Parents as carers on a neonatal unit: Qualitative study of parental and staff perceptions in a low-income setting.

Aim To determine parents' experiences on a neonatal unit in a low-income country, how they and staff perceive the role of parents and if parents' role as primary carers could be extended. BACKGROUND: A busy, rural district hospital in Rwanda. Rwandan neonatal mortality is falling, but achieving Sustainable Development Goal target is hampered by trained staff shortage. METHODS: Qualitative thematic content analysis of semi-structured interviews with 12 parents and 16 staff. RESULTS: Parental concerns were around their baby's survival, stress and discharge. They were satisfied with their baby's care but feared their baby may die. Mothers described stress from remaining in hospital throughout baby's stay, providing all non-technical care including tube or breast feeds day and night, followed by kangaroo mother care until discharge. They expressed loneliness from lack of visitors, difficulty finding food and somewhere to sleep, financial worries, concern about family at home, and were desperate to be discharged. Staff focused on shortage of nurses limiting technical care, ability to educate parents and provide follow-up. Neither groups thought parents' role could be extended. CONCLUSION: Staff, including senior management, were mainly focused on increasing nursing numbers. Parents' concerns were psychosocial and about coping emotionally with their baby's care and practical concerns about inpatient facilities, particularly lack of food and accommodation and absence from home. Staff preoccupation with nurse numbers made them concentrate on medical care, but parental issues identified are more likely to be provided by experienced mothers, allied health professionals, mothers' groups or community health workers.

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.

Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant.

UNLABELLED: Chemical burns in extremely preterm infants have major implications in terms of morbidity and risk management. We report a case of extensive chemical burn in an extremely low birth weight (ELBW) infant caused by clear, colourless solution of 0.5% chlorhexidine in 70% alcohol mistaken for normal saline for skin cleansing during umbilical catheter insertion. This case reflects the on going problem faced by many neonatal intensive care units of similar coloured solutions with similar packages, but with varying degrees of toxic effects. CONCLUSION: The case highlights the importance of having a clear policy for skin cleansing in every neonatal unit and measures to avoid errors by vigilant checking of all medications including topical solutions.

Factors associated with fall in neonatal intubation rates in the United Kingdom--prospective study.

OBJECTIVE: To investigate the trend of neonatal resuscitation by intubation or mask ventilation over time and to assess its association with changes in prevalence of caesarean section and use of general anaesthesia in labour. METHODS: All women booking pregnancy at any of 15 maternity units, analysed using logistic regression. DESIGN: Prospective study. SETTING: UK hospital-based maternity units (15 centres). POPULATION: A total of 221,322 first singleton births of babies weighing 200 g or more in the St Mary's Maternity Information System cohort, 1988-2000, covering the North West Thames area of London. MAIN OUTCOME MEASURES: Prevalence of intermittent positive-pressure ventilation (IPPV) (by intubation or mask) by calendar year. RESULTS: Overall use of IPPV decreased markedly (two-sided P<0.01) over the course of the study, and this decrease was evident by all modes of delivery. Adjusted mean prevalence of intubated IPPV decreased from 0.51% (95% CI 0.44-0.58) in 1988 to 0.07% (95% CI 0.06-0.09) in 2000. There was a similar decrease in the prevalence of IPPV by mask. However, despite substantial increases in prevalence of caesarean sections and reductions in the use of general anaesthesia over the course of the study, adjusting for these variables made little difference to the temporal trends in intubation or use of mask ventilation. CONCLUSIONS: There has been a marked reduction in the prevalence of infants given resuscitation by positive-pressure ventilation that cannot be explained by changes in the prevalence of caesarean section or use of general anaesthesia in labour.

How should paediatric examiners be trained?

Analysis of both the content and process of examinations is central to planning the appropriate education and training of examiners in paediatric clinical examinations. This paper discusses the case for developing training, reviews the current literature, and suggests the desirable attributes of examiners and the components of a training programme. Potential areas of further research are also considered.

Incarcerated inguinal hernia in premature babies--a report of two cases.

UNLABELLED: We highlight the morbidity of incarcerated inguinal hernia in very low birthweight (VLBW) infants by presenting a report of two cases. Our aim is to raise the question of the optimal timing of surgery when this common problem presents on the neonatal unit. In each of our cases the hernia was diagnosed but surgery was delayed, as per normal policy on the unit, pending growth of the baby and improvement in respiratory status. Both babies suffered significant morbidity when the hernias subsequently became acutely incarcerated. CONCLUSION: In conclusion, we question whether the widespread practice of delayed surgery for inguinal hernia in VLBW infants should be reconsidered.

Syphilis in pregnant women and their children in the United Kingdom: results from national clinician reporting surveys 1994-7.

OBJECTIVE: To measure the incidence of syphilis detected in pregnancy and congenital syphilis in the United Kingdom. DESIGN: Surveys through consultants in genitourinary medicine and paediatricians with active surveillance. SETTING: United Kingdom, 1994-7. SUBJECTS: Women treated for syphilis in pregnancy, and children with early congenital syphilis born in the United Kingdom. RESULTS: Over 3 years 139 women were diagnosed with and treated for syphilis in pregnancy; 121 were detected through antenatal screening. Thirty one had confirmed or probable congenitally transmissible syphilis, putting their pregnancies at risk. These were minimum figures but are compatible with the 90 to 100 women newly diagnosed annually as having infectious or early latent syphilis. A universal screening policy would require 18 600 and 55 700 women (maximum numbers) to be screened, respectively, to detect one woman needing treatment and to prevent one case of congenital syphilis. Nine presumptive cases of children with congenital syphilis born in the United Kingdom were reported. Mothers requiring treatment for syphilis were found in almost every health region but were more prevalent in London and the south east. Being born abroad and belonging to an ethnic minority group were strong risk factors, but 14% (19 of 121) of cases treated and six of 31 definite or probably transmissible cases occurred in white women born in the United Kingdom. CONCLUSIONS: Congenitally transmissible syphilis continues to occur among pregnant women in the United Kingdom. Cases would be missed and stillbirths and congenitally infected babies would occur if antenatal screening was abandoned.

Influence of homelessness on acute admissions to hospital.

The aim of this study was to look at the influence of homelessness on acute medical admissions. A prospective case-controlled study was therefore performed on all homeless children admitted through the accident and emergency department over one year, comparing them with the next age matched admission from permanent housing. Assessments made were: whether homelessness or other social factors influenced the doctors' decision to admit; differences in severity of illness; length of stay; and use of primary care. The admitting doctors completed a semi-structured questionnaire during admission about social factors that influenced their decision to admit and graded the severity of the child's illness. The length of hospital stay was recorded. The family's social risk factors and accommodation were assessed at a home visit using a standardised questionnaire and by observation. Seventy homeless children were admitted. Social factors influenced the decision to admit in 77% of homeless children and 43% of controls. More of the homeless children were only mildly ill (33/70) than those from permanent housing (21/70), although three of the homeless children died of overwhelming infections compared with none of the controls. Among homeless families many were recent immigrants (44%). There was a marked increase in socioeconomic deprivation, in major life events in the previous year (median score 3 v 1), and in maternal depression (27% v 8%). Referral to the hospital was made by a general practitioner in only 5/50 (10%) of homeless compared with 18/50 (36%) of controls. Social factors were an important influence on the decision to admit in over three quarters of the homeless children and resulted in admission when less severely ill even when compared with admissions from an inner city population. Even though there was marked social deprivation among the homeless families, the decision to admit was based on vague criteria that need to be further refined.

Evaluation of computer generated neonatal discharge summaries.

Computer generated and dictated discharge summaries were compared for all 133 babies admitted for intensive and special care during a six month period. Whereas 130/133 (98%) had a computer generated summary, only 94/133 (71%) had a dictated summary. In addition, computerised summaries were completed at discharge, but there was a delay up to 26 weeks for dictated summaries. Dictated summaries had more items of basic data missing but were more readable. A main diagnosis was missing in only 5/95 (5%) of dictated and 1/130 (1%) computerised summaries. Of the computer generated summaries, 114/133 (86%) were suitable to give to parents. Satisfactory discharge summaries for babies requiring intensive or special care can be generated with an on line computer system.

Interrelationships among abnormal cardiotocograms in labor, meconium staining of the amniotic fluid, arterial cord blood pH, and Apgar scores.

A prospective study of the relationships among fetal heart rate pattern, meconium staining of the amniotic fluid, umbilical cord artery pH, and Apgar score was carried out in 1219 consecutive births. Interpretable cardiotocogram patterns and cord arterial pH and blood gas analysis were obtained in 698 cases. The sensitivity of an abnormal cardiotocogram at any time for acidosis (more than 1 SD below the mean, pH less than 7.17) was 80%, and for severe acidosis (more than 2 SDs below the mean, pH less than 7.085) was 83%. However, the predictive value was low, and 32% of fetuses had an abnormal cardiotocogram but no acidosis. If only cardiotocogram abnormality in the first stage of labor was considered, sensitivity was still 47% for acidosis and 67% for severe acidosis, and the false-positive rate was reduced to only 14%. We attempted to improve the prediction of acidosis by including meconium staining of the amniotic fluid, but 65% of the variation in umbilical cord artery pH and 72 and 86% of the variation in 1- and 5-minute Apgar scores, respectively, remained unexplained. In light of these poor correlations, the current practice of considering cardiotocogram abnormality, meconium staining of the amniotic fluid, acidosis, and low Apgar scores as indicating one single disorder, "fetal distress," is not valid.

A comparison of the rheologic properties of neonatal and adult blood.

A number of studies have indicated that the rheologic properties of neonatal blood are different from those of the adult. The frequent administration of blood components to the neonate during intensive care make it important that these differences be established and their causes understood. The purpose of this study was to make a detailed comparison of the rheologic properties of neonatal and adult blood, with particular emphasis on low shear rate viscosity and rouleaux-related phenomena. The viscometric data was obtained from seven preterm (PT) and 18 normal term (NT) babies and compared with those from 18 adults (A). In the present study, viscometry was performed over a wide range of shear rates, from about 0.3 to 130 s-1, and the low shear rate data were compared with direct measurement of rouleaux formation using the Myrenne Erythrocyte Aggregometer. A major factor leading to the viscometric differences observed was the high hematocrit common in the newborn (46.8 +/- 2.1% PT, 52.8 +/- 6.1% NT, 44.1 +/- 2.5% A males, 40.5 +/- 1.9% A females). However, this tended to be compensated for by the lower plasma viscosity (1.05 +/- 0.07 mPas PT, 1.23 +/- 0.14 mPas NT, 1.34 +/- 0.08 mPas A--no sex difference) and reduced rouleaux formation observed in the newborn and more marked in the preterm baby. The lowered levels of red cell aggregation were found not to be due to cellular differences between the adults and the babies but rather to differing plasma components. The presence of the fetal variant of fibrinogen and low levels of immunoglobulins, especially IgM and IgA, are likely to be of particular importance.

Quantification of cardiovascular instability in premature infants using spectral analysis of waveforms.

Spectral analysis was applied to blood pressure and cerebral blood flow velocity recordings in premature infants with respiratory distress in order to quantify respiration-induced cardiovascular variability. Aortic blood pressure was transduced via an umbilical arterial catheter and cerebral blood flow velocity measured in the anterior cerebral artery using a 10 MHz continuous wave Doppler velocimeter in 16 infants less than or equal to 32 wk gestational age. Spectral analysis of the resulting waveforms revealed heart rate and respiratory rate components whose relative amplitudes (heart rate/respiratory rate amplitude ratio) represent an index of that component of variability induced by respiratory events. The mean (heart rate/respiratory rate amplitude) ratio was 47.2 in spontaneously breathing infants and rose to 165.9 in infants who were ventilated during muscle paralysis (p = 0.0003). Cerebral blood flow velocity recordings showed R components in only 22 of 38 simultaneous recordings. This method can be used to quantify respiration-induced cardiovascular variability and its response to therapy, and may provide a means of identifying infants at risk from brain injury due to an inability to regulate cerebral blood flow.

Pulse oximeter and transcutaneous arterial oxygen measurements in neonatal and paediatric intensive care.

Pulse oximeter (SaO2P) measurements were compared with direct arterial line oxygen saturation (SaO2) from co-oximeters in 92 instances in 43 patients, and with arterial line oxygen measurements (PaO2) in 169 instances in 81 patients. The mean (SD) absolute difference between SaO2P and SaO2 was 2.6% (2.4) after attempt to correct for the co-oximeter falsely measuring a proportion of fetal haemoglobin as carboxy haemoglobin. For 19 infants and children greater than or equal to 5 months old, who have very little fetal haemoglobin, the mean (SD) absolute difference of 27 comparisons was 1.8% (2.1). Comparison of SaO2P and PaO2 measurements in 46 instances when PaO2 was less than 6.67 kPa showed SaO2 to be less than 90% on 40 occasions. In 24 instances when PaO2 was greater than or equal to 13.3 kPa the SaO2P was greater than or equal to 98% on 22 occasions. In 23 infants undergoing neonatal intensive care, transcutaneous oxygen monitors were compared with arterial PO2 measurements in 60 instances. The mean (SD) absolute difference between PaO2 and transcutaneous oxygen measurements was 1.60 kPa (1.73). Ten of the 60 comparisons had differences greater than 2.67 kPa and three greater than 5.33 kPa (maximum 8.40 kPa). Pulse oximetry is a clinically useful technique for managing oxygenation but further studies are needed to confirm its safety in premature infants at risk of retinopathy of prematurity.

The relation between the need for intubation at birth, abnormal cardiotocograms in labour and cord artery blood gas and pH values.

A consecutive series of 56 infants of 32 weeks gestation or more who were resuscitated at birth by endotracheal intubation was studied to determine the occurrence of abnormal cardiotocograph traces and acidosis as determined by cord artery blood measurements. Thirty-two infants (57%) had neither cardiotocographic abnormalities nor acidosis; in this group the factors associated with the need for intubation were meconium stained amniotic fluid, operative delivery, anaesthetic agents given to the mother, a tight nuchal cord, and traumatic vaginal delivery. The need for intubation at birth should not automatically be regarded as evidence of intrapartum hypoxia or disturbed acid-base balance.

Neonatal herpes simplex pneumonia.

A neonate with herpes simplex pneumonia is described. Herpes simplex infection should be considered in the differential diagnosis of pneumonia in newborn infants, even in the absence of clinically apparent herpes in the mother.