A descriptive systematic review of salivary therapeutic drug monitoring in neonates and infants.

AIMS: Saliva, as a matrix, offers many benefits over blood in therapeutic drug monitoring (TDM), in particular for infantile TDM. However, the accuracy of salivary TDM in infants remains an area of debate. This review explored the accuracy, applicability and advantages of using saliva TDM in infants and neonates. METHODS: Databases were searched up to and including September 2016. Studies were included based on PICO as follows: P: infants and neonates being treated with any medication, I: salivary TDM vs. C: traditional methods and O: accuracy, advantages/disadvantages and applicability to practice. Compounds were assessed by their physicochemical and pharmacokinetic properties, as well as published quantitative saliva monitoring data. RESULTS: Twenty-four studies and their respective 13 compounds were investigated. Four neutral and two acidic compounds, oxcarbazepine, primidone, fluconazole, busulfan, theophylline and phenytoin displayed excellent/very good correlation between blood plasma and saliva. Lamotrigine was the only basic compound to show excellent correlation with morphine exhibiting no correlation between saliva and blood plasma. Any compound with an acid dissociation constant (pKa) within physiological range (pH 6-8) gave a more varied response. CONCLUSION: There is significant potential for infantile saliva testing and in particular for neutral and weakly acidic compounds. Of the properties investigated, pKa was the most influential with both logP and protein binding having little effect on this correlation. To conclude, any compound with a pKa within physiological range (pH 6-8) should be considered with extra care, with the extraction and analysis method examined and optimized on a case-by-case basis.

A feminist exploration of Traveller women's experiences of maternity care in the Republic of Ireland.

OBJECTIVE: to explore Traveller women's experiences of maternity care so that their needs might be identified and perceptions of helpful responses elicited. DESIGN: feminist research methodology using unstructured non-directive interviews. SETTING: community setting in the Republic of Ireland. PARTICIPANTS: snowball sample of 13 Traveller women aged 19-42 years. Each had experienced between two and eight pregnancies. FINDINGS: a fluid concept of culture affected Traveller women's expectations and negotiation of maternity care. The essential nature of familism, socialisation and religious beliefs, and the particular emphasis placed upon peer support, reflected cohesive and supportive aspects of culture. The concept of 'possessive individualism' was portrayed as conflicting with contraceptive use, the uptake of preventive care and women's reporting of mental-health problems. Majority norm expectations of breast feeding, husband participation and 'rooming in' were culturally unacceptable. Political and structural factors, such as the direct discriminatory barriers created by general practitioner services, indirect discrimination arising from dysfunctional communication and control of information, poor housing and lack of public transport were the basic causes of inequity of access to care. IMPLICATIONS FOR PRACTICE: midwives are challenged to respond sensitively to cultural preferences, meet informational needs and act as political advocates in efforts to improve maternity care experiences for Traveller women.

Midwifery practice and the crisis of modernity: implications for the role of the midwife.

Almost since its inception, the concept of modernity was found to display tensions between its emancipatory potential to liberate the human subject from the manacles of tradition, and the application of reason to co-ordinate and control the natural world through scientific knowledge. This paper presents a qualitative analysis of in-depth interviews with 12 midwives about their role in the Irish maternity services and argues that, in a period of late modernity, these tensions continue to manifest themselves in the context of the midwife's role. Although the contemporary period is marked by a loss of faith in scientific truths, widely contested obstetric knowledge and practices continue to exercise mastery over nature while undermining a central feature of the midwife's role-the liberation of the autonomous subject. Drawing on the theory of communicative action developed by the critical theorist Jürgen Habermas, it is argued that the midwife's role in facilitating the autonomous choices of women through communicative action is impeded by the colonization of the lifeworld of labour and childbirth by the technocratic system of obstetrics. Although participants reported that their role involved empowering women and facilitating choices through dialogue congruent with communicative action, data also suggested that participants used strategic communication with clients aimed at achieving particular ends. The use of strategic communication was linked to the way in which the midwife's role is determined to a large extent by the practices and protocols of obstetrics, and also to the notion of client passivity. The instrumental rationality of obstetrics is linked to an outcome orientation to power and money, and a political economy perspective of medicine. It appears that communicative action between midwives and obstetricians is important in bringing about structural changes to facilitate the conditions for communicative action between midwives and their clients.

Suspected child abuse: communicating with a child and her mother.

The purpose of this article is to explore and examine how the value judgments of the health professionals involved affected the interaction between themselves and a mother with her injured child who presented at an accident and emergency department. The interaction is depicted by means of a classroom role-play in which the "actors" are nurses. Analysis of the interaction demonstrates clearly how the perspectives of health professionals may be enshrouded by a miasma of suspicion. Indeed, by focusing on the actions of the mother rather than the needs of the child, suspicion gained momentum and finally entered the public domain. Encouraging health professionals to listen to what the child has to say goes some way to challenging the suspicion of abuse. Nonetheless, in the role-play analyzed, the mounting suspicion so antagonized the mother that an angry confrontation with the doctor ensued, the doctor being forced to make an embarrassing apology. Yet the interaction is so irredeemably prejudiced that it remains impossible either to confirm or reject the suspicion of abuse. Analysis of the interaction attempted to unravel some of the knots in which we, as health professionals, unfailingly tie ourselves when communicating with patients-knots of suspicion, labeling, conflict, embarrassment, and power that fail to anchor the humanity of "self" or others.