Neonatal-perinatal Medicine Research Articles

Educational Perspectives

Historically the performance of health-care professionals has been evaluated primarily through assessment of content knowledge retained in memory. Yet human performance is influenced by elements that are both intrinsic and extrinsic to the human being. Intrinsic elements consist of cognitive, technical, and behavioral skill sets. Extrinsic elements are described by the field of ergonomics and include cognitive, physical, and organizational domains. Identifying the requisite skills, defining competent performance in each of these skills, determining appropriate forms of competency assessment for each skill, and designing easy-to-use assessment tools are the key steps to achieving objective, comprehensive, and consistent evaluation of performance. Performance assessments that fail to take into account these complexities are incomplete and simplistic at best, and at worst, inaccurate and misleading. Rigorous assessment of human performance in neonatal-perinatal medicine will greatly enhance the delivery of effective, safe, and efficient neonatal care.

How to Develop, Implement, and Assess Multi-Source Feedback (MSF) for Trainees

Abstract Introduction Multi-source feedback (MSF) imparts feedback from a multidisciplinary group of raters within the trainee's sphere of influence. Faculty involved in residency and fellowship tr...

Neonatal–perinatal medicine in a transitional period in China

With an annual birth rate of 12‰, or 16 millions, of all population (1.34 billions), and an implementation of universal healthcare policy for all rural residents in recent years, China...

The Development of Neonatology as a Paediatric Subspecialty in Singapore

Singapore ranks amongst the very few countries with the lowest neonatal and infant mortality rates in the world in the last decade. Advance in obstetric care and the development of neonatal intensive care are important contributory factors, built upon a solid foundation of socio-economic improvements and sound primary maternal and child health services. Riding on the waves of global technological advances in neonatal care, the development of neonatal-perinatal medicine in Singapore has reached a crucial stage when the challenge is to achieve further reduction of our perinatal mortality without a concomitant increase in long-term mortality of the survivors. The journey of neonatology in Singapore mirrors that in other developed countries venturing into neonatal intensive care over the past half-century. Rarely have the processes and products of scientific medicine been as heralded and harangued, as lauded and condemned, as publicised and misunderstood as they have in the context of neonatology. We have overcome major challenges and neonatology is now recognised as the first paediatric subspecialty in Singapore. Our vision is to continue to develop neonatology as a scientific art and an artistic science in medicine.

How we teach ethics and communication during a Canadian neonatal perinatal medicine residency: An interactive experience

Background: Ethically challenging clinical situations frequently confront health care professionals in neonatology. These situations require neonatologists to exercise professionalism by communicating effectively throughout evolving physician–parent relationships in order to arrive at shared decisions for care that are in the best interest of the neonate and grounded solidly in ethical precepts.Aim: This article describes the process by which a well-delineated, interactive program to teach ethical reasoning and skillful communication with parents was implemented at the University of Ottawa, Canada.Methods: A revised ethics program implemented in 2009 identified competencies that should be demonstrated at the end of the Neonatal-Perinatal Medicine (NPM) residency. Several seminars were refined while new workshops, problem-based learning in ethics, and a personal portfolio were added.Results: All teaching strategies were well received based on the average level of satisfaction (5.8 out of 7, SD 0.4). We are now moving forward by formally assessing our program including the impact on knowledge acquisition and behavior.Conclusion: A dedicated, interactive competency-based neonatal ethics teaching program is vital to support NPM trainees in learning how to integrate ethical thinking with competencies in communication.

Ethical Responsivity and Pediatric Parental Pedagogy

This article explores the experience of ethical responsivity from the perspective of the parent whose child requires medical care. The concern is with the lived meaning of ethics itself as it originates and wells up in the parent’s experience of being touched by his or her child. Examples are taken from the practice of neonatal-perinatal medicine where newborns require hospitalization for issues such as prematurity, transitional problems, congenital abnormalities, and so forth. Here, the condition of the child and the techno-medical environment itself have the potential of complicating the touching contact of parent and child.

Anemia in Infancy

1. Jennifer Cobelli Kett, MD 1. Children’s National Medical Center Washington, DC 1. Anemia and Pallor . Kolb EA, Levy AS. In: McInerny TK, Adam HM, Campbell DE, Kamat DM, Kelleher KJ, eds. American Academy of Pediatrics Textbook of Pediatric Care. Elk Grove Village, IL: American Academy of Pediatrics; 2009:1395–1405. 2. Diseases of the Blood . In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, PA: Saunders; 2004:1599–1678. 3. The Blood and Hematopoietic System . In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 8th ed. Philadelphia, PA: Mosby; 2006:1287–1356. Anemia is the reduction in red blood cell (RBC) number, hematocrit, or hemoglobin concentration to a value >2 SDs below the age-specific mean. Anemia in infancy, which may result from increased erythrocyte loss or inadequate RBC production, raises unique considerations. Understanding the development of the hematopoietic system may be helpful in the evaluation of neonates with anemia. Erythropoiesis begins in the yolk sac at 2 weeks’ gestation, generating cells that express embryonic hemoglobin. At 6 weeks’ gestation, the liver becomes the predominant site of RBC production, and the cells produced primarily express fetal hemoglobin. Not until 6 months’ gestation does the bone marrow become the major site of hematopoiesis. Throughout fetal life, erythrocytes decrease in size and increase in number: hematocrit increases from 30% to 40% during the second trimester to 50% to 63% at term. In late gestation and after birth, RBCs gradually switch from the production of fetal hemoglobin to adult hemoglobin. After birth, RBC mass normally declines in response to an increase in the availability of oxygen and downregulation of erythropoietin. RBC count decreases until oxygen delivery is inadequate for metabolic demand and erythropoietin production is stimulated again. In healthy term infants, the RBC nadir, a physiologic response to postnatal life and not a hematologic disorder, typically occurs at 8 to 12 weeks of life and at a hemoglobin level of 9 to 11 g/dL. Preterm infants also experience a decrease in hemoglobin concentration after birth, with a decline that typically is more abrupt and more profound than in term infants, reaching hemoglobin levels of …

Use of medical simulation in neonatal-perinatal fellowship training programs

Objective: Simulation-based training is being increasingly used in undergraduate and graduate medical education. There are no prior studies on the use of simulation-based training in Neonatal-Perinatal Medicine (NPM) fellowship programs in the U.S. We conducted this study to evaluate the current use of simulation-based training in these programs. Subjects and methods: An 18 question survey was sent to all NPM fellowship Program Directors in the U.S. The survey contained questions regarding the use of simulation-based training, details on how the training was accomplished and perceived barriers to its use. Results: 62% (60/97) of the programs surveyed responded. Eighty-one percent of responding programs reporting using simulation. Of those, 86% used mannequin-based high-fidelity simulation. The most common uses for simulation training included: neonatal resuscitation skills (86%), procedural skills (71%), airway management (69%), crisis resource management/team training (69%), and professionalism (47%). Most programs are still developing their curriculums and there was a wide range in the amount of time spent on simulation training. Common barriers included time and cost of equipment. Conclusions: The majority of NPM fellowship programs we surveyed used simulation as part of their training and most did so with the use of high-fidelity mannequins. The proportion of programs using simulation for crisis team management and professionalism suggest that these types of training are important components of simulation-based training in addition to the traditional use for resuscitation skills. Further research is needed to determine if simulation-based training in NPM fellowship provides important benefits over traditional teaching methods.

Individual Patient Meta-analysis in Pediatrics

In this issue of Pediatrics , Askie et al1,2 present their report of an individual patient data (IPD) meta-analysis of randomized controlled trials of inhaled nitric oxide (iNO) in preterm infants. This article is of great interest regarding what it tells us about both IPD meta-analysis and the use of iNO in preterm infants. By now, everyone in the pediatric community is familiar with the idea of systematic reviews and meta-analyses. Most meta-analysis reports that pediatricians would have read involve aggregate data analyzed at the trials level. Meta-analyses of aggregate data are typical of Cochrane reviews. Data from these types of analyses enable us to gain greater precision regarding clinically important outcomes. Aggregate-data meta-analyses at the trials level have been used in creating policies and guidelines. Systematic reviews and meta-analyses of antenatal3 and postnatal4,5 corticosteroids have greatly influenced practice in neonatal-perinatal medicine. However, there are limitations to this analytic approach. There are … Address correspondence to Roger F. Soll, MD, University of Vermont, College of Medicine, Division of Neonatal-Perinatal Medicine, Fletcher Allen Health Care, Smith 552A, 111 Colchester Ave, Burlington, VT 05401. E-mail: roger.soll{at}vtmednet.org

Maintenance of Certification: Realities for the Practitioner

During the 2011 Workshop on Perinatal Practice Strategies sponsored by the American Academy of Pediatrics Section on Perinatal Pediatrics, I reviewed the essentials of the American Board of Pediatrics (ABP) program for Maintenance of Certification (MoC). This article is a synopsis of that presentation. Although the principles of MoC are applicable across pediatric subspecialties (and many apply to General Pediatrics as well as the subspecialties), my comments in this article are directed primarily to clinicians interested in the MoC program as it applies to certificate holders in Neonatal-Perinatal Medicine (NPM).

Historical Perspectives

Twenty vibrant years, starting in 1960, marked the beginning of modern neonatology, and during those years, the participation of women in medical science increased amid a flurry of national and international social and historical events. The availability of grants allowed the exploration of the newborn infant's biology. Young women pediatricians and scientists studied brain development, and newborn intensive care started to proliferate. The virtues of early feeding were recognized. Infections were actively prevented and treated. Assisted ventilation provided life support to infants whose lungs could not remain inflated due to surface tension deficiency. Noninvasive measurement of Pao2 signaled a kinder approach to oxygenation monitoring and newborn care. Advances were made in the understanding of jaundice and the prevention of kernicterus. Sudden infant death syndrome came under question, leading to studies on the control of respiration. Many of these outstanding women were rewarded, but leadership academic positions frequently remained out of the reach of other deserving women. By the beginning of 1980, the number of women in neonatal-perinatal medicine began to climb exponentially.

Historical Perspectives

This first article in a series that tells of the difficult integration of women in neonatology over almost a century (1870 to 1945) will be followed by two other articles to cover the more recent period of exponential progress. At the end of the nineteenth century, many professions were closed to women, including medicine. The very few women who trickled through the doors of medical schools were relegated to the care of women and children. These pioneers, such as Mary Putnam Jacobi, Elizabeth Garrett, and Madeleine Brès, inspired other young women. Major societal changes for women, including the right to vote in a few countries, opened more doors to universities. Following World War I, the medical horizon widened for creative women physicians such as Ethel Collins Dunham, Virginia Apgar, Martha Eliot, and Mary Crosse, who participated in the creation of modern neonatal-perinatal medicine.

Assessment of multiple physician competencies in postgraduate training: utility of the structured oral examination

Competency based medical education involves assessing physicians-in-training in multiple roles. Training programs are challenged by the need to introduce appropriate yet feasible assessment methods. We therefore examined the utility of a structured oral examination (SOE) in the assessment of the 7 CanMEDS roles (Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional) in a Neonatal-Perinatal Medicine subspecialty training program. Between 2004 and 2008, 68 trainees participated in an annual SOE. Each SOE consisted of 4 1st year and 4 2nd year clinical scenarios with standardized questions written by neonatologists that addressed all 7 CanMEDS roles. Examiners assigned a checklist score and global rating scores for knowledge and organization. A satisfaction survey was completed at the end of 3 examinations. Across the 5 SOEs, questions related to each competency were tabulated and an overall checklist score for each competency calculated. Inter-station reliability was determined for each CanMEDS role. Values for Cronbach's alpha were 0.62 ± 0.2 (Medical Expert), 0.43 (Communicator), 0.40 ± 0.34 (Collaborator), 0.19 ± 0.17 (Manager), 0.46 ± 0.32 (Advocate), 0.67 ± 0.18 (Scholar) and 0.79 (Professional). Inter-rater reliability, determined for the first examination when there were 2 examiners per case, was moderate to substantial for 67% of cases. Participant satisfaction was high. Electronic communication facilitated exam development and costs were minimal. The SOE demonstrates psychometric properties suitable for a formative, in-training assessment as well as low cost, ease of administration and acceptability. It may be a useful way to assess physician competencies in training programs.

Something Old, Something New

In 2010, we commemorated our 10th anniversary of NeoReviews by collecting previously published Historical Perspectives into a book titled “Milestones in Neonatal-Perinatal Medicine.” The past decade was one of substantial growth for NeoReviews . At this time, I would like to acknowledge the important contribution made by one of the founding editors, Dr Bill Hay. We all owe him a debt of gratitude. He was responsible for setting the tone of the journal, maintaining that it should have a strong academic flavor and not become a chat room. Until the present time, he has continued as coeditor, but he now relinquishes this position. Joining the editorial staff as Associate Editor is Dr Joe Neu, who is currently on the Editorial Board of NeoReviews …

Pain Control in Infants and Young Children

School of Nursing, McGill University, Montreal, Quebec; Division of Neonatal-Perinatal Medicine, IWK Health Centre, Halifax, Nova Scotia Correspondence: Dr Celeste Johnston, Department of Nursing, McGill University Hospital, 3506 University Street, Montreal, Quebec H3A 2A7. Telephone 514-398-4157, fax 514-398-8455, e-mail celeste.johnston@mcgill.ca The current issue of Pain Research & Management contains an authoritative review of the efficacy of specific nonpharmacological interventions for acute procedural pain in children up to three years of age (1) (pages 321-330), which is an abridged version of a more exhaustive review (2). These publications provide strong justification for health care professionals and parents, as well as others caring for these highly dependent children, to use nonpharmacological approaches to pain control on a continuing basis. At a time when the prevalence of painful events in infants and young children remains high – and yet the rate of interventions remains low (3) – this very thorough abridged Cochrane review of specific nonpharmacological interventions is timely. Pillai Riddell et al have elected to focus on infants and young children because these populations are most vulnerable to exposure to painful procedures including the inevitable series of painful immunization injections. Excluded from this particular review are certain nonpharmacological intervention strategies, such as sweet taste and breastfeeding, because there are existing reviews covering these topics. Although there are other pending reviews on some of the topics covered, such as kangaroo care (4), at this point in time, the review is thorough. A summary statement of the results of the nonincluded interventions may have served to place those that were reviewed in context; however, these are readily available through the Cochrane Library. The search was exhaustive according to Cochrane protocol and, furthermore, strict criteria were used to include studies that were scientifically sound. An interesting differentiation made by the authors was to distinguish efficacy of the interventions for reactivity and pain regulation. The authors selected 30 s as the cut-off point between reactivity and regulation. While this cut-off point may appear arbitrary, it was likely selected based on the reports themselves because many studies would report results only within 30 s. However, it would be interesting to know whether there was a theoretical justification for that cut-off point. Conceivably, examining time to recover following the procedure would be another reflection of regulation. Reporting the time to recover is not common, but should be adopted to further assess regulation. As is common in Cochrane reviews, the authors separated the studies that compared the interventions with no treatment controls versus active treatment controls. There were surprisingly few studies with active control conditions or groups. Given what is known about the impact of pain on infants and young children (5-7), it is disappointing that studies with a no treatment control are still being conducted. This particular review clearly demonstrates that there is sufficient evidence to support specific nonpharmacological interventions, as well as the Cochrane reviews on other strategies, and that there is no longer an ethical rationale for conducting studies with no treatment control conditions (8). For practicing clinicians who must conduct procedures that will inflict pain on infants and young children, there are several safe nonpharmacological interventions that can be used either alone or in combination with topical anesthetics that have been shown to be effective for some age groups (9). This review provides a rigorous, comprehensive summary of several of the strategies including those that are effective with specific age groups. Furthermore, clinicians can now have confidence in instructing parents and other adults in these strategies. This review, along with the other reviews referred to, will provide an evidence-based compendium from which clinicians can choose appropriate, inexpensive approaches to procedural pain management. Given the breath of their review and the evidence that has been accrued in this and similar Cochrane-based reviews, there is no reason why a young child or infant needs to experience untreated procedural pain. editorial

Meta-analysis in Neonatal Perinatal Medicine

Systematic overviews provide a comprehensive and thorough review of the available data from clinical trials. When these reviews include meta-analyses, clinicians can synthesize the results of related studies and gain greater precision in their estimates of the effects of therapy. Even when inconclusive, meta-analyses allow for the exploration of differences between studies and may point toward promising areas of future research (or steer clinicians away from further nonproductive areas). In the field of neonatal-perinatal medicine, systematic overviews have provided the basis of several major changes in guidelines with measurable impact on neonatal outcome.

PP-257. Development of a bioethics curriculum in a neonatal–perinatal medicine fellowship program

PP-257. Development of a bioethics curriculum in a neonatal–perinatal medicine fellowship program

A Full-Term Infant with Rash at Birth

negative. There was no known maternal history of herpes simplex infection, candidal vaginitis, intrauterine device (IUD) usage, cervical cerclage, or amniocentesis. The mother tested positive for group B Streptococcus and received antibiotics before delivery. The mother had artifi cial rupture of membranes 2 hours before delivery, and there were no signs of chorioamnionitis. On examination, the infant was vigorous, afebrile, with only mild grunting, although gas exchange was good. On his skin were diffusely distributed, erythematous Adrian Florens, MD; Medha Kamat, MD; Tessy Joseph, MD; and Suma Pyati, MD, are with the Division of NeonatalPerinatal Medicine, John H. Stroger Hospital of Cook County, Chicago. Warren Piette, MD, and Giacomo Maggiolino, MD, are with the Division of Dermatology, John H. Stroger Hospital of Cook County. Dr. Florens; Dr. Kamat; Dr. Joseph; Dr. Piette; Dr. Maggiolino; and Dr. Pyati have disclosed no relevant fi nancial relationships. The authors would like to thank Cory Olans for his collaboration with the picture material. doi: 10.3928/00904481-20100825-05 Figure 1. Erythematous papules coalescing into plaques with overlying pinpoint vesiculopustules in face, neck, and trunk. These lesions were apparent at birth.

Trainees' Perspectives On An in ternational Training Program in Neonatal-Perinatal Medicine in Shanghai

Trainees' Perspectives On An in ternational Training Program in Neonatal-Perinatal Medicine in Shanghai

Probiotics: Are We Ready for Routine Use?

Necrotizing enterocolitis (NEC) is a significant cause of morbidity and mortality among premature infants and affects 7% of very low birth weight infants.1 The cause of NEC is unclear, and its etiology is multifactorial; NEC seems to be the “single final pathway” created by a variety of injuries, including mucosal damage from gastrointestinal ischemia or hypoxia, increased osmolarity from enteral feedings, and the presence of potentially invasive pathogenic bacteria. Few treatments are available that have been proven to either prevent or ameliorate NEC. Feeding fresh human breast milk seems to be one of the more effective approaches to preventing NEC.2,3 The use of enteral antibiotics and other feeding practices may or may not affect NEC.4 Probiotics may be one of the most effective therapies for the prevention of NEC. At birth, an infant's gastrointestinal tract is sterile. Colonization of the gastrointestinal tract starts immediately after birth with the initiation of enteral feedings and is well established within the first few days of life.5 In breastfed infants, Bifidobacterium and lactobacillus predominate, with other enteric organisms being present less frequently.6,–,10 This is not the case for formula-fed infants. In these infants, coliforms, enterococci, and Bacteroides predominately colonize the intestinal tract. Preterm … Address correspondence to Roger F. Soll, MD, Division of Neonatal-Perinatal Medicine, University of Vermont, College of Medicine, Fletcher Allen Health Care, Smith 552A, 111 Colchester Ave, Burlington, VT 05401. E-mail: roger.soll{at}vtmednet.org