Reference centiles for infant sleep parameters from 4 to 16 weeks of age: findings from an Irish cohort.

OBJECTIVES: To establish unconditional reference centiles for sleep parameters in infants 4-16 weeks of age. DESIGN AND SETTING: Secondary data analysis of sleep parameters recorded at 4-16 weeks of age in a longitudinal randomised controlled trial (RCT) (BabySMART). PATIENTS: Healthy term infants assigned to the non-intervention arm of the RCT. MAIN OUTCOME MEASURES: Infants' sleep duration was recorded by parents/guardians daily, from week 2-16 of age using a sleep diary. Reference centiles for total, daytime, night-time and longest sleep episode duration were estimated using multilevel modelling. RESULTS: One hundred and six infants, mean (SD) gestational age of 39.9 (1.2) weeks and mean (SD) birth weight of 3.6 (0.5) kg had sleep recorded contributing 1264 measurements for each sleep parameter. Between 4 and 16 weeks of age total sleep duration in a 24-hour period, night-time sleep duration in a 12-hour period and infant's longest sleep episode duration increased, while daytime sleep duration in a 12-hour period decreased. CONCLUSIONS: Reference centiles up to 4 months of age in infants highlight the gradual decrease in daytime sleep and large increases in night-time sleep, which occur in tandem with increasing lengths of sleep episodes. These reference centiles provide useful sleep values for infant sleep trajectory occurring in early life and may be helpful for parents and clinicians. TRIAL REGISTRATION NUMBER: NCT03381027.

Doctors' attitudes to maintenance of professional competence: A scoping review.

CONTEXT: Recent decades have seen the international implementation of programmes aimed at assuring the continuing competence of doctors. Maintenance of Professional Competence (MPC) programmes aim to encourage doctors' lifelong learning and ensure high-quality, safe patient care; however, programme requirements can be perceived as bureaucratic and irrelevant to practice, leading to disengagement. Doctors' attitudes and beliefs about MPC are critical to translating regulatory requirements into committed and effective lifelong learning. We aimed to summarise knowledge about doctors' attitudes to MPC to inform the development of MPC programmes and identify under-researched areas. METHODS: We undertook a scoping review following Arksey and O'Malley, including sources of evidence about doctors' attitudes to MPC in the United States, the United Kingdom, Canada, Australia, New Zealand and Ireland, and using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as a guide. RESULTS: One hundred and twenty-five sources of evidence were included in the review. One hundred and two were peer-reviewed publications, and 23 were reports. Most were from the United Kingdom or the United States and used quantitative or mixed methods. There was agreement across jurisdictions that MPC is a good idea in theory but doubt that it achieves its objectives in practice. Attitudes to the processes of MPC, and their impact on learning and practice were mixed. The lack of connection between MPC and practice was a recurrent theme. Barriers to participation were lack of time and resources, complexity of the requirements and a lack of flexibility in addressing doctors' personal and professional circumstances. CONCLUSIONS: Overall, the picture that emerged is that doctors are supportive of the concept of MPC but have mixed views on its processes. We highlight implications for research and practice arising from these findings.

Multichannel EEG abnormalities during the first 6 hours in infants with mild hypoxic-ischaemic encephalopathy.

BACKGROUND: Infants with mild HIE are at risk of significant disability at follow-up. In the pre-therapeutic hypothermia (TH) era, electroencephalography (EEG) within 6 hours of birth was most predictive of outcome. This study aims to identify and describe features of early EEG and heart rate variability (HRV) (<6 hours of age) in infants with mild HIE compared to healthy term infants. METHODS: Infants >36 weeks with mild HIE, not undergoing TH, with EEG before 6 hours of age were identified from 4 prospective cohort studies conducted in the Cork University Maternity Services, Ireland (2003-2019). Control infants were taken from a contemporaneous study examining brain activity in healthy term infants. EEGs were qualitatively analysed by two neonatal neurophysiologists and quantitatively assessed using multiple features of amplitude, spectral shape and inter-hemispheric connectivity. Quantitative features of HRV were assessed in both the groups. RESULTS: Fifty-eight infants with mild HIE and sixteen healthy term infants were included. Seventy-two percent of infants with mild HIE had at least one abnormal EEG feature on qualitative analysis and quantitative EEG analysis revealed significant differences in spectral features between the two groups. HRV analysis did not differentiate between the groups. CONCLUSIONS: Qualitative and quantitative analysis of the EEG before 6 hours of age identified abnormal EEG features in mild HIE, which could aid in the objective identification of cases for future TH trials in mild HIE. IMPACT: Infants with mild HIE currently do not meet selection criteria for TH yet may be at risk of significant disability at follow-up. In the pre-TH era, EEG within 6 hours of birth was most predictive of outcome; however, TH has delayed this predictive value. 72% of infants with mild HIE had at least one abnormal EEG feature in the first 6 hours on qualitative assessment. Quantitative EEG analysis revealed significant differences in spectral features between infants with mild HIE and healthy term infants. Quantitative EEG features may aid in the objective identification of cases for future TH trials in mild HIE.

Paediatric attendances of the emergency department in a major Irish tertiary referral centre before and after expansion of free GP care to children under 6: a retrospective observational study.

Objectives: To examine the characteristics of paediatric attendances to the emergency department (ED) in Cork University Hospital (CUH) before and after the expansion of free general practitioner (GP) care to children under the age of 6 years. Design: This is a retrospective observational study that used a large administrative dataset. Setting: The study was conducted in major Irish tertiary referral centre that serves a total population of over 1.1 million. It is a public hospital, owned and managed by the health service executive. Participants: Children aged 0-15 years who attended CUH ED during the study period of 6 years (2012-2018) were included in this study (n=76 831). Interventions: Free GP care was expanded to all children aged 0-5 years in July 2015. Main outcome measures: Paediatric attendances to CUH ED were examined before (Time Period 1: July 2012-June 2015) and after (Time Period 2: July 2015-June 2018) the expansion of free GP care to children under 6. Changes in GP referral rates and inpatient hospital admissions were investigated. Results: Paediatric presentations to CUH ED increased from 35 819 during the Time Period 1 to 41 012 during the Time Period 2 (14.5%). The proportion of the CUH ED attendances through GP referrals by children under 6 increased by over 8% in the Time Period 2 (from 10 148 to 14 028). Although the number of all children who attended CUH ED and were admitted to hospital increased in Time Period 2 (from 8704 to 9320); the proportion of children in the 0-5 years group who attended the CUH ED through GP referral and were subsequently admitted to hospital, decreased by over 3%. Conclusion: The expansion of free GP care has upstream health service utilisation implications, such as increased attendances at ED, and should be considered and costed by policy-makers.

Doctors' attitudes to, beliefs about, and experiences of the regulation of professional competence: a scoping review protocol.

BACKGROUND: Historically, individual doctors were responsible for maintaining their own professional competence. More recently, changing patient expectations, debate about the appropriateness of professional self-regulation, and high-profile cases of malpractice have led to a move towards formal regulation of professional competence (RPC). Such programmes require doctors to demonstrate that they are fit to practice, through a variety of means. Participation in RPC is now part of many doctors' professional lives, yet it remains a highly contested area. Cost, limited evidence of impact, and lack of relevance to practice are amongst the criticisms cited. Doctors' attitudes towards RPC, their beliefs about its objectives and effectiveness, and their experiences of trying to meet its requirements can impact engagement with the process. We aim to conduct a scoping review to map the empirical literature in this area, to summarise the key findings, and to identify gaps for future research. METHODS: We will conduct our review following the six phases outlined by Arksey and O'Malley, and Levac. We will search seven electronic databases: Academic Search Complete, Business Source Complete, CINAHL, PsycINFO, PubMed, Social Sciences Full Text, and SocINDEX for relevant publications, and the websites of medical regulatory and educational organisations for documents. We will undertake backward and forward citation tracking of selected studies and will consult with international experts regarding key publications. Two researchers will independently screen papers for inclusion and extract data using a piloted data extraction tool. Data will be collated to provide a descriptive summary of the literature. A thematic analysis of the key findings will be presented as a narrative summary of the literature. DISCUSSION: We believe that this review will be of value to those tasked with the design and implementation of RPC programmes, helping them to maximise doctors' commitment and engagement, and to researchers, pointing to areas that would benefit from further enquiry. This research is timely; internationally existing programmes are evolving, new programmes are being initiated, and many jurisdictions do not yet have programmes in place. There is an opportunity for learning across different programmes and from the experiences of established programmes. Our review will support that learning. SYSTEMATIC REVIEW REGISTRATION: PROSPERO does not register scoping reviews.

Temporal evolution of quantitative EEG within 3 days of birth in early preterm infants.

For the premature newborn, little is known about changes in brain activity during transition to extra-uterine life. We aim to quantify these changes in relation to the longer-term maturation of the developing brain. We analysed EEG for up to 72 hours after birth from 28 infants born <32 weeks of gestation. These infants had favourable neurodevelopment at 2 years of age and were without significant neurological compromise at time of EEG monitoring. Quantitative EEG was generated using features representing EEG power, discontinuity, spectral distribution, and inter-hemispheric connectivity. We found rapid changes in cortical activity over the 3 days distinct from slower changes associated with gestational age: for many features, evolution over 1 day after birth is equivalent to approximately 1 to 2.5 weeks of maturation. Considerable changes in the EEG immediately after birth implies that postnatal adaption significantly influences cerebral activity for early preterm infants. Postnatal age, in addition to gestational age, should be considered when analysing preterm EEG within the first few days after birth.

Early EEG Grade and Outcome at 5 Years After Mild Neonatal Hypoxic Ischemic Encephalopathy.

OBJECTIVE: More than half of all infants with neonatal hypoxic ischemic encephalopathy (HIE) are graded as mild and do not meet current criteria for therapeutic hypothermia. These infants are often not enrolled in follow-up, and hence our knowledge of their long-term outcome is sparse. We wished to compare 5-year outcomes in a group of infants with mild, moderate, and severe HIE, graded with both early EEG and clinical assessment, none of whom were treated with therapeutic hypothermia. METHODS: Term infants with HIE and a healthy comparison group were recruited at birth. Both groups had early continuous EEG recordings. Cognitive and motor outcome was assessed at 5 years. RESULTS: Outcome was available in 53 infants with HIE and 30 infants in the comparison group at 5 years. Infants with mild HIE at birth (n = 22) had significantly lower full-scale IQ, verbal IQ, and performance IQ than comparison infants (n = 30) at 5 years (P = .001, .001, and 0.004, respectively). No difference in cognitive measures was seen between infants with mild and moderate grades HIE. Intact survival at 5 years varied across EEG grade HIE at 6 hours after birth; 75% in mild, 46% in moderate, 43% in major abnormalities, and 0% with inactive EEGs, compared with 97% in the comparison group. CONCLUSIONS: Survivors of mild HIE, graded clinically or by early EEG, have higher rates of disability than their peers and have cognitive outcomes similar to that of children with moderate encephalopathy in an uncooled HIE cohort.

Sleep-wake cycle of the healthy term newborn infant in the immediate postnatal period.

OBJECTIVE: To examine sleep-wake cycle (SWC) composition of healthy term infants in the immediate postnatal period using EEG, and investigate factors that might influence it. METHODS: Multichannel video-EEG was recorded for a median of 61.9 min (IQR: 60.0-69.3). The absolute and relative scores of sleep states were calculated for each infant's recording. Parametric/non-parametric statistical tests and multiple linear regression analysis were used to investigate the influence of perinatal factors on SWC composition. RESULTS: Eighty healthy term infants aged 1-36 h were studied. A well-developed SWC was evident as early as within the first 6h after birth. The mean (SD) percentage of active sleep (AS) was 52.1% (12.9) and quiet sleep (QS) was 38.6% (12.5). AS was longer and QS shorter in infants delivered by elective caesarean section (CS) compared to infants delivered by vaginal delivery or emergency CS. CONCLUSIONS: This is the first large cohort EEG study that has quantified neonatal sleep. SWC is clearly present immediately after birth, it is dominated by AS, and is influenced by mode of delivery. SIGNIFICANCE: This knowledge of the early neonatal EEG/SWC can be used as reference data for EEG studies of neurologically compromised infants.

Automated analysis of multi-channel EEG in preterm infants.

OBJECTIVE: To develop and validate two automatic methods for the detection of burst and interburst periods in preterm eight-channel electroencephalographs (EEG). To perform a detailed analysis of interobserver agreement on burst and interburst periods and use this as a benchmark for the performance of the automatic methods. To examine mathematical features of the EEG signal and their potential correlation with gestational age. METHODS: Multi-channel EEG from 36 infants, born at less than 30 weeks gestation was utilised, with a 10 min artifact-free epoch selected for each subject. Three independent expert observers annotated all EEG activity bursts in the dataset. Two automatic algorithms for burst/interburst detection were applied to the EEG data and their performances were analysed and compared with interobserver agreement. A total of 12 mathematical features of the EEG signal were calculated and correlated with gestational age. RESULTS: The mean interobserver agreement was found to be 77% while mean algorithm/observer agreement was 81%. Six of the mathematical features calculated (spectral entropy, Higuchi fractal dimension, spectral edge frequency, variance, extrema median and Hilberts transform amplitude) were found to have significant correlation with gestational age. CONCLUSIONS: Automatic detection of burst/interburst periods has been performed in multi-channel EEG of 36 preterm infants. The algorithm agreement with expert observers is found to be on a par with interobserver agreement. Mathematical features of EEG have been calculated which show significant correlation with gestational age. SIGNIFICANCE: Automatic analysis of preterm multi-channel EEG is possible. The methods described here have the potential to be incorporated into a fully automatic system to quantitatively assess brain maturity from preterm EEG.

Cooling and seizure burden in term neonates: an observational study.

OBJECTIVE: To investigate any possible effect of cooling on seizure burden, the authors quantified the recorded electrographic seizure burden based on multichannel video-EEG recordings in term neonates with hypoxic-ischaemic encephalopathy (HIE) who received cooling and in those who did not. STUDY DESIGN: Retrospective observational study. PATIENTS: Neonates >37 weeks gestation born between 2003 and 2010 in two hospitals. METHODS: Off-line analysis of prolonged continuous multichannel video-EEG recordings was performed independently by two experienced encephalographers. Comparison between the recorded electrographic seizure burden in non-cooled and cooled neonates was assessed. Data were treated as non-parametric and expressed as medians with interquartile ranges (IQR). RESULTS: One hundred and seven neonates with HIE underwent prolonged continuous multichannel EEG monitoring. Thirty-seven neonates had electrographic seizures, of whom 31 had EEG recordings that were suitable for the analysis (16 non-cooled and 15 cooled). Compared with non-cooled neonates, multichannel EEG monitoring commenced at an earlier postnatal age in cooled neonates (6 (3-9) vs 15 (5-20) h)and continued for longer (88 (75-101) vs 55 (41-60) h). Despite this increased opportunity to capture seizures in cooled neonates, the recorded electrographic seizure burden in the cooled group was significantly lower than in the non-cooled group (60 (39-224) vs 203 (141-406) min). Further exploratory analysis showed that the recorded electrographic seizure burden was only significantly reduced in cooled neonates with moderate HIE (49 (26-89) vs 162 (97-262) min). CONCLUSIONS: A decreased seizure burden was seen in neonates with moderate HIE who received cooling. This finding may explain some of the therapeutic benefits of cooling seen in term neonates with moderate HIE.

Presence of both parents during consent process in non-therapeutic neonatal research increases positive response.

AIM: To investigate factors that influenced parental consent/non-consent in a non-therapeutic electroencephalogram (EEG) study in healthy newborns. METHODS: Parents of healthy newborns were approached to participate in a neonatal EEG study within 36 h of birth. The rationale and risks/benefits of the study were explained. Any concerns were discussed, and detailed information about the EEG study was provided in the consent form. In the case of refusing/withdrawing consent, an informal interview was used to investigate the reasons, which were subsequently analysed and grouped according to the four principles of the consent process. RESULTS: A total of 123 parents were included in the study. Parental consent was obtained in 72/123 (59%) cases, 10/123 (8%) parents subsequently withdrew their consent and 41/123 (33%) parents refused to participate in the study. Consent was more likely if both parents were present (p < 0.0001). When the mothers were approached alone, obtaining consent was significantly more difficult within the first 6 hours of delivery, compared to a later approach (37% vs. 67% respectively; p = 0.009). Refusals were classified into issues of voluntariness (7%), informed choice (10%), understanding (54%) and competence (29%). CONCLUSION: Parents of healthy newborns demonstrated a positive attitude towards non-therapeutic neonatal research with maximal consent occurring when both parents were present. Parental perception of harm was the main reason for declining consent.