Examining service utilisation and impact among consumers of a national mental health stepped care programme in Australia: a protocol using linked administrative data.

INTRODUCTION: Mental well-being is a global public health priority with increasing mental health conditions having substantial burden on individuals, health systems and society. 'Stepped care', where services are provided at an intensity to meet the changing needs of the consumer, is the chosen approach to mental health service delivery in primary healthcare in Australia for its efficiencies and patient outcomes; yet limited evidence exists on how the programme is being rolled out and its impact in practice. This protocol outlines a data linkage project to characterise and quantify healthcare service utilisation and impacts among a cohort of consumers of a national mental health stepped care programme in one region of Australia. METHODS AND ANALYSIS: Data linkage will be used to establish a retrospective cohort of consumers of mental health stepped care services between 1 July 2020 and 31 December 2021 in one primary healthcare region in Australia (n=approx. 12 710). These data will be linked with records from other healthcare service data sets (eg, hospitalisations, emergency department presentations, community-based state government-delivered mental healthcare, hospital costs). Four areas for analysis will include: (1) characterising the nature of mental health stepped care service use; (2) describing the cohort's sociodemographic and health characteristics; (3) quantifying broader service utilisation and associated economic costs; and (4) assessing the impact of mental health stepped care service utilisation on health and service outcomes. ETHICS AND DISSEMINATION: Approval from the Darling Downs Health Human Research Ethics Committee (HREA/2020/QTDD/65518) has been granted. All data will be non-identifiable, and research findings will be disseminated through peer-reviewed journals, conference presentations and industry meetings.

Model Development for Fat Mass Assessment Using Near-Infrared Reflectance in South African Infants and Young Children Aged 3-24 Months.

Undernutrition in infants and young children is a major problem leading to millions of deaths every year. The objective of this study was to provide a new model for body composition assessment using near-infrared reflectance (NIR) to help correctly identify low body fat in infants and young children. Eligibility included infants and young children from 3-24 months of age. Fat mass values were collected from dual-energy x-ray absorptiometry (DXA), deuterium dilution (DD) and skin fold thickness (SFT) measurements, which were then compared to NIR predicted values. Anthropometric measures were also obtained. We developed a model using NIR to predict fat mass and validated it against a multi compartment model. One hundred and sixty-four infants and young children were included. The evaluation of the NIR model against the multi compartment reference method achieved an r value of 0.885, 0.904, and 0.818 for age groups 3-24 months (all subjects), 0-6 months, and 7-24 months, respectively. Compared with conventional methods such as SFT, body mass index and anthropometry, performance was best with NIR. NIR offers an affordable and portable way to measure fat mass in South African infants for growth monitoring in low-middle income settings.

Near-Infrared Spectroscopy to Monitor Nutritional Status of Neonates: A Review.

The World Health Organization reported that half or more of all under five deaths were caused by undernutrition in developing countries, with the majority of these deaths occurring in the first week of life. Even if the undernourished neonates manage to survive, they are exposed to long-term health impacts, including obesity, cardiovascular disease, and hypertension. Along with those health-impacts they can be exposed to risks related to detrimental early development, such as physical impairment, stunting, brain dysfunction, and reduced cognitive development. Body fat percentage has been recognized to be closely associated with undernutrition in neonates. In this article, the potential of near infrared spectroscopy (NIRS), along with previous methods to measure body fat in neonates, is reviewed and discussed.

An anthropometric approach to characterising neonatal morbidity and body composition, using air displacement plethysmography as a criterion method.

BACKGROUND: With the greatest burden of infant undernutrition and morbidity in low and middle income countries (LMICs), there is a need for suitable approaches to monitor infants in a simple, low-cost and effective manner. Anthropometry continues to play a major role in characterising growth and nutritional status. METHODS: We developed a range of models to aid in identifying neonates at risk of malnutrition. We first adopted a logistic regression approach to screen for a composite neonatal morbidity, low and high body fat (BF%) infants. We then developed linear regression models for the estimation of neonatal fat mass as an assessment of body composition and nutritional status. RESULTS: We fitted logistic regression models combining up to four anthropometric variables to predict composite morbidity and low and high BF% neonates. The greatest area under receiver-operator characteristic curves (AUC with 95% confidence intervals (CI)) for identifying composite morbidity was 0.740 (0.63, 0.85), resulting from the combination of birthweight, length, chest and mid-thigh circumferences. The AUCs (95% CI) for identifying low and high BF% were 0.827 (0.78, 0.88) and 0.834 (0.79, 0.88), respectively. For identifying composite morbidity, BF% as measured via air displacement plethysmography showed strong predictive ability (AUC 0.786 (0.70, 0.88)), while birthweight percentiles had a lower AUC (0.695 (0.57, 0.82)). Birthweight percentiles could also identify low and high BF% neonates with AUCs of 0.792 (0.74, 0.85) and 0.834 (0.79, 0.88). We applied a sex-specific approach to anthropometric estimation of neonatal fat mass, demonstrating the influence of the testing sample size on the final model performance. CONCLUSIONS: These models display potential for further development and evaluation in LMICs to detect infants in need of further nutritional management, especially where traditional methods of risk management such as birthweight for gestational age percentiles may be variable or non-existent, or unable to detect appropriately grown, low fat newborns.

Determining optimal impairment rating methodology for a new HIV-associated neurocognitive disorder screening procedure.

INTRODUCTION: The current study sought to determine the optimal impairment rating definition for a new HIV-associated neurocognitive disorder (HAND) screening procedure as compared to standard neuropsychological testing. METHOD: A total of 55 HIV-infected (HIV+; 19% AIDS; 87% on combination antiretroviral therapy, cART; 80% plasma undetectable) and 22 demographically comparable HIV-uninfected (HIV-) control adults (all male) enrolled in an urban Australian primary care cohort study completed the CogState computerized cognitive screen, a standard independence in activities of daily living (ADL) questionnaire, and a standard neuropsychological test battery. Local or American demographically adjusted norms were applied to the neuropsychological data, taking into account premorbid reading level. CogState norms that corrected for age and sex were applied to raw CogState data. The HAND Frascati classification criteria were implemented to determine "impairment" on both the standard neuropsychological test and the CogState-based screen using two established methods: a battery-wide summary score (global deficit score; GDS), and cognitive domain rating, both combined with ADL independence data. Criterion validity was operationalized by comparing rate of impairment derived from the CogState-based screen to that obtained from the standard neuropsychological test battery first in the combined HIV- and HIV+ sample, and then in the HIV+ sample only. RESULTS: In the combined sample, CogState-based screen criterion validity was higher using the GDS (79% correct classification, 73% sensitivity, 82% specificity) over the cognitive domain rating (correct classification, sensitivity, specificity all 69%) method. A similar pattern was found for the HIV+ group separately [GDS (74% correct classification, 76% sensitivity, 71% specificity) versus cognitive domain rating (64% correct classification, 72% sensitivity, 57% specificity)]. The cases that resulted in disagreement across the two methods were those with borderline impaired/unimpaired cognitive performance. CONCLUSIONS: The GDS is a relatively easy statistical method for computing impairment rate when using the CogState-based screen that yields adequate criterion validity compared to standard neuropsychological testing. Feasibility of standardized test administration and appropriate interpretation of results for this CogState-based screen in primary care was enhanced by the training and consultation provided by study neuropsychologists.

Length-free near infrared measurement of newborn malnutrition.

Under-nutrition in neonates can cause immediate mortality, impaired cognitive development and early onset adult disease. Body fat percentage measured using air-displacement-plethysmography has been found to better indicate under-nutrition than conventional birth weight percentiles. However, air-displacement-plethysmography equipment is expensive and non-portable, so is not suited for use in developing communities where the burden is often the greatest. We proposed a new body fat measurement technique using a length-free model with near-infrared spectroscopy measurements on a single site of the body - the thigh. To remove the need for length measurement, we developed a model with five discrete wavelengths and a sex parameter. The model was developed using air-displacement-plethysmography measurements in 52 neonates within 48 hours of birth. We identified instrumentation required in a low-cost LED-based screening device and incorporated a receptor device that can increase the amount of light collected. This near-infrared method may be suitable as a low cost screening tool for detecting body fat levels and monitoring nutritional interventions for malnutrition in neonates and young children in resource-constrained communities.

A Screening Strategy for HIV-Associated Neurocognitive Disorders That Accurately Identifies Patients Requiring Neurological Review.

BACKGROUND: Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) are not routinely assessed due to the lack of an adequate screening strategy. We aimed to develop a clinically relevant screening procedure for symptomatic HAND, validated against a gold standard neuropsychological (NP) test battery. METHODS: Representative HIV-infected (HIV+) and demographically matched HIV-uninfected (HIV-) participants in an observational study completed a standard evaluation for mood, drug and/or alcohol use, and activities of daily living and a newly designed 20-minute computerized CogState battery that assessed 5 cognitive domains. A subset completed standard NP assessment for 8 cognitive domains. HAND definition on screening and gold standard NP was determined using demographically corrected z scores and the global deficit score (≥ 0.5), applying the Frascati criteria. Participants were blinded to screening results, and the NP examiner was blinded to screening and HIV status. RESULTS: A total of 254 HIV+ participants were enrolled-mean age, 48.9 ± 10.2 years; median nadir CD4, 270 cells/mL; tertiary educated, 54%; and HIV- controls, 72. HIV+ HAND screening prevalence was 30.7% (HIV-associated dementia, 3.2%; mild neurocognitive disorder, 12.6%; and asymptomatic neurocognitive disorder, 15.0%; HIV- group: 13.9%; P = .004). Of the 75 participants who completed the NP battery, the HAND rate in the HIV+ group was 50.9% vs 43.4% by screening (P > .50). HAND screening vs gold standard NP sensitivity was 76% and specificity was 71%. Clinically relevant HIV-associated dementia and mild neurocognitive disorder sensitivity was 100% and specificity was 98% (positive predictive value 0.92). CONCLUSIONS: Symptomatic HAND warranting neurological review was accurately predicted using a CogState-based screening procedure.

Antenatal management of gestational diabetes mellitus can improve neonatal outcomes.

OBJECTIVE: Pregnancies complicated with gestational diabetes mellitus (GDM) are at a higher risk for caesarean and instrumental deliveries as well as adverse neonatal outcomes such as fetal overgrowth, hypoglycaemia and neonatal intensive care admission. Our primary objective was to describe neonatal outcomes in a sample that included term infants of both GDM mothers and mothers with normal glucose tolerance (NGT). DESIGN AND SETTING: this cross-sectional study included 599 term babies born between September and October 2010 at Royal Prince Alfred Hospital, Sydney, Australia. Maternal and neonatal data were collected from medical records and a questionnaire. Glycaemic control data was based on third trimester HbA1c levels and self-monitoring blood glucose levels (BGL). Univariate associations between GDM status and maternal demographic factors, as well as pregnancy outcomes, were estimated using χ(2) tests and t-tests, as appropriate. FINDINGS: of 599 babies, 67(11%) were born to GDM mothers. GDM mothers were more likely to be overweight/obese and of Asian ethnicity. Good glycaemic control was achieved in most GDM mothers. GDM babies were more likely to have been induced (p=0.013) and delivered earlier than non-GDM mothers (p<0.001), and they were also more likely to be breastfed within one hour of birth. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: in this study, GDM infants were more likely to be induced and delivered earlier but otherwise they did not have significantly different neonatal outcomes compared to infants of NGT mothers. This can be attributed to the good GDM control by lifestyle modification and insulin if necessary. The role of labour induction in GDM pregnancies should be further investigated. Midwives have an important role in maternal education during pregnancy and in the postnatal period.

Planned early delivery versus expectant management of the term suspected compromised baby for improving outcomes.

BACKGROUND: Fetal compromise in the term pregnancy is suspected when the following clinical indicators are present: intrauterine growth restriction (IUGR), decreased fetal movement (DFM), or when investigations such as cardiotocography (CTG) and ultrasound reveal results inconsistent with standard measurements. Pathological results would necessitate the need for immediate delivery, but the management for 'suspicious' results remains unclear and varies widely across clinical centres. There is clinical uncertainty as to how to best manage women presenting with a suspected term compromised baby in an otherwise healthy pregnancy. OBJECTIVES: To assess, using the best available evidence, the effects of immediate delivery versus expectant management of the term suspected compromised baby on neonatal, maternal and long-term outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing expectant management versus planned early delivery for women with a suspected compromised fetus from 37 weeks' gestation or more. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: Of the 20 reports identified by the search strategy, we included three trials (546 participants: 269 to early delivery and 277 to expectant management), which met our inclusion criteria. Two of the trials compared outcomes in 492 pregnancies with IUGR of the fetus, and one in 54 pregnancies with oligohydramnios. All three trials were of reasonable quality and at low risk of bias. The level of evidence was graded moderate, low or very low, downgrading mostly for imprecision and for some indirectness. Overall, there was no difference in the primary neonatal outcomes of perinatal mortality (no deaths in either group, one trial, 459 women, evidence graded moderate), major neonatal morbidity (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.01 to 2.81, one trial, 459 women, evidence graded low), or neurodevelopmental disability/impairment at two years of age (RR 2.04, 95% CI 0.62 to 6.69,one trial, 459 women, evidence graded low). There was no difference in the risk of necrotising enterocolitis (one trial, 333 infants) or meconium aspiration (one trial, 459 infants), There was also no difference in the reported primary maternal outcomes: maternal mortality (RR 3.07, 95% CI 0.13 to 74.87, one trial, 459 women, evidence graded low), and significant maternal morbidity (RR 0.92, 95% CI 0.38 to 2.22, one trial, 459 women, evidence graded low).The gestational age at birth was on average 10 days earlier in women randomised to early delivery (mean difference (MD) -9.50, 95% CI -10.82 to -8.18, one trial, 459 women) and women in the early delivery group were significantly less likely to have a baby beyond 40 weeks' gestation (RR 0.10, 95% CI 0.01 to 0.67, one trial, 33 women). Significantly more infants in the planned early delivery group were admitted to intermediate care nursery (RR 1.28, 95% CI 1.02 to 1.61, two trials, 491 infants). There was no difference in the risk of respiratory distress syndrome, (one trial, 333 infants), Apgar score less than seven at five minutes (three trials, 546 infants), resuscitation required (one trial, 459 infants), mechanical ventilation (one trial, 337 infants), admission to neonatal intensive care unit (NICU) (RR 0.88, 95% CI 0.35 to 2.23, three trials, 545 infants, evidence graded very low), length of stay in NICU/SCN (one trial, 459 infants), and sepsis (two trials, 366 infants).Babies in the expectant management group were more likely to be < 2.3rd centile for birthweight (RR 0.51, 95% CI 0.36 to 0.73, two trials, 491 infants), however there was no difference in the proportion of babies with birthweight < 10th centile (RR 0.98, 95% CI 0.88 to 1.10). There was no difference in any of the reported maternal secondary outcomes including: caesarean section rates (RR 1.02, 95% CI 0.65 to 1.59, three trials, 546 women, evidence graded low), placental abruption (one trial, 459 women), pre-eclampsia (one trial, 459 women), vaginal birth (three trials 546 women), assisted vaginal birth (three trials 546 women), breastfeeding rates (one trial, 218 women), and number of weeks of breastfeeding after delivery one trial, 124 women). There was an expected increase in induction in the early delivery group (RR 2.05, 95% CI 1.78 to 2.37, one trial, 459 women).No data were reported for the pre-specified secondary neonatal outcomes of the number of days of mechanical ventilation, moderate-severe hypoxic ischaemic encephalopathy or need for therapeutic hypothermia. Likewise, no data were reported for secondary maternal outcomes of postnatal infection, maternal satisfaction or views of care. AUTHORS' CONCLUSIONS: A policy for planned early delivery versus expectant management for a suspected compromised fetus at term does not demonstrate any differences in major outcomes of perinatal mortality, significant neonatal or maternal morbidity or neurodevelopmental disability. In women randomised to planned early delivery, the gestational age at birth was on average 10 days earlier, women were less likely to have a baby beyond 40 weeks' gestation, they were more likely to be induced and infants were more likely to be admitted to intermediate care nursery. There was also a significant difference in the proportion of babies with a birthweight centile < 2.3rd, however this did not translate into a reduction in morbidity. The review is informed by only one large trial and two smaller trials assessing fetuses with IUGR or oligohydramnios and therefore cannot be generalised to all term pregnancies with suspected fetal compromise. There are other indications for suspecting compromise in a fetus at or near term such as maternal perception of DFM, and ultrasound and/or CTG abnormalities. Future randomised trials need to assess effectiveness of timing of delivery for these indications.

The medical schools outcomes database project: Australian medical student characteristics.

BACKGROUND: Global medical workforce requirements highlight the need for effective workforce planning, with the overall aims being to alleviate doctor shortages and prevent maldistribution. The Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project provides a foundation for evaluating outcomes of medical education programs against specified workforce objectives (including rural and areas of workforce needs), assisting in medical workforce planning, and provision of a national research resource. This paper describes the methodology and baseline results for the MSOD project. METHODS: The MSOD Project is a prospective longitudinal multiple-cohort study. The project invites all commencing and completing Australian medical students to complete short questionnaires. Participants are then asked to participate in four follow-up surveys at 1, 3, 5 and 8 years after graduation. RESULTS: Since 2005, 30,635 responses for medical students (22,126 commencing students and 8,509 completing students) in Australia have been collected. To date, overall eligible cohort response rates are 91% for commencing students, and 83% for completing students. Eighty three percent of completing medical student respondents had also completed a commencing questionnaire.Approximately 80% of medical students at Australian medical schools are Australian citizens. Australian medical schools have only small proportions of Indigenous students. One third of medical students speak a language other than English at home.The top three vocational choices for commencing medical students were surgery, paediatrics and child health and general practice. The top three vocational choices for completing students were surgery, adult medicine/ physician, and general practice. Overall, 75.7% of medical students changed their first career preference from commencement to exit from medical school.Most commencing and completing medical students wish to have their future medical practice in capital cities or in major urban centers. Only 8.1% of commencing students and 4.6% of completing students stated an intention to have their future medical practice in smaller towns and small communities. CONCLUSIONS: The MSOD longitudinal project is now an established national resource that is beginning to generate significant research outputs, along with providing key information for workforce planning and policy makers. The project has now expanded to enrol New Zealand medical students.

Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women.

BACKGROUND: Fetal growth restriction is defined as failure to reach growth potential and considered one of the major complications of pregnancy. These infants are often, although not universally, small for gestational age (SGA). SGA is defined as a weight less than a specified percentile (usually the 10th percentile). Identification of SGA infants is important because these infants are at increased risk of perinatal morbidity and mortality. Screening for SGA is a challenge for all maternity care providers and current methods of clinical assessment fail to detect many infants who are SGA. Large observational studies suggest that customised growth charts may be better able to differentiate between constitutional and pathologic smallness. Customised charts adjust for physiological variables such as maternal weight and height, ethnicity and parity. OBJECTIVES: To assess the benefits and harms of using population-based growth charts compared with customised growth charts as a screening tool for detection of fetal growth in pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 March 2014), reviewed published guidelines and searched the reference lists of review articles. SELECTION CRITERIA: Randomised, quasi-randomised or cluster-randomised clinical trials comparing customised versus population-based growth charts used as a screening tool for detection of fetal growth in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: No randomised trials met the inclusion criteria. AUTHORS' CONCLUSIONS: There is no randomised trial evidence currently available. Further randomised trials are required to accurately assess whether the improvement in detection shown is secondary to customised charts alone or an effect of the policy change. Future research in large trials is needed to investigate the benefits and harms (including perinatal mortality) of using customised growth charts in different settings and for both fundal height and ultrasound measurements.

Is body fat percentage a better measure of undernutrition in newborns than birth weight percentiles?

BACKGROUND: Undernutrition in neonates increases the risk of serious morbidities. The objective of this study was to describe neonatal morbidity associated with low body fat percentage (BF%) and measure the number of undernourished neonates defined by BF% and compare this with birth weight percentiles (<10th). METHODS: Eligibility included term (≥37 wk) neonates. BF% measurements were undertaken by air displacement plethysmography. Data on neonatal outcomes were extracted from medical records and used to develop a measure of neonatal morbidity. We assessed the association between neonatal morbidity and population-based birth weight percentiles compared with the BF% measurements. RESULTS: Five hundred and eighty-one neonates were included. Low BF% was defined by 1 SD below the mean and identified in 73 per 1,000 live births. Neonatal morbidity was found in 3.4% of neonates. Birth weight percentile was associated with neonatal morbidity (odds ratio (OR): 1.03 (95% confidence interval (CI): 1.01, 1.05); P = <0.001). BF% was associated with a higher risk of neonatal morbidity (OR: 1.30 (95% CI: 1.15, 1.47); P = <0.001). CONCLUSION: In this population, measuring BF% is more closely associated with identification of neonates at risk of neonatal morbidity as compared with birth weight percentiles. BF% measurements could assist with identifying neonates who are appropriately grown yet undernourished and exclude small neonates not at risk.

Customized versus population-based birth weight charts for the detection of neonatal growth and perinatal morbidity in a cross-sectional study of term neonates.

Customized birth weight charts that incorporate maternal characteristics are now being adopted into clinical practice. However, there is controversy surrounding the value of these charts in the prediction of growth and perinatal outcomes. The objective of this study was to assess the use of customized charts in predicting growth, defined by body fat percentage, and perinatal morbidity. A total of 581 term (≥37 weeks' gestation) neonates born in Sydney, Australia, in 2010 were included. Body fat percentage measurements were taken by using air displacement plethysmography. Objective composite measurements of perinatal morbidity were used to identify neonates who had poor outcomes; these data were extracted from medical records. The value of customized charts was assessed by calculating positive predictive values, negative predictive values, and odds ratios with 95% confidence intervals. Customized versus population-based charts did not improve the prediction of either low body fat percentage (59% vs. 66% positive predictive value and 87% vs. 89% negative predictive value, respectively) or high body fat percentage (48% vs. 53% positive predictive value and 90% vs. 89% negative predictive value, respectively). Customized charts were not better than population-based charts at predicting perinatal morbidity (for customized charts, odds ratio = 1.02, 95% confidence interval: 1.01, 1.04; for population-based charts, odds ratio = 1.03, 95% confidence interval: 1.01, 1.05) per percentile decrease in birth weight. Customized birth weight charts do not provide significant improvements over population-based charts in predicting neonatal growth and morbidity.

Fetal and maternal factors associated with neonatal adiposity as measured by air displacement plethysmography: a large cross-sectional study.

BACKGROUND: There is evidence that the fetal and early postnatal environments play a role in determining the risk of lifetime obesity, diabetes and cardiovascular disease. Neonatal body composition, as a surrogate marker of the in-utero environment, can be reliably and accurately measured by air displacement plethysmography (ADP). Our primary objective was to identify preconception, fetal and maternal factors affecting neonatal body composition. METHODS: This cross-sectional study included 599 term babies born between September and October 2010 at Royal Prince Alfred Hospital, Sydney, Australia. Neonatal body fat percentage (BF%) was measured within 48 h of birth using ADP. Maternal demographic, anthropometric and medical data as well as neonatal gestational age and sex were used to develop a regression model that predicted body composition and birthweight. RESULTS: The mean (SD) neonatal BF% in our whole population was 9.2(4.4)%. Significant variables in the model for neonatal BF% were neonatal sex, gestational age, maternal ethnicity, gestational weight gain (GWG), pre-pregnancy BMI, parity and maternal hypertension (p<0.05); together, these explained 19% of the variation in BF%. GDM status was not a significant variable. Neonatal female sex, maternal Caucasian ethnicity and increased gestational weight gain explained the most variation and were most strongly associated with increased BF%. CONCLUSIONS: This study highlights maternal obesity and increased gestational weight gain as two factors that are amenable to intervention as risk factors for newborn adiposity, which is important in the future study of the "developmental origins of health and disease" hypothesis.

Audit of a clinical guideline for neonatal hypoglycaemia screening.

AIM: This study aims to evaluate adherence to a clinical guideline for screening and prevention of neonatal hypoglycaemia on the post-natal wards. METHODS: Retrospective chart review of 581 healthy term neonates born at a tertiary maternity hospital. Indications for hypoglycaemia screening included small for gestational age (SGA), infants of diabetic mothers (IDM; gestational, Type 1 or 2), symptomatic hypoglycaemia, macrosomia and wasted (undernourished) appearance. Outcomes were protocol entry and adherence with hypoglycaemia prevention strategies including early and frequent feeding and timely blood glucose measurement. RESULTS: Of 115 neonates screened for hypoglycaemia, 67 were IDM, 19 were SGA (including two both IDM and SGA), and two were macrosomic. One IDM and one SGA were not screened. Twenty-two neonates were screened for a reason not identifiable from the medical record, and 13 neonates were SGA by a definition different to the guideline definition, including five who were also IDM. Guideline adherence was variable. Few neonates (41 of 106, 39%) were fed in the first post-natal hour, and blood glucose measurement occurred later than recommended for 41 of 106 (39%) of neonates. CONCLUSIONS: Most IDM and SGA neonates were screened. While guideline adherence overall was comparable with other studies, neonates were fed late. We recommend staff education about benefits of early (within the first hour) frequent breastfeeding for neonates at risk.

Neonatal length inaccuracies in clinical practice and related percentile discrepancies detected by a simple length-board.

AIM: The study aims to assess accuracy of standard practice measurement of neonatal length compared with a gold-standard length-board technique. METHODS: Data were obtained from a population-based, cross-sectional study of 602 term babies at Royal Prince Alfred Hospital, Sydney, Australia, in 2010. Neonatal length was measured by standard clinical practice and by a length-board (gold standard) and measurements compared. Standard growth curve percentiles were used to plot length measurements. The Bland and Altman method was used to assess agreement, and acceptable levels of agreement were set at ≤1 cm and ≤0.5 cm. RESULTS: The limits of agreement were between -3.06 cm (95% CI -3.08 to -3.04) and 2.67 cm (95% CI 2.65 to 2.69). Neonates whose standard-practice length fell within 0.5 cm of the gold standard totalled 41% (241 neonates), while 59% (342) were >0.5 cm. The change in length resulted in a change in the percentile range of 53% (309) on a standard growth curve percentile. When examining neonates whose length was plotted at the extremes of percentile regions, the positive predictive value results of the standard practice compared with the gold standard were poor, with positive predictive values of 37.5%, 57.1% and 31.3% for neonates who were measured as <3rd, <10th and ≥90th percentile, respectively. CONCLUSIONS: In current clinical practice, measures of neonatal length are often inaccurate, which has implications for potentially erroneous clinical care. Health-care providers should be educated on the importance of length and trained in how to measure length with the correct technique using a length-board.