Improving postgraduate clinical assessment tools: the introduction of video recordings to assess decision making.

BACKGROUND: Competency in the management of acutely unwell patients has not previously been formally assessed as part of an objective structured clinical examination (OSCE). AIM: The reliability of the paediatric postgraduate OSCE was calculated. An objective structured video examination was designed to assess candidates' clinical decision making ability when managing acutely unwell children. METHODS: The performance of 3522 postgraduate paediatric trainees was assessed (2006-2008). OSCE reliability was determined using Cronbach's alpha and mean inter-item correlation. Performance in the video station was compared with overall performance (not including video station; Mann-Whitney U) and video station scores correlated with individual station scores (Spearman's Rho correlation coefficient). RESULTS: Clinical examination pass rates for the 684 UK graduates, 1608 overseas candidates training in the UK and 1104 overseas candidates training overseas were 69.7%, 28% and 22.3%, respectively (graduation information not available for 126 candidates). Cronbach's alpha was 0.62. Mean inter-item correlation was 0.15. Candidates who passed the OSCE overall had significantly higher scores on the video station (t(3520) = 14.48); p < 0.001). There was significant positive correlation between scores on the video station, individual stations and overall total score (r's = 0.300; p = 0.001). CONCLUSIONS: The postgraduate paediatric OSCE provides a sound and valid means of assessing clinical skills at the postgraduate level. The video station provides an important new method of assessment. Its use in other postgraduate clinical examinations should be explored.

Clinical decision support systems for neonatal care.

BACKGROUND: Clinical decision support systems (CDSS) are computer-based information systems used to integrate clinical and patient information to provide support for decision-making in patient care. They may be useful in aiding the diagnostic process, the generation of alerts and reminders, therapy critiquing/planning, information retrieval, and image recognition and interpretation. CDSS for use in adult patients have been evaluated using randomised control trials and their results analysed in systematic reviews. There is as yet no systematic review on CDSS use in neonatal medicine. OBJECTIVES: To examine whether the use of clinical decision support systems has an effect on 1. the mortality and morbidity of newborn infants and 2. the performance of physicians treating them SEARCH STRATEGY: The standard search method of the Cochrane Neonatal Review Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), MEDLINE (from 1966 to August 2004), EMBASE (1980-2004), CINAHL (1982 to August 2004) and AMED (1985 to August 2004). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials which compared the effects of CDSS versus no CDSS in the care of newborn infants. Trials which compared CDSS against other CDSS were also considered. The eligible interventions were CDSS for computerised physician order entry, computerised physiological monitoring, diagnostic systems and prognostic systems. DATA COLLECTION AND ANALYSIS: Studies were assessed for eligibility using a standard pro forma. Methodological quality was assessed independently by the different investigators. MAIN RESULTS: Two studies fitting the selection criteria were found for computer aided prescribing and one study for computer aided physiological monitoring.Computer-aided prescribing: one study (Cade 1997) examined the effects of computerised prescribing of parenteral nutrition ordering. No significant effects on short-term outcomes were found and longer term outcomes were not studied. The second study (Balaguer 2001) investigated the effects of a database program in aiding the calculation of neonatal drug dosages. It was found that the time taken for calculation was significantly reduced and there was a significant reduction in the number of calculation errors.Computer-aided physiological monitoring: one eligible study (Cunningham 1998) was found which examined the effects of computerised cot side physiological trend monitoring and display. There were no significant effects on mortality, volume of colloid infused, frequency of blood gases sampling (samples per day) or severe (Papile Grade 4) intraventricular haemorrhage. Published data did not permit us to analyse effects on long-term neurodevelopmental outcome. AUTHORS' CONCLUSIONS: There are very limited data from randomised trials on which to assess the effects of clinical decision support systems in neonatal care. Further evaluation of CDSS using randomised controlled trials is warranted.

Randomised controlled study of clinical outcome following trophic feeding.

AIMS: To determine the effect of trophic feeding on clinical outcome in ill preterm infants. METHODS: A randomised, controlled, prospective study of 100 preterm infants, weighing less than 1750 g at birth and requiring ventilatory support and parenteral nutrition, was performed. Group TF (48 infants) received trophic feeding from day 3 (0.5-1 ml/h) along with parenteral nutrition until ventilatory support finished. Group C (52 infants) received parenteral nutrition alone. "Nutritive" milk feeding was then introduced to both groups. Clinical outcomes measured included total energy intake and growth over the first six postnatal weeks, sepsis incidence, liver function, milk tolerance, duration of respiratory support, duration of hospital stay and complication incidence. RESULTS: Groups were well matched for birthweight, gestation and CRIB scores. Infants in group TF had significantly greater energy intake, mean difference 41.4 (95% confidence interval 9, 73.7) kcal/kg p=0.02; weight gain, 130 (CI 1, 250) g p = 0.02; head circumference gain, mean difference 0.7 (CI 0.1, 1.3) cm, p = 0.04; fewer episodes of culture confirmed sepsis, mean difference -0.7 (-1.3, -0.2) episodes, p = 0.04; less parenteral nutrition, mean difference -11.5 (CI -20, -3) days, p = 0. 03; tolerated full milk feeds (165 ml/kg/day) earlier, mean difference -11.2 (CI -19, -3) days, p = 0.03; reduced requirement for supplemental oxygen, mean difference -22.4 (CI-41.5, -3.3) days, p = 0.02; and were discharged home earlier, mean difference -22.1 (CI -42.1, -2.2) days, p = 0.04. There was no significant difference in the relative risk of any complication. CONCLUSIONS: Trophic feeding improves clinical outcome in ill preterm infants requiring parenteral nutrition.

Effect of fortifying breast milk on gastric emptying.

A study was performed to determine if the addition of a fortifier to expressed breast milk (EBM) affected gastric emptying in low birthweight infants. Using ultrasonography, the gastric emptying of EBM alone was compared with that containing a fortifier, in a blind, crossover study. Twenty two low birthweight infants were studied: median (range) gestation 31.5 weeks (28-37); birthweight 1495 g (1000-2480 g). The gastric antral cross-sectional area (ACSA) was measured by ultrasonography before each feed and then sequentially after its completion until the ACSA returned to its pre-feed value. The half emptying time was calculated as the time taken for the ACSA to decrease to half the maximum increment. The mean difference (standard error) between half emptying times for EBM alone and for EBM with added fortifier was not significant: 1.48 (4.9) minutes. These data show that fortifying breast milk does not affect gastric emptying and suggests that the practice is unlikely to affect feed tolerance in low birthweight infants.

Randomised controlled trial of trophic feeding and gut motility.

OBJECTIVES: To determine the effect of trophic feeding on gastric emptying and whole gut transit time in sick preterm infants. METHODS: A randomised, controlled, prospective study of 70 infants weighing less than 1750 g at birth, who were receiving ventilatory support, was performed. Group TF (33 infants) received trophic feeding from day 3 (0.5 ml/h if birthweight less than 1 kg, 1 ml/h if greater or equal to 1 kg) in addition to parenteral nutrition until ventilatory support finished. Group C (37 infants) received parenteral nutrition alone until ventilatory support finished. Expressed breast milk or a preterm formula were given according to maternal preference. Gastric emptying was assessed within 24 hours of nutritive milk feeding equal to 90 ml/kg/day, using ultrasound scans to measure the reduction in the gastric antral cross sectional area after a feed. Whole gut motility was assessed at both 3 and 6 weeks of age by measuring the whole gut transit time (WGTT) of the marker carmine red. RESULTS: There was no significant difference between groups in their gastric half emptying time, median difference (95% confidence interval) 2.6 (-5.9, 13.9) minutes. The WGTT was significantly faster (p < 0.05) in group TF at both 3 and 6 weeks; median difference -13 (-47, -0.1) and -12.5 (-44, -0.5) hours, respectively. CONCLUSIONS: Trophic feeding enhances whole gut motility but not gastric emptying. This effect could subsequently improve milk tolerance in sick preterm infants.

Effect of changes in oscillatory amplitude on PaCO(2) and PaO(2) during high frequency oscillatory ventilation.

AIMS: To describe the relation between oscillatory amplitude changes and arterial blood gas (ABG) changes in preterm infants receiving high frequency oscillatory ventilation, using a multiparameter intra-arterial sensor (MPIAS). METHODS: Continuous MPIAS ABG data were collected after amplitude changes and stratified according to FIO(2): high (> 0.4) or low (< 0.3). For each amplitude change, the maximum change (from baseline) in PaCO(2) and PaO(2) over the following 30 minutes was determined. In total, 64 oscillatory amplitude changes were measured in 21 infants (median birth weight 1040 g; gestation 27 weeks). RESULTS: All amplitude increases produced PaCO(2) falls (median -0.98 and -1.13 kPa for high and low FIO(2) groups respectively). All amplitude decreases produced PaCO(2) rises (median +0.94 and +1.24 kPa for high and low FIO(2) groups respectively). About 95% of the change in PaCO(2) was completed in 30 minutes. Amplitude changes did not affect PaO(2) when FIO(2) > 0.4. When FIO(2) < 0.3, amplitude increases produced a PaO(2) rise (median = +1.1 kPa; P < 0.001) and amplitude decreases a fall (median = -1.2 kPa; P < 0.001). CONCLUSIONS: After oscillatory amplitude changes, the speed but not the magnitude of the PaCO(2) change is predictable, and a rapid PaO(2) change accompanies the PaCO(2) change in infants with mild lung disease and a low FIO(2).

Positioning long lines: contrast versus plain radiography.

AIM: To assess the value of contrast versus plain radiography in determining radio-opaque long line tip position in neonates. METHODS: In a prospective study, plain radiography was performed after insertion of radio-opaque long lines. If the line tip was not visible on the plain film, a second film with contrast was obtained in an attempt to visualise the tip. RESULTS: Sixty eight lines were inserted during the study period, 62 of which were included in the study. In 31, a second radiographic examination with contrast was necessary to determine position of the tip. In 29 of these, the line tip was clearly visualised with contrast. On two occasions, the line tip could not be seen because the contrast had filled the vein and obscured the tip from view. Eight of the lines that required a second radiograph with contrast were repositioned. CONCLUSION: Intravenous contrast should be routinely used in the assessment of long line position in the neonate.

Continuous neonatal blood gas monitoring using a multiparameter intra-arterial sensor.

AIMS: To compare arterial blood gas (ABG) readings obtained with a multiparameter intra-arterial sensor with those from an ABG analyser. METHODS: An MPIAS with the ability to measure continuously pH, PaCO2, and PaO2 was introduced via an umbilical arterial catheter in 27 neonates requiring intensive care. They underwent 3260 hours of MPIAS monitoring, during which 753 ABG readings were performed. RESULTS: Overall bias (mean difference: MPIAS-ABG) and precision (standard deviation of differences) values were: -0.002 and 0.022, respectively, for pH; +0.26 and 0.52 for PaCO2 (kPa); and -0.19 and 0.99 for PaO2 (kPa). This gave 95% limits of agreement as: -0.047 to +0.042 for pH, -0.76 to +1.28 kPa for PaCO2, and -2.13 to +1.75 kDa for PaO2. For each variable, precision across readings from the same individual was better than overall precision for all data. No complications related to the use of the catheter were observed. CONCLUSIONS: Continuous MPIAS ABG monitoring is an exciting development, with the potential to reduce blood transfusions and improve ABG homeostasis.

Role of epidermal growth factor and transforming growth factor alpha in the developing stomach.

AIMS: To determine whether epidermal growth factor (EGF) or the related transforming growth factor alpha (TGF alpha) may have a role in the developing human stomach; to substantiate the presence of EGF in human liquor in the non-stressed infant and whether EGF in amniotic fluid is maternally or fetally derived. METHODS: The temporal expression and localisation of EGF, TGF alpha, and their receptors during fetal and neonatal life were examined in 20 fetal and five infant stomachs. Simultaneously, samples of amniotic fluid and fetal urine from 10 newborn infants were collected and assayed for EGF by radioimmunoassay. RESULTS: EGF immunoreactivity was not noted in any of the specimens examined. In contrast, TGF alpha immunoreactivity was shown in mucous cells from 18 weeks of gestation onwards. EGF receptor immunoreactivity was seen on superficial mucous cells in gastric mucosa from 18 weeks of gestation onwards. The median concentration of EGF was 30 and 8.5 pg/ml in amniotic fluid and fetal urine, respectively, suggesting that EGF is not produced by the fetus. CONCLUSIONS: This study adds weight to the hypothesis that swallowed EGF, probably produced by the amniotic membranes, and locally produced TGF alpha, may have a role in the growth and maturation of the human stomach.

Gastric secretory function in the developing human stomach.

Little data exists regarding the activity of gastric parietal cells in the very immature infant. Therefore we have examined the developing human stomach for the presence and location of parietal cells, using both standard histological methods and antibodies to the H+/K+ ATPase (proton pump) and intrinsic factor, in 35 fetuses (ranging from 13-28 weeks) and in five infants (2-21 weeks). Parietal cell activity was noted in the body, antrum and pyloric regions in all the fetal specimens examined. However, this activity was much more limited in the infant specimens. We have noted that from the end of the first trimester parietal cells are present in a mature, functional form with the potential to secrete both gastric acid and intrinsic factor.

Gastric acid secretion in preterm infants.

Little is known about the ontogeny of gastric acid secretion in the very preterm infant. In order to study this we recorded intragastric pH continuously for 24 h on 71 occasions in 22 enterally starved preterm infants. Infants ranged from 24 to 29 weeks' gestation and were studied in the first 5 days, and in the third week, of life. As the infants became more mature, both in terms of gestation and postnatal age, there was a decrease in intragastric pH from median (range) 3.7, 2.5 (0.6-3.9) and 1.8 (1.3-2.6) for infants of 24-25, 26-27 and 28-29 weeks' gestation, respectively on the first day of life to 1.8 (1.7-1.9), 2.0 (1.8-2.3) and 1.7 (1.5-2.0) on day 16. All the infants were able to maintain a gastric pH of below 4 from the first day of life. Our data lay to rest the suggestion that the preterm infant is incapable of hydrogen ion secretion. Gastric acid secretion in the newborn preterm infant should allow normal proteolytic activity and the well recognised clinical problems of intragastric bleeding, gastritis or oesophagitis may be attributable to intragastric acid.

Central venous catheter tip in the right atrium: a risk factor for neonatal cardiac tamponade.

Fatal cardiac tamponade is a well recognised complication of the use of central venous catheters in neonatal patients. There is controversy over optimum catheter tip position to balance catheter performance against risk of adverse events. We report a series of five cases of tamponade occurring in one neonatal unit over a 4-year period, related to catheter tip placement in the right atrium. Right atrial catheter angulation, curvature or looping (CA) was present in all five cases on plain radiograph. It was frequently seen in other patients over the same period. Review of the literature indicates that CA was present in 6 of the 11 previous cases where the presence or absence of CA can be determined. Where right atrial catheter tip placement is accepted, clinicians should be aware of this characteristic catheter configuration, which is a major risk factor for cardiac tamponade. We recommend that catheter tips should not be placed in the right atrium to avoid risk of tamponade.

Enteral feeding of the micropremie.

Clinical practice demands knowledge of gastrointestinal ontogeny and the factors that affect our ability to use enteral feeding in the micropremie. The decisions regarding milk type (when and how it should be given) are considered in the light of current physiologic and clinical evidence. Special considerations apply in the micropremie who is also small for gestational age and NEC must be avoided. Trophic feeding now has an established role, allowing the infant to benefit from enteral feeds even when full nutritive milk feeding is not possible.

Postnatal intravenous steroids and long-term neurological outcome: recommendations from meta-analyses.

Postnatal steroids have been widely used to facilitate the extubation of ventilator-dependent preterm infants. Reports published in the late 1990s and early 2000s raised concerns about their long-term impact on neurodevelopmental outcomes. Since then, postnatal steroid use has declined sharply, but they continue to be regarded by many clinicians as an essential part of neonatal care, and there is considerable confusion as to the most appropriate time to use them. This review examines the meta-analyses of the relationship between intravenous postnatal steroids and neurodevelopmental impairment, and provides recommendations for their use based upon that body of evidence.

Minidex: very low dose dexamethasone (0.05 mg/kg/day) in chronic lung disease.

OBJECTIVE: Postnatal dexamethasone therapy is controversial. This study aimed to determine the short-term effects of Minidex (low-dose dexamethasone 0.05 mg/kg/day) on ventilator-dependent preterm babies. METHODS: Very preterm babies (less than 30 weeks of gestation or under 1500 g) who were ventilator dependent at over 2 weeks of life and received Minidex therapy (low-dose dexamethasone 0.05 mg/kg/day for 10 days followed by alternate-day doses for 6 days) were compared retrospectively to a matched comparison group who received neither Minidex nor standard-dose dexamethasone. RESULTS: 50 babies who received Minidex were compared to a comparison group of 26 babies. Babies treated with Minidex extubated significantly faster than controls, Cox regression hazard ratio 6.24 (95% CI 2.34 to 16.63). By day 4, 34% of babies treated with Minidex had extubated but no controls had. Babies who received Minidex showed significant improvements in both ventilatory index and oxygen requirements, had no increased rate of clinical hypertension (OR 1.16 (95% CI 0.42 to 3.21)) or hyperglycaemia (OR 1.55 (95% CI 0.44 to 5.45)) and had a similar rate of chronic lung disease at 36 weeks' corrected age (OR 1.61 (95% CI 0.62 to 4.22)). No baby developed gastrointestinal perforation or haemorrhage. CONCLUSION: Minidex therapy facilitates extubation and is not associated with clinically significant short-term side effects. A randomised controlled trial is required to further assess efficacy and long-term outcomes.

Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas.

Gastrooesophageal reflux disease (GORD) provides a diagnostic and therapeutic challenge to many neonatologists. Reflux of gastric contents is common in preterm infants but usually not pathological. GORD is frequently diagnosed despite the lack of a fully identified clinical syndrome and of a truly valid diagnostic test. Treatment modalities, for which there is little convincing evidence regarding efficacy, are commonly instigated for troublesome symptoms attributed to GORD. Diagnosis is so problematic in preterm infants that GORD is starting to be described as the clinical syndrome that responds to anti-reflux treatment. We discuss the dilemmas facing us when dealing with this condition, summarise the best available evidence regarding diagnosis and management, and use it to inform a suggested treatment pathway. We introduce the concept of a clinical scoring system to aid the diagnosis and monitoring of GORD in preterm infants and highlight areas where further research would be beneficial.

Survey of paediatric complementary and alternative medicine use in health and chronic illness.

Groups of 25 children with cerebral palsy (CP), inflammatory bowel disease (IBD), and cancer were compared to 25 healthy children to establish use of complementary or alternative medicine (CAM). Children with chronic disease were greater than three times more likely to use CAM, usually without paediatricians' knowledge.