Neonatal Consultants Research Articles

Range of NICU Practice in England and Wales Regarding Thresholds for Neonatal Conjugated Hyperbilirubinaemia and Relevant Investigations

Background: Conjugated jaundice is a common problem in a neonatal intensive care. However, several investigations are performed to exclude underlying liver disease. Opinion differs on their diagnostic value. Aim: To evaluate practice related to investigation of conjugated jaundice Method: Questionnaire survey of lead neonatal consultants from all neonatal units in England and Wales. Results: 102/194 neonatal units (52%), responded to the survey of which 33 were level 3 units, 50 level 2 and 19 level 1 units. 96 units (94%) performed conjugated jaundice screen and 6 units (6 %) did not. 77 units (75%) had a written policy. 49% of responders defined conjugated jaundice as conjugated bilirubin >20% of total bilirubin and 46% as >15% of total bilirubin and 5% of units did not have a clear definition. Conjugated bilirubin levels that prompted investigations varied between units with 28 (30%) using conjugated bilirubin >20% of total, 33(36%) a conjugated bilirubin >15% of total and 20 (21%) with no definite threshold. Majority (>76%) of units performed liver and thyroid function tests, Galactosaemia screen, α-1 antitrypsin and liver ultrasound. 65% of units performed urine culture and hepatitis serology, 32% performed urine organic acids, NH3 and lactate. 19 units performed CF genetics and 23 HIDA scan. 71% of responders thought ‘diagnostic yield’ was ‘poor’ and 44% based this on their personal view, 29% on local data and 27% on anecdotal evidence. Conclusion: Our study identified a wide variation in definition and investigation of neonatal conjugated jaundice. National consensus guidelines are required to standardize practice.

New NANN Practice Guideline

The Management of Hypotension in the Very-Low-Birth-Weight Infant: Guideline for Practice, developed by Lyn Vargo, PhD, RN, NNP-BC, and Istvan Seri, MD, PhD, in 2011 under the auspices of the National Association of Neonatal Nurse Practitioners, focuses on the challenging topic of clinical management of systemic hypotension in the very low-birth-weight (VLBW) infant during the first 3 days of postnatal life. The recommendations and rationale in the excerpt below from the complete online publication are based on the best evidence available through both neonatal research and consultation of experts on the subject. They suggest a conservative, evidence-based treatment approach for the management of hypotension in the VLBW infant during the first 3 days of postnatal life that is logical, safe, and physiologically sound. The insufficient fund of knowledge on transitional cardiovascular physiology in general and pathophysiology in particular makes establishment of strict guidelines on the treatment of hypotension in VLBW neonates impossible. What becomes clear when presenting the evidence is how much more we need to know. Readers are strongly encouraged to refer to the complete text of the guideline, which has been endorsed by the American Academy of Pediatrics, for further understanding of this complex topic. The guideline is available free of charge at www.nann.org (click on Guidelines in the Education section).

Antenatal Consent in the SUPPORT Trial: Challenges, Costs, and Representative Enrollment

The purposes of this study were to quantify the time and effort involved in obtaining prenatal consent for the Neonatal Research Network Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial (SUPPORT) and to determine whether the enrolled infants were representative of the eligible population. Eligible subjects were likely to deliver in the SUPPORT gestational age window (24-27(6/7)] weeks). Data included who approached the subjects for consent, how often they approached, the duration of each contact, whether consent was obtained, and whether subjects were enrolled in the trial. Eligible, nonenrolled infants entered into the Neonatal Research Network Generic Database throughout the period of SUPPORT enrollment were compared with enrolled infants. A total of 2826 women were identified at 18 sites, 2228 were approached for consent, and 1219 (54.7%) agreed. For 76.9% of those approached, <3 visits (mean: 2.0 +/- 1.2 visits) were required to complete the consent process. Of the 659 infants with consent who were delivered within the study window, 611 were enrolled. Mothers who received a neonatal consultation were more likely to give consent (P < .001). The proportion of infants not exposed to steroids was significantly greater in the nonapproached group than in the approached group (20.0% vs 3.4%; P < .0001). In a trial that involved preterm infants and required prenatal consent, >5 women were identified as being likely to deliver in the SUPPORT gestational age window for each 1 who delivered an enrolled infant.

Clinicians' perceptions of telemedicine for remote neonatal consultation.

Telemedicine may have a useful role in neonatal care, particularly in regionalised health care systems where there may be impediments to access. Following the development of a system for neonatal teleconsultation, we assessed its efficacy, usability and preliminary effectiveness. While results were positive, uptake in routine clinical use was less than expected. The study described in this paper examined aspects of clinicians' perceptions of telemedicine in neonatal care. Overall, clinicians had positive perceptions of telemedicine. Further work is required to understand the negative perceived usefulness of telemedicine held by some clinicians and to determine whether this may be overcome.

Neonatal Neurologic Consultations

The pediatric neurologist can serve as a subspecialty consultant for both the fetus and neonate in whom a brain disorder is suspected. Although acute neonatal brain disorders must be assessed and treated vigorously, neurologic disease may occur before the intrapartum period, either from a primary brain disease or secondarily from systemic diseases. Medical conditions during the antepartum and intrapartum periods can predispose the fetus or neonate to express acute brain dysfunction as a neonate, representing both acute and chronic conditions. The pediatric neurologist must, therefore, consider maternal, placental, and fetal diseases on which a neonatal encephalopathy may be superimposed. This review describes four consultations by a neonatal neurointensive care service in which an integrative approach to fetal neurology is applied to neonatal consultations, emphasizing perspectives from other subspecialties concerning maternal-fetal medicine, developmental pathology, neonatology, and other pediatric subspecialties. Future strategies for fetal or neonatal brain resuscitation will need to consider the developmental context in which a suspected brain injury occurred during antepartum, intrapartum, and neonatal periods. Accurate etiologic diagnoses and timing of an insult will influence the forms of therapy of neuroprotection or neurorescue.

Letters to the Editor

22 December 2006 Dear Editor, BASIC PAEDIATRIC KNOWLEDGE: IS IT STILL RELEVANT? The ‘new morbidity’ is a well-established concept in current paediatric practice.1 Oberklaid has documented these changes in Australia and has pointed out that many paediatricians felt that they were poorly equipped after their training to deal with this new style of practice.2, 3 While not arguing that these changes have come about, but before any radical change is introduced into training, it is worth re-evaluating what clinical problems are encountered currently by paediatricians in smaller centres and assessing how important social and environmental factors are. A sequential series of referrals to the Paediatric Department of Wairau Hospital, Blenheim, New Zealand was evaluated prospectively. Data relating to 100 new referrals were collected. Information about the child's age, sex and the referring general practitioner or specialist’s diagnosis was collected initially. The outpatient nurse collected data on the family structure and size. After the first consultation a working diagnosis was formed and information recorded as to whether the diagnosis was primarily a physical disorder, a reflection on social dysfunction, an emotional problem or a developmental disorder. The primary ‘trigger’ for the consultation was ranked from the above categories accepting that all may have a degree of social and environmental factors involved. The study period was during late 2005 and early 2006. The same paediatrician saw all referrals. The 100 referred children had an average age of 5.4 years (SD ± 5.8, range: 11 days–15.8 years). There were 44 (44%) boys and 56 (56%) girls. Table 1 outlines the final diagnostic categories as each child had a specific diagnosis given following assessment. Urinary tract infection and its subsequent management were the single commonest referral diagnoses followed by disorders of bowel function. A physical disorder was the prime indication for referral in 92%, a behavioural issue in 4%, an emotional problem in 2% and a developmental problem in 2%. No referrals were as a result of family dysfunction only. This sample represents about 10% of the annual new patient referrals to a paediatrician working in a small rural area of New Zealand. It does not include emergency and acute admissions to the wards, neonatal consultation nor the large number of outpatients followed for chronic disorders. The diagnostic categories show a wide range of disorders seen and the need for knowledge over a wide field of paediatric medicine. There was a striking absence of factors that could be attributed to ‘environmental and social processes’,4 that is to say, the family structure, size and function or ethnic diversity and its contribution to ill health. It is accepted that this is a rural sample and does not reflect the needs of a large inner city multiethnic group. However, it does reflect much of the pattern seen in rural New Zealand. Family structures appear to reflect the changes reported throughout New Zealand. However, our data did not point to these changes being the major factor in the reason for the referral for the outpatient consultation or contributing to the child’s medical condition, in all but a small percentage of children. Indeed, it could be argued from our results that paediatricians working in rural or remote areas need a very wide experience and exposure to the physical disorders of childhood and not a narrow psychosocial perspective. Further, Oberklaid has stressed the need for those going into general paediatric practice do need to maintain skills at both ends of the clinical spectrum.3 Our results support this view but indicate further that basic physical and developmental problems predominate still in everyday practice and training should still reflect these -predominantly.

Deciding to resuscitate extremely premature babies: How do parents and neonatologists engage in the decision?

Parents at risk of delivering a baby at the threshold of viability are faced with a critical decision. When a child is born between 23 and 25 weeks of gestation, parents are asked to decide whether or not to resuscitate their child. In essence, they are faced with a choice between life and death. We conducted a qualitative study to explore how parents and neonatologists engage in decision-making in a context of imminent and unplanned delivery at the threshold of viability. Twelve parents and attending neonatologists in a specialized tertiary care centre in Montreal, Canada were separately interviewed immediately following neonatal consultation. Results highlight how neonatologists and parents engage in decision making from different standpoints: while neonatologists focus on the management of the unborn baby, parents have yet to fully conceptualize their infant as a distinct entity since they are in a process of grieving their pregnancy and their parenthood project. Moreover, in their attempt to ensure an informed decision, neonatologists adopt either of two models through provision of the most up-to-date and objective information available: “remaining as neutral as possible to allow parents to make their own decision”, or, “formulating a proposal to which parents can choose or not to assent”. Overall, if the provided information fits parents’ expectations, they tend to feel confident with their decision. However, if it does not take their experience into account, their decision is experienced as a solitary process. Parents express the need to receive more than just factual information from neonatologists. They also require support and engagement from caregivers to manage the uncertainty. This brings into question the traditional concept of neutral informed consent and suggests the necessity of a shared decision-making model to ensure that the decision to resuscitate extremely premature babies, at the limits of viability, becomes a truly ethical task.

Implementing a comprehensive cost information system in rural health facilities: the case of Nouna health district, Burkina Faso

To present first findings of a cost-of-illness (COI) information system implemented in Nouna health district, Burkina Faso. The entire project will include household and provider tangible COI, whereas this article concentrates on the development of a provider cost information system in rural first-line health facilities. Special forms and reports are prepared to routinely collect capital and recurrent costs of first-line facilities. Inventory lists are designed, and buildings and equipment are assessed by engineers. Total, fixed, variable and average costs are calculated for 15 rural health centres with five cost centres: general outpatient consultation, ambulatory nursing care, deliveries, immunization and other services (neonatal consultation, child care and family planning). In 2003, the average costs per service unit were 1.34 US$ for a general consultation, 0.51 US$ for ambulatory nursing care, 6.73 US$ per delivery, 3.64 US$ per vaccination and 1.11 US$ per service unit of other care. On average, a health centre consumes 29,900 US$ per year for a catchment population of 10,000 inhabitants. The major share of costs is fixed and does not depend on the workload of the health centre. Consequently, the costs of first-line facilities will hardly increase if the demand for health services rises. These findings can be used to improve the health financing in Nouna health district, Burkina Faso.

Hospitalización neonatal desde el servicio de urgencias en un centro hospitalario de Uruguay

To determine the prevalence of neonatal admissions through a pediatric emergency department (PED), and to evaluate the characteristics of patients who present vital risk on arrival. We performed a descriptive, retrospective review of neonates aged 2-28 days arriving from home who presented to the pediatric emergency department between 01/01/03 and 31/12/03. Of a total of 943 neonatal consultations, 277 (29.3 %) required admission. The most common diseases were respiratory (42.6 %) and fever without source (17 %). Among the 943 patients attended, 42 (4,5 %) showed vital risk, and in this group, 81 % were full term neonates, with a P50 of age of 19 days, and a P50 of weight of 3200 g. Among these, there was a predominance of infectious diseases (74 %), especially respiratory tract infections (50 %). Respiratory syncytial virus (RSV) was identified in 14 of the 42 patients. Thirty-six percent required mechanical ventilation and 71.5 % were transferred to the pediatric intensive care unit. Sixty percent of the critically-ill neonates were admitted in the 3 winter months (p < 0.001). A high percentage of the neonates arriving from home required admission, and vital risk was more frequent in this age group than in other ages (p < 0.001). This does not correspond to risk related to perinatal pathology, or to nutritional reasons, but to community-acquired infections, particularly those of the respiratory tract, the most frequent cause of which is RSV.

The use of volume expansion in preterm infants.

There is no consensus of opinion regarding the appropriate use of volume expansion in the sick preterm infant. Recent evidence suggests that excessive volume expansion may increase mortality in this group. We determined the use of volume expansion in non-surgical preterm infants (<30 weeks gestation) among neonatal consultants in the West Midlands. A questionnaire was sent to 40 consultants working in all 16 neonatal units in the West Midlands region and re-sent one year later after presentation of interim regional mortality data. Responses were received from 15 units in 2000 and all 16 in 2001. Written guidelines for volume expansion were available in only 6 units (38%) in 2000 compared with 15 (94%) in 2001. The maximum volume expansion considered appropriate in the first 36 h of life reduced from a mean 37 mL/kg (range 15-150 mL/kg) in 2000 to 24 mL/kg (range 10-60 mL/kg) in 2001. In 2000 64% limited volume expansion to < or = 30 mL/kg (compared with 94% in 2001). Following regional discussion of interim mortality data and the subsequent development of unit guidelines, the prescription of volume expansion in the West Midlands region changed, with a reduction in the mean volume considered appropriate and greater consistency between units. The impact on neonatal outcome needs to be determined.

Fetal and neonatal neurologic consultations: Identifying brain disorders in the context of fetal-maternal-placental disease

Pediatric neurologists provide an important consultative role for the fetus or neonate with a suspected brain disorder. Although most consultations are initiated after birth, neonatal neurologic dysfunction may be reflective of fetal brain damage or maldevelopment. Maternal or placental/cord disease states can predispose the fetus or neonate to brain disorders during the antepartum, intrapartum, or early postpartum periods. Neurologists must therefore consider maternal, placental, and fetal conditions on which a neonatal encephalopathy may be superimposed, with or without recent brain injury. This review suggests how the pediatric neurologist can contribute more effectively to fetal and neonatal neurologic evaluations regarding etiologies and mechanisms of brain injury; their role will enhance diagnostic services composed of maternal-fetal specialists, placental and pediatric pathologists, neonatologists, neurosurgeons, geneticists, and other pediatric subspecialists. Selected examples of structural markers during fetal life, and functional markers during neonatal life, illustrate the wide spectrum of disease states that are highly dependent on the timing and location of brain injury. The pediatric neurologist has the opportunity to integrate these complementary lines of investigation into a responsive consultative opinion, which is both medically accurate and ethical, responsible to the welfare of the mother and child.

Experience with neonatal palliative care consultation at the Medical College of Wisconsin-Children's Hospital of Wisconsin.

At Children's Hospital of Wisconsin there is a pediatric palliative care consultation service that serves a diverse patient population, including infants. However, the value of a palliative care consultation for infants has not been well evaluated. We performed a retrospective, case series, descriptive chart review of infants in our neonatal intensive care unit (NICU) who received palliative care consults between January 1996 and June 1998. We specifically looked at their diagnoses, the timing of consults, reasons that consultations were ordered, what recommendations were made, and the subsequent outcomes. During the series period there were 898 admissions to the NICU, 51 neonatal deaths, and 12 neonatal palliative care consultations. The diagnostic categories for those with a palliative care referral included prematurity, lethal anomalies, and catastrophic or overwhelming illness. Reasons for the consultations were organization of home hospice, facilitation of medical options, such as do-not-resuscitate (DNR) orders and treatment withdrawal, facilitation of comfort measures, and grief/loss issues. Recommendations that the palliative care staff made fell into four categories: advance directive planning, the optimal environment for supporting neonatal death, comfort and medical care, and psychosocial support. This series is a description of what a palliative care service can offer for terminally ill infants in an NICU. We speculate that such consults can more consistently and comprehensively provide appropriate end-of-life care for these patients and their families.

The advantages of prenatal consultation by a neonatologist.

The neonatologist can be a valuable source of information for the pregnant woman and her partner faced with making difficult decisions. In specific clinical situations, a focused, thorough consultation by a neonatologist provides benefits for the parents, their child, the physicians, and the health care delivery system as a whole. Members of the perinatal team should act to facilitate early neonatal consultation in order to ease the transition from the obstetric to the neonatal team after delivery.

Early experience using telemedicine for neonatal surgical consultations

Background/Purpose: Telemedicine affords the opportunity to extend the presence of surgical evaluation to centers without an on-site pediatric surgeon. However, concern for cost, accuracy of diagnosis, and physician acceptance have limited its use. Methods: Using a low-cost, desktop computer-based system, this study was designed to test the effectiveness of telemedicine in neonatal surgical consultation. Results: Early experience with six video-teleconference (VTC) and six store-and-forward consultations are presented. Diagnosis was established accurately in all cases. With the three intestinal cases (jejunal atresia, duplication cyst, and r o malrotation), diagnostic studies were guided by the images transmitted with the consult. Earlier care could be implemented in other cases. Technical problems were encountered primarily with the VTC modality, which also proved more consuming of physician time. Conclusions: Telemedicine was used successfully in each case and proved accurate in diagnosis and guiding further evaluation. This is the first report of the use of telemedicine for surgical consultation in the intensive care nursery.

Elective induction versus spontaneous labor: A retrospective study of complications and outcome

This retrospective study was undertaken to identify whether electively induced labor places the mother or her fetus at increased risk as compared with her spontaneous labor cohort. This study compares the labor, delivery, and fetal outcome of 253 parturients in which labor was electively induced with 253 matched controls who began labor spontaneously. All patients were delivered at Huntington Memorial Hospital in Pasadena, California, during the calendar year 1990. The patients were between 37 and 41 weeks' gestation and had no medical or obstetric conditions necessitating induction. The cases and controls were matched for age group, parity, gestational age, and delivering obstetrician. Epidural anesthesia was used in 83.8% of patients in the induction group versus 55.7% in the spontaneous group. Patients with labor induced had a shorter first stage of labor. Meconium staining was found significantly more often in the spontaneous group than in the induced group (16.2% vs 6.7%). This contributed to a greater rate of neonatal consultations in the spontaneous labor group. Although cesarean section rates between the two groups were similar, nulliparous patients in the induction group with an estimated Bishop score of less than or equal to 5 had a 50% cesarean section rate. Iatrogenic prematurity was not encountered. No differences existed between the two groups with respect to intrapartum maternal complications, fetal complications, or postpartum complications. When compared with spontaneous labor, elective induction of labor at term does not appear to pose an increased risk to the mother or her fetus in a carefully selected patient population. However, elective induction of labor in a nulliparous patient with an unfavorable cervix should be discouraged.