Goals and options in keeping preterm babies warm.

More than 50 years after Silverman showed the association between temperature control and mortality, recent data again stress the importance of the thermal environment of the preterm infant. The goals of care are straightforward: maintain a normal body temperature, ensure a stable thermal environment and avoid cold stress; but the options to achieve them are many and less certain. There is a problem in defining a 'normal' temperature. A single measurement will tell nothing about whether the baby is using energy for thermal balance. The preterm baby should be monitored with the continuous recording and display of a central and peripheral temperature. This will give an early indication of cold stress before any change is seen in the central temperature. Reducing evaporative heat losses at birth has improved temperatures on admission, although no studies have shown any effect on outcome. No data have shown that the use of incubators is any better than radiant heaters.

Design issues for socially intelligent user interfaces. A discourse analysis of a data-to-text system for summarizing clinical data.

OBJECTIVES: This study aims to demonstrate the usability of discourse analyses as a means of evaluating medical informatics systems by examining one particular computer-based data-to-text system for delivering neonatal health care information. METHODS: Six textual summaries of clinical information, three produced by human clinicians and three by the data-to-text system, were subjected to fine-grain discourse analysis. Analysis was performed 'blind' on all six textual summaries. Analysis focused on the identification of lexical items and on the potential effects of these items on users of these clinical information summaries. RESULTS: Results showed that there were clear differences between human- and system-generated clinical summaries, with human clinicians providing better narrative flow and textual detail. The data-to-text system successfully produced textual summaries although it fell short of human abilities. CONCLUSIONS: These results indicate potential future improvements to the system. Discourse analysis as used here may offer significant advantages in evaluating and developing similar medical informatics systems.

Implementation of NICE recommendation for a policy of routine antenatal anti-D prophylaxis: a survey of UK maternity units.

The aim of this study was to determine how many UK maternity units have implemented National Institute for Clinical Excellence (NICE) guidance for routine antenatal anti-D prophylaxis (RAADP). In May 2002, the NICE recommended a policy of RAADP for RhD-negative pregnant women. The policy has the potential to reduce maternal sensitization and prevent deaths from haemolytic disease of the foetus and newborn, but implementation entails considerable clinical, financial and organizational challenges. A postal survey of all 324 UK maternity units was completed in 2005.Responses were received from 91% of units (294 of 324). RAADP was offered by 220 of 294 (75%) and in England and Wales 19% of those offered a single-dose regime. At 12% of maternity units, routine paternal blood group testing was offered. For 84% of maternity units, staff education was offered at the time of implementation. Written patient information was provided at 97% of maternity units and 147 of 217 (69%) returned a copy. We received 60 different leaflets. Three years after NICE guidance was issued, one in four maternity units did not offer RAADP. Among those that do offer RAADP, practice with regard to anti-D administration, paternal testing, provision of written information and staff education varied. Unit and clinician level research is required to understand why.

Effect of suckling on the peripheral sensitivity of full-term newborn infants.

BACKGROUND: Sucking may reduce the manifestations of pain in newborn infants. OBJECTIVE: To examine the effect of suckling on the threshold for peripheral somatosensory responses. SUBJECTS AND METHODS: Graded Von Frey filaments were applied to the heel to initiate peripheral somatosensory responses (withdrawal reflex and gross body movements) in term infants. RESULTS: Dummy sucking increases the somatosensory threshold, but breast feeding had a more marked effect, increasing the threshold of the flexion withdrawal reflex (p

Risk management, or just a different risk?

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.

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

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

Modulations in breathing patterns during intermittent feeding in term infants and preterm infants with bronchopulmonary dysplasia.

As infants with bronchopulmonary dysplasia (BPD) have difficulty maintaining adequate levels of oxygenation during rest, it was decided to investigate how the additional respiratory demands associated with nutritive feeding disrupt their breathing rates. The sucking and breathing patterns of six (three male, three female) preterm infants (between 23 and 29 weeks gestational age at birth), classified as having BPD were individually compared with the patterns observed in 12 (six male, six female) healthy term (control) infants (> or = 38 weeks gestational age at birth) with no known respiratory ailments. All infants were recruited from the neonatal unit at Simpson's Maternity Pavilion, Edinburgh, Scotland. In general, the breathing patterns recorded for the infants with BPD during the pause periods of intermittent feeding lacked the striking regularity observed in the term infants. It was found that the severity of the BPD affected breathing rates by significantly reducing the duration and the regularity of a breath (P<0.05) while sucking during the intermittent phase of feeding.