but would have appreciated additional support.Incidents under emotionally demanding circumstances are among the most difficult situations, but may not be recognized as critical incidents by colleagues. Both adequate and inadequate coping strategies, with long-lasting problems after critical incidents, were reported. Feelings of anger, shame and powerlessness, may have hindered recovery. Talking to colleagues was perceived to be helpful, but intensive care nurses' need for support was insufficiently met.Managers should acknowledge the effects of critical incidents on intensive care nurses and take preventive measures: reducing critical incidents, improving open communication, imposing a buddy-system for collegial support, and timely evaluating the necessity of professional help.

Objective: To describe the experiences of a regional audit of perinatal deaths, including the experiences of the audit members, to discuss similarities and differences with other, existing perinatal audits and to summarize the implications for future implementation.Study design: Perinatal audit with blinded regional auditors. Consecutive cases of perinatal death were analysed for the presence of substandard care. A random selection of cases was reviewed by an external audit panel. The prevalence of substandard care in the Amsterdam audit was compared with other, existing audits. A survey among audit members was executed.Results: Care providers from all Amsterdam hospitals, as well as general practitioners and independent midwives cooperated. One hundred thirty-seven perinatal deaths were reviewed. In 25% of all perinatal death cases, substandard care factors were present. After 23 completed weeks substandard care factors were present in 35% of cases, and in 52% of intrapartum deaths. These figures are comparable with other, non-regional oriented audits. The review of the external panel was also comparable to the review of the regional audit committee. All audit members felt secure to discuss freely the presence of substandard care.Conclusion: First systematic experiences with a regional perinatal audit are described. We conclude that a regional perinatal audit is executable. Cooperation of regional care providers is good. Review of substandard care factors is comparable to other, non-regional oriented perinatal audits. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

Aim: To compare the short-term clinical outcomes of Newborn Individualized Developmental Care and Assessment Program (NIDCAP®) and conventional care. Methods: A prospective phase-lag cohort study was performed in a Dutch tertiary level neonatal intensive care unit (NICU). Infants born before 30 weeks of gestational age (GA) were included, 26 in the conventional and 25 in the NIDCAP group. Outcomes were respiratory status, cerebral ultrasound findings, growth and length of NICU stay. Results: At study entry, NIDCAP infants had a lower birth weight (mean [SD]: 1043 [191] vs. 1154 [174] g, p = 0.044), were more often small for GA (8 vs. 2, p = 0.038), had smaller head circumferences (mean [SD]: 25.1 [1.3] vs. 26.1 [1.8] cm, p = 0.041) and were less often multiples (6 vs. 14, p = 0.029) than conventional care infants. During NICU stay, more infants in the NIDCAP group developed pneumonia (9 vs. 3, p = 0.040) due to nosocomial infections. After adjustment for these differences, a decreased risk for more severe cerebral damage in favour of NIDCAP was seen (Odds ratio: 0.12, 95% CI: 0.03–0.46, p = 0.002). No differences were observed for the other outcomes. Conclusions: We conclude with precaution that in this phase-lag cohort study NIDCAP may have resulted in less severe cerebral damage, but was not associated with other clinical outcomes. In light of these findings, NIDCAP deserves further exploration.

The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality.Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA-28 days after delivery). A standardized procedure to establish the cause of death and substandard care by perinatal audit was developed. The main outcome measures were perinatal mortality rates in ethnic groups, cause of death classified by extended Wigglesworth classification, presence of substandard care (unlikely to be, possibly or likely to be related to perinatal death), and component of care considered to be substandard.In Surinamese and other non-Western mothers (mainly from Ghana) perinatal mortality, beyond 16 weeks' gestation, was statistically significantly higher than among native Dutch mothers. (4.01, 2.50, and 1.07%, respectively). In Surinamese and Moroccan mothers, we observed a higher rate of early preterm deliveries. The prevalence of substandard care differed statistically significantly among ethnic groups (p=0.034), with the highest prevalence among Surinamese mothers. These differences were especially apparent in the prevalence of (more) maternal substandard care factors among Surinamese and Moroccan mothers. These factors consisted of a later start date for antenatal care or a later notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements).The higher perinatal mortality in Surinamese and other non-Western groups is mainly due to a higher rate of early preterm deliveries. No differences in care were observed among ethnic groups during labour and delivery. Among Surinamese mothers, however, the results indicate that substandard care with maternal involvement plays a role in explaining their higher perinatal mortality rates.

Background. We have conducted a randomized trial with thyroxine (T4) in 200 infants Methods. For each infant, the average FT4 of 5 scheduled measurements was calculated between day 3 and day 28. Infants of the placebo and the T4 group separately were divided in 2 groups. The placebo group consisted of a group of infants with average FT4 in the lowest quartile and a group in the upper 75%. The T4 group consisted of a group of infants with average FT4 in the upper quartile and a group in the lower 75%. Developmental outcome (mental/cognitive, motor, and neurologic) at 2 and 5.7 years was compared between high and low FT4 groups, and then compared separately for the T4 and placebo group. Results. In the placebo group, low FT4 was associated with worse outcome on all domains at both time points. After correction for confounding variables, mental and neurologic outcome remained significantly different at 2 years, and motor outcome at 5 years. In the T4 group, high FT4 was not associated with worse outcome, neither at 2 nor at 5 years. Conclusions. In untreated infants, low FT4 values during the first 4 weeks after birth in infants born at

Item does not contain fulltext Posthaemorrhagic ventricular dilatation (PHVD) in very preterm infants carries a poor prognosis. As earlier studies have failed to show a benefit of early intervention, it is recommended that PHVD be first treated when head circumference is rapidly increasing and/or when symptoms of raised intracranial pressure develop. Infants with PHVD, admitted to 5 of the 10 Dutch neonatal intensive care units were studied retrospectively, to investigate whether there was a difference in the time of onset of treatment of PHVD and, if so, whether this was associated with a difference in the requirement of a ventriculo-peritoneal (VP) shunt and/or neurodevelopmental outcome. The surviving infants with a gestational age

1328 Adjustments of Spo 2 Alarm Limits and Corresponding Spo 2 Levels in Very Preterm Infants

BACKGROUND: Premature infants who have transient hypothyroxinemia in the first weeks of life may have developmental delay and neurologic dysfunction. Whether thyroxine treatment during this period results in improved developmental outcomes is not known. METHODS: We carried out a randomized, placebo-controlled, double-blind trial of thyroxine supplementation in 200 infants born at less than 30 weeks' gestation. Thyroxine (8 microg per kilogram of birth weight) or placebo was administered daily, starting 12 to 24 hours after birth, for six weeks. Plasma free thyroxine concentrations were measured weekly for the first eight weeks after birth. Scores on the Bayley Mental and Psychomotor Development Indexes and neurologic function were assessed at 6, 12, and 24 months of age (corrected for prematurity). RESULTS: Mortality and morbidity up to the time of discharge from the hospital were similar in the study groups. At 24 months of age, 157 infants were evaluated. Overall, neither mental nor psychomotor scores differed significantly between the study groups at any time, nor was the frequency of abnormal neurologic outcome significantly different. In thyroxine-treated infants born at gestational ages of less than 27 weeks, the score on the Bayley Mental Development Index at 24 months of age was 18 points higher than the score for the infants with similar gestational ages at birth in the placebo group (P=0.01); for thyroxine-treated infants born at 27 weeks or later, the mental-development score was 10 points lower than that of their counterparts in the placebo group (P=0.03). There was no relation between the initial plasma free thyroxine concentration and the effect of treatment. CONCLUSIONS: In infants born before 30 weeks' gestation, thyroxine supplementation does not improve the developmental outcome at 24 months

Objective To describe the use of heel blood sampling and non-pharmacological analgesia in a large representative sample of neonatal intensive care units (NICUs) in eight European countries, and compare their self-reported practices with evidence-based recommendations. Methods Information on use of heel blood sampling and associated procedures (oral sweet solutions, non-nutritive sucking, swaddling or positioning, topical anaesthetics and heel warming) were collected through a structured mail questionnaire. 284 NICUs (78% response rate) participated, but only 175 with ≥50 very low birth weight admissions per year were included in this analysis. Results Use of heel blood sampling appeared widespread. Most units in the Netherlands, UK, Denmark, Sweden and France predominantly adopted mechanical devices, while manual lance was still in use in the other countries. The two Scandinavian countries and France were the most likely, and Belgium and Spain the least likely to employ recommended combinations of evidence-based pain management measures. Conclusions Heel puncture is a common procedure in preterm neonates, but pain appears inadequately treated in many units and countries. Better compliance with published guidelines is needed for clinical and ethical reasons.

The Neurologic Development of the Newborn and Young Child in Relation to Maternal Thyroid Function

Objective: To study the effect of L-thyroxine supplementation on neurologic maturation in infants < 30 weeks' gestational age with transient hypothyroxinemia.

Background: Transient hypothyroxinemia, which is common in very preterm infants, is related to an increased risk of neurodevelopmental dysfunction as well as to slow motor nerve conduction velocity (MNCV).

The "four principles approach" has been popularly accepted as a set of universal guidelines for biomedical ethics. Based on four allegedly trans-cultural principles (respect for autonomy, nonmaleficence, beneficence and justice), it is supposed to fulfil the need of a 'culturally neutral approach to thinking about ethical issues in health care'. On the basis of a case-history, this paper challenges the appropriateness of communicating in terms of these four principles with patients with a different background. The case describes the situation in which Muslim parents bring forward that their religion keeps them from consenting to end-of-life decisions by non-religious paediatricians. In a literature analysis, the different meanings and roles of the relevant principles in non-religious and Islamic ethics are compared. In non-religious ethics, the principle of nonmaleficence may be used to justify withholding or withdrawing futile or damaging treatments, whereas Islamic ethics applies this principle to forbid all actions that may harm life. And while the non-religious version of the principle of respect for autonomy emphasises the need for informed consent, the Islamic version focuses on "respect for the patient". We conclude that the parties involved in the described disagreement may feel committed to seemingly similar, but actually quite different principles. In such cases, communication in terms of these principles may create a conflict within an apparently common conceptual framework. The four principles approach may be very helpful in analysing ethical dilemmas, but when communicating with patients with different backgrounds, an alternative approach is needed that pays genuine attention to the different backgrounds.