Estimation of bilirubin using BiliChek?, a transcutaneous bilirubin measurement device: Effects of gestational age and use of phototherapy

BACKGROUND

Heel puncture to obtain bilirubin measurements is painful for infants and distressing for parents. Transcutaneous bilirubin measurement using BiliChek (Respironics, USA) is easily performed in any setting. Reliable transcutaneous testing should decrease the number of painful procedures in otherwise well infants, reduce the volume of phlebotomy losses in ill newborns, and reduce the need for hospital or specialized clinic visits after discharge.

OBJECTIVE

To correlate bilirubin measurements using the transcutaneous device BiliChek with ‘gold standard’ serum measurements in well term infants, and in ill term and preterm infants admitted to the authors’ neonatal intensive care unit.

METHODS

The study consisted of two phases. In phase 1, informed consent was obtained from mothers of 99 healthy, full-term infants not receiving phototherapy to perform both serum and transcutaneous bilirubin measurements at the time of heel puncture for routine neonatal screening. In phase 2, 56 infants in the neonatal intensive care unit had a total of 99 transcutaneous readings performed at the time serum bilirubin measurements were ordered for clinical reasons by the attending staff. The operators of the transcutaneous device, who were unaware of the serum bilirubin levels, performed readings within 1 h of the heel puncture.

RESULTS

Using a Bland-Altman comparison in the well term infants, the transcutaneous measurements were −32.2 μmol/L to +31.2 μmol/L (1.96 SD); however, 79 (79.8%) of the transcutaneous measurements were within 15 μmol/L of the serum measurements. The variation in preterm infants was greater at −69.6 μmol/L to +62.0 μmol/L, and only 49 (49.5%) were within 15 μmol/L. For infants receiving phototherapy, the variation was −76.3 μmol/L to +49.5 μmol/L, but improved to −40.4 μmol/L to +31.0 μmol/L if an area of skin was patched for testing, approximating the group not receiving phototherapy.

CONCLUSIONS

Transcutaneous bilirubin measurements obtained with the BiliChek instrument were accurate for measuring bilirubin levels in term jaundiced infants not receiving phototherapy and in those receiving phototherapy if an area of skin was patched. The instrument was not as sensitive in the small sample of preterm infants, and a larger study is required before recommending the use of this instrument in this population.     

Does primary surgical closure of the patent ductus arteriosus in infants <1500 g or ≤32 weeks’ gestation reduce the incidence of necrotizing enterocolitis?

BACKGROUND:

The hemodynamic perturbation related to patent ductus arteriosus (PDA) is associated with a higher risk of necrotizing enterocolitis (NEC).

OBJECTIVE:

To determine whether primary surgical closure, as compared with treatment with indomethacin or exposure to prophylactic indomethacin, reduces the incidence of NEC in preterm infants <1500 g and/or ≤32 weeks’ gestation with clinically and echocardiogram-identified PDA.

METHODS:

The literature was reviewed using the methodology for systematic reviews for the Consensus of Science adapted from the American Heart Association’s International Liaison Committee on Resuscitation.

RESULTS:

Ten studies were reviewed. The incidence of NEC was not lower in infants who underwent primary surgery for closure of the PDA compared with infants treated with indomethacin or infants exposed to prophylactic indomethacin (level of evidence 2).

CONCLUSION:

Primary surgical closure of the PDA cannot be recommended as an intervention to decrease the incidence of NEC in infants <1500 g and/or ≤32 weeks’ gestation.     

Transcutaneous bilirubin measurement at the time of hospital discharge in a multiethnic newborn population

BACKGROUND:

Severe neonatal hyperbilirubinemia continues to occur in healthy newborns. Recent guidelines have supported using transcutaneous devices in estimating bilirubin levels. Previous studies using these devices are limited.

METHODS:

Newborns requiring serum bilirubin level measurements before hospital discharge were recruited prospectively. The agreement between a transcutaneous bilirubin (TCB) and total serum bilirubin (TSB) level was assessed. Sensitivity analysis was conducted.

RESULTS:

A total of 430 infants were enrolled. Correlation between the values was high (Pearson’s correlation coefficient 0.83; Lin’s concordance coefficient 0.81 [95% CI 0.77 to 0.84]; P<0.001). The mean (± SD) TSB level was 194±60 μmol/L. The TCB measurement tended to overestimate the value (mean difference 12.7), with wide 95% limits of agreement (−52 μmol/L to 77 μmol/L). Sensitivity and specificity analysis of TCB values allowed estimation of clinically important TSB levels.

CONCLUSIONS:

The TCB correlated, but was imprecise in predicting TSB. TCB values can be used at the time of discharge to safely plan care for jaundiced infants if the limits of agreement are considered and clinical judgment is maintained.     

Does the use of primary continuous positive airway pressure reduce the need for intubation and mechanical ventilation in infants ≤32 weeks’ gestation?

BACKGROUND:

Ventilator-induced lung injury is a recognized risk factor for bronchopulmonary dysplasia.

OBJECTIVE:

To determine whether primary continuous positive airway pressure (CPAP), defined as CPAP without previous endotracheal intubation for any indication, can reduce the need for intubation and mechanical ventilation in infants born at ≤32 weeks’ gestational age.

METHODS:

The literature was reviewed using the methodology for systematic reviews for the Consensus on Resuscitation Science adapted from the American Heart Association’s International Liaison Committee on Resuscitation.

RESULTS:

Fourteen studies were reviewed. Eleven studies provided varying degrees of supportive evidence (level of evidence 3 to 4) that the use of primary CPAP can reduce the need for intubation and mechanical ventilation.

CONCLUSION:

The use of CPAP as a primary intervention and mode of respiratory support is an option for infants ≤32 weeks’ gestation, but avoidance of intubation and mechanical ventilation is more likely in mature infants >27 weeks’ gestation.     

Influenza vaccination options to prevent hospitalization

BACKGROUND:

Vaccination of children against influenza remains a controversial topic despite the substantial morbidity caused by this infection.

OBJECTIVE:

To estimate the effect of three different vaccination strategies on preventing hospitalization due to influenza.

METHODS:

A retrospective chart review was conducted of all children admitted to a tertiary health care centre who tested positive for influenza during three consecutive influenza seasons.

RESULTS:

The final analysis included 208 cases with an age range of five days to 16.1 years. Seventy-six children were considered ‘high-risk’ and 132 were considered ‘previously healthy’. Length of stay (LOS) ranged from one day to 46 days with a mean of 6.3 days. The mean LOS was 8.6 days for children with risk factors and 4.9 days for those without risk factors. The number of preventable influenza admissions was determined over three years and averaged over one year for the three vaccination strategies. A universal strategy of vaccinating all previously healthy and high-risk children over six months of age would have prevented 118 admissions. Using a selective strategy of vaccinating only children over six months of age with risk factors and a third strategy of vaccinating only two- to six-month-old infants would have prevented 58 and 55 admissions, respectively.

CLINICAL IMPLICATION:

Use of the universal vaccination strategy would have prevented over one-half of the influenza admissions, which was over twice that of targeted vaccination. Until the challenges of implementing universal vaccination are fully understood, targeted vaccination remains an acceptable alternative.     

Heparin is not required for peripheral intravenous locks in neonates

OBJECTIVE:

To determine the relative efficacy and safety of peripheral intravenous locks maintained with heparin saline solutions compared with those maintained with normal saline.

DESIGN:

Randomized, controlled trial comparing the two methods of maintaining peripheral intravenous locks.

SETTING:

Infants in the neonatal intensive care unit (NICU) at Foothills Hospital, Calgary, Alberta.

PATIENTS:

Neonates requiring the maintenance of intravenous locks for medications, primarily antibiotics, were randomly placed in either a heparin saline (n=93) or normal saline (n=93) group.

INTERVENTIONS:

Patients were chosen to receive either heparinized saline (5 units/mL) or normal saline, 0.3 mL in the intravenous catheter every 6 h, administered by nursing staff in a blinded manner.

RESULTS:

There was no difference in catheter lifespan (39±24 h for the heparinized saline group; 34±22 h for the normal saline group) and no difference in the number of intravenous catheters per patient (1.9 heparinized group, 1.6 normal saline group). There were no differences in the reasons for catheter removal, complications at the skin site or systemic bleeding including intracranial hemorrhage between the two groups. The risk of catheter occlusion was inversely correlated with gestational age and the administration of vancomycin and cefotaxime versus ampicillin and gentamicin.

CONCLUSIONS:

Heparin is not required for the maintenance of peripheral intravenous locks in neonates regardless of the solution used. Catheter occlusion is more likely to be associated with a low gestational age and the administration of vancomycin and cefotaxime versus ampicillin and gentamicin.     

Effects of exclusive formula or breast milk feeding on oxidative stress in healthy preterm infants

Background

Compared to formula, breast milk is considered to have superior antioxidant properties and consequently may reduce the occurrence of a number of diseases of prematurity associated with oxidative stress.

Aims

To test whether the antioxidant properties of breast milk in healthy premature infants are different to those of formula milk by comparing vitamin E levels in milk and determining the excretion of malondialdehyde (MDA) in urine.

Methods

Vitamin E was measured in the breast milk of 20 mothers who had given birth prematurely. Urinary MDA was measured in 10 exclusively breast milk fed and 10 exclusively formula fed healthy preterm infants receiving no vitamin supplements. MDA was measured after derivatisation with 2,4‐dinitrophenylhydrazine and consecutive HPLC with UV detection.

Results

Urinary MDA concentrations were consistently very low (0.074±0.033 μM/mM Cr and 0.078±0.026 μM/mM Cr in breast and formula fed infants respectively) and not significantly different between healthy breast milk and formula fed infants. Both breast and formula milk contained satisfactory levels (0.3–3.0 mg/100 ml) of vitamin E.

Conclusion

Antioxidant properties of both breast milk and formulae are sufficient to prevent significant lipid peroxidation in healthy premature infants.     

Does the use of glycerin laxatives decrease feeding intolerance in preterm infants?

BACKGROUND:

Glycerin laxatives are often prescribed in the neonatal population for meconium evacuation and to promote enteral feeding. However, the literature regarding their effectiveness has not been systematically reviewed.

OBJECTIVE:

To assess the effectiveness of glycerin enema or suppository in preventing feeding intolerance in preterm infants at ≤32 weeks’ gestational age or weighing ≤1500 g at birth.

METHODS:

The Medline, Embase, Cochrane Library, Scopus and Web of Science databases were searched to identify studies that evaluated glycerin enemas/suppositories for feeding intolerance. Using the Evidence Evaluation Worksheet adapted from the American Heart Association’s International Liaison Committee on Resuscitation, eligible studies were scored for quality, level of evidence and direction of support.

RESULTS:

Two clinical studies that evaluated meconium evacuation and feeding intolerance were included. One study showed no difference in the time to complete meconium evacuation or establishment of full enteral feeds, while the other showed that the times to first meconium passage and full enteral feeding were significantly shorter, and the rate of sepsis was lower in the glycerin enema group.

CONCLUSION:

The evidence regarding the effectiveness of glycerin laxatives for improving feeding tolerance is inconclusive in infants at ≤32 weeks’ gestational age or weighing ≤1500 g at birth.     

Hypoglycemia in term newborns with a birth weight below the 10th percentile

BACKGROUND:

Current recommendations suggest that routine screening for hypoglycemia should be performed in all term newborns with a birth weight (BW) below the 10th percentile. The impact of updated growth curves on the incidence of hypoglycemia in small-for-gestational-age (SGA) newborns has not been evaluated.

OBJECTIVES:

To evaluate the occurrence and severity of hypoglycemia in term newborns with a BW between the 10th and fifth percentile, and below the fifth percentile, using recently updated growth curves.

DESIGN:

A one-year prospective cohort study.

METHODS:

Inclusion criteria were gestational age of 37 weeks or greater and BW below the 10th percentile. Neonatal hypoglycemia was defined as a blood glucose level of less than 2.6 mmol/L measured after 2 h of life. Blood glucose was measured routinely for all SGA infants during the first 36 h of life.

RESULTS:

A total of 187 SGA infants met the study criteria: 85 infants with a BW between the 10th and fifth percentile, and 102 infants with a BW below the fifth percentile. The characteristics of the study cohort were similar between BW groups. Twenty-six per cent of the infants screened had at least one episode of hypoglycemia: 22% of infants in the 10th to fifth percentile group and 28% in the less than fifth percentile group. Hypoglycemia was symptomatic in four infants, all of whom were below the fifth percentile for BW. The mean (± SD) lowest blood glucose level was 2.1±0.4 mmol/L (range 0.6 mmol/L to 2.5 mmol/L) in the 10th to fifth percentile group and 2.0±0.5 mmol/L (range 0.8 mmol/L to 2.5 mmol/L) in the less than fifth percentile group (P=0.05).

CONCLUSION:

The present study demonstrates a high incidence of hypoglycemia among SGA infants with a BW below the 10th percentile using updated growth curves. There was no difference in the incidence of hypoglycemia among SGA infants with a BW below the fifth percentile versus those with a BW between the 10th and fifth percentile.     

Mothers' postpartum psychological adjustment and infantile colic

Background

Infantile colic is a common problem of early infancy. There is limited data on the relation between postpartum maternal psychological problems and colic.

Aim:

To investigate whether infantile colic is associated with postpartum mood disorders or insecure adult attachment style of the mother.

Methods

Seventy eight mothers and newborns were enrolled in this prospective, longitudinal study. Maternal depressive symptoms were screened with Edinburgh Postpartum Depression Score (EPDS) and maternal anxiety was assessed with State‐Trait Anxiety Inventory (STAI). The Adult Attachment Scale was used to determine the attachment style of the mother. Infantile colic was defined according to Wessel criteria.

Results

Infantile colic was present in 17 infants (21.7%); 12.9% of the mothers had an EPDS ⩾13. The mean EPDS of the mothers whose infants had infantile colic (10.2±6.0) was significantly higher than that of the mothers of infants without colic (6.3±4.0). Among infants with infantile colic, 62.5% had mothers who had insecure attachment style, whereas only 31.1% of mothers had insecure attachment when the infant did not have infantile colic.

Conclusion

Postpartum maternal depressive symptoms and insecure attachment style are associated with infantile colic. Screening and early intervention of postpartum depression might promote the health of both the mother and infant.     

Outcome of Very Low Birth Weight Infants Over 3 Years Report From an Iranian Center

Objective

Very low birth weight (VLBW) infants are at high risk for morbidity and mortality. This article determines the frequency of disease, rate od survival, complications and risk factors for morbidity and mortality in VLBW neonates admitted to a level III neonatal intensive care unit (NICU) at Mahdieh Hospital in Tehran.

Methods

This cross-sectional retrospective study was performed from April 2007 to March 2010 on all hospitalized VLBW neonates. Relevant pre- and peri-natal data up to the time of discharge from the hospital or death, including complications during the course of hospitalization, were collected from the case notes, documented on a pre-designed questionnaire and analyzed.

Findings

Out of 13197 neonates, 564 (4.3%) were VLBW with 51.4% males. Mean gestational age was 29.6±2.5 weeks; mean birth weight 1179±257 grams. Mean birth weight, gestational age and Apgar scores were significantly higher in babies who survived than in those who died, (1275±189 vs. 944±253 grams; 30.5±2.2 vs. 27.5±2 weeks and 6.9±1.7 vs. 5±2.1 respectively, P<0.001 in all instances). Overall survival was 70.9%; in extremely low birth weight (ELBW) newborns this figure was 33.3% rising to 84.1% in infants weighing between 1001-1500 grams. Respiratory failure resulting from RDS in ELBW babies was the major factor leading to death. Need for mechanical ventilation, pulmonary hemorrhage and gastro-intestinal bleeding were also significant predictive factors for mortality.

Conclusion

Birth weight and mechanical ventilation are the major factors predicting VLBW survival.     

The Montreal Children's Hospital Feeding Scale: A brief bilingual screening tool for identifying feeding problems

OBJECTIVE:

To establish the psychometric characteristics of a newly developed, brief bilingual 14-item parent report tool (The Montreal Children’s Hospital Feeding Scale [MCH-Feeding Scale]) designed to identify feeding problems in children six months to six years of age.

METHODS:

To establish construct validity, 198 mothers of children visiting community paediatrician’s offices (normative sample) and 174 mothers of children referred to a feeding clinic (clinical sample) completed the scale. Test-retest reliability was obtained by the re-administration of the MCH-Feeding Scale to 25 children in each sample.

RESULTS:

Excellent construct validity was confirmed when the mean [± SD] scores of the normative and clinical samples were compared (32.65±12.73 versus 60.48±13.04, respectively; P<0.01). Test-retest reliabilities were high for both groups (normative r=0.845, clinical r=0.92).

CONCLUSION:

The MCH-Feeding Scale can be used by paediatricians and other health care professionals for quick identification of feeding problems.     

The Effects of Non-Nutritive Sucking and Pre-Feeding Oral Stimulation on Time to Achieve Independent Oral Feeding for Preterm Infants

Background:

The survival rates of preterm infants has increased over the last years, but oral feeding difficulties are the most common problems encountered by them

Objectives:

This study aimed at comparing the effects of non-nutritive sucking (NNS) and pre-feeding oral stimulation on feeding skills, length of hospital stay and weight gain of 26-32 weeks gestational age preterm infants in NICU, to determine the more effective intervention.

Patients and Methods:

Thirty-two preterm infants were assigned randomly into three groups. One intervention group received pre-feeding oral stimulation program and the other received non-nutritive sucking stimulation, while the control group received a sham intervention. Gestational age of infants was calculated during 1, 4 and 8 oral feeding and discharge time from NICU. The infants’ weights were measured weekly from birth and at discharge time.

Results:

Mean gestational age on 8 time oral feeding per day, in 3 groups was not significant (P = 0.282). Although NNS and pre-feeding oral stimulation groups has fulfilled this criterion 7.55 and 6.07 days sooner than the control group, respectively (a result which is of great clinical and economic importance), but the difference did not reach statistical significance. Weight gaining at discharge time in NNS group was significantly higher than control and pre-feeding oral stimulation groups (P < 0.05).

Conclusions:

This study revealed that pre-feeding oral stimulation and NNS programs both were effective on oral feeding skills and weight gaining of the immature newborns. Yet, it seems that NNS program was more effective than pre-feeding oral stimulation on weight gaining.     

Perinatal brachial plexus palsy

BACKGROUND

Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births.

OBJECTIVES

To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions.

METHODS

A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included ‘brachial plexus’, ‘brachial plexus neuropathy’, ‘brachial plexus injury’, ‘birth injury’ and ‘paralysis, obstetric’.

RESULTS

There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments.

CONCLUSIONS

It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.     

Life and death decisions in the extremely preterm infant: What happens in a level III perinatal centre?

OBJECTIVE:

To describe resuscitation decisions and withdrawal of treatment practices in live-born infants at the extremes of prematurity at St Joseph’s Health Care (London, Ontario).

STUDY DESIGN:

A retrospective chart review was conducted on all neonatal deaths between 22 weeks, zero days’ and 25 weeks, six days’ gestational age over an eight-year period. Documentation concerning end-of-life discussions was subjected to thematic review to limit or withhold resuscitation or withdraw treatment.

RESULTS:

Three hundred eighteen infants were delivered between 22 weeks, zero days’ and 25 weeks, six days’ gestational age. Of these, 21% of infants (67 of 318) were stillborn, 38% (121 of 318) were alive on discharge from hospital and 41% (130 of 318) died in the neonatal period. Of the live-born infants who did not survive to discharge, 34% (44 of 130) had no initial attempts at resuscitation. Withdrawal of life-sustaining treatment was the immediate cause of death in 84% of cases (61 of 73) in which the infant survived initial resuscitation. Documented parental rationale for withdrawal of treatment included “preventing pain and suffering”, “not wanting (their baby) to die on a ventilator” and “poor quality of life”. Families in which the mother identified as Catholic were more likely to withhold resuscitation and to withdraw life-sustaining treatment because death was imminent despite ongoing treatment. Non-Catholic families were more likely to withdraw life-sustaining treatment based on prediction of a poor long-term prognosis.

CONCLUSIONS:

Decisions not to initiate resuscitation remain fairly common practice at the extremes of prematurity. The majority of deaths in those who survive initial resuscitative measures are secondary to withdrawal of treatment decisions made in the neonatal intensive care unit.     

Severe injury mechanisms in two paediatric trauma centres: Determination of prevention priorities

BACKGROUND

To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.

METHODS

The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.

RESULTS

A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.

CONCLUSION

The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.     

Health care professionals' grief after the death of a child

OBJECTIVES:

To evaluate the intensity of grief experienced by health care professionals (HPs) after the death of a child, to explore factors associated with a memorable death (defined as an unforgettable child’s death that has touched them in their career) and to identify the needs of HPs.

METHODS:

A cross-sectional study was performed to assess emotional reactions, coping strategies and perceived needs of paediatric HPs in a general hospital.

RESULTS:

One hundred one HPs (46 nurses, 22 paediatric physicians, 11 paediatric residents, 13 respiratory therapists and nine ‘others’) completed the questionnaire. The level of grief experienced by HPs after a memorable death was intense. Respiratory therapists showed the highest mean (± SD) intensity of grief after a memorable death versus other HPs, as measured by the Texas Revised Inventory of Grief (TRIG) (29±15 versus 16±14; P=0.002). Younger HPs (20 to 25 years of age) reported higher early grief intensity than older ones (older than 50 years of age) (22±16 versus 10±8; P=0.01). There was no significant association between the TRIG score and an HP being a parent, having received palliative care training or the length of his/her relationship with the child and family. Seventy per cent of HPs spoke with their colleagues after the death of a child and 48% with family and friends. Many participants (37%) believed that this social support helped them the most.

CONCLUSION:

Grief after a child’s death is intense for HPs. This emotional intensity and difference between professions raises issues about the emotional support received following the death of a patient.     

A randomized trial of aggressive versus conservative phototherapy for hyperbilirubinemia in infants weighing less than 1500 g: Short- and long-term outcomes

OBJECTIVE

Treatment regimens for hyperbilirubinemia vary for very low birth weight infants. The present study seeks to determine whether the initiation of conservative phototherapy is as effective as aggressive phototherapy in reducing peak bilirubin levels without increasing adverse effects.

STUDY DESIGN

The present randomized, controlled study included infants with birth weights between 500 g and 1500 g, stratified into two birth weight groups. In one group, aggressive phototherapy was commenced by 12 h of age, while in the other group, conservative phototherapy was commenced if serum bilirubin levels exceeded 150 μmol/L. The primary outcome variables were peak serum bilirubin levels and hours of phototherapy. Secondary outcomes were age at peak bilirubin levels, number of infants with rebound hyperbilirubinemia, and number of adverse short- and long-term outcomes.

RESULTS

Of 174 eligible infants, 95 consented to participate −49 in the conservative arm and 46 in the aggressive arm. Ninety-two infants completed the study. There was no significant difference in peak bilirubin levels except in infants who weighed less than 1000 g −171.2±26 μmol/L (conservative) versus 139.2±46 μmol/L (aggressive); P<0.02. There was no difference in duration of phototherapy or rebound hyperbilirubinemia. There were no differences in short-term adverse outcomes. Of the 87 infants who survived until hospital discharge, 82 (94%) had some follow-up and 75 (86%) attended follow-up until 18 months corrected age. The incidence of cerebral palsy, abnormal mental developmental index at 18 months corrected age, or combined outcome of cerebral palsy and death did not significantly differ between the two groups.

CONCLUSIONS

In infants weighing less than 1000 g, peak bilirubin levels were significantly higher using conservative phototherapy regimens and there was a tendency for poor neurodevelopmental outcome.     

Reference chart for relative weight change to detect hypernatraemic dehydration

Objective

The validity of the rule of thumb that infants may have a weight loss of 10% in the first days after birth is unknown. We assessed the validity of this and other rules to detect breast‐fed infants with hypernatraemic dehydration.

Design

A reference chart for relative weight change was constructed by the LMS method. The reference group was obtained by a retrospective cohort study.

Participants

1544 healthy, exclusively breast‐fed infants with 3075 weight measurements born in the Netherlands and 83 cases of breast‐fed infants with hypernatraemic dehydration obtained from literature.

Results

The rule of thumb had a sensitivity of 90.4%, a specificity of 98.3% and a positive predictive value of 3.7%. Referring infants if their weight change is below −2.5 SDS (0.6th centile) in the reference chart in the first week of life and using the rule of thumb in the second week had a sensitivity of 85.5%, a specificity of 99.4% and a positive predictive value of 9.2%.

Conclusions

The rule of thumb is likely to produce too many false positive results, assuming that for screening purposes the specificity needs to be high. A chart for relative weight change can be helpful to detect infants with hypernatraemic dehydration.     

Paediatric primary care quality and accessibility: Parents�� perspective

OBJECTIVE

To measure parents’ satisfaction with paediatric primary care quality and accessibility.

BACKGROUND

High-quality paediatric primary care is a cornerstone of efforts to improve health outcomes and access to care, as well as to control health care spending. A strong primary care infrastructure is related to improved health outcomes, including an improved mortality rate.

METHODS

A cross-sectional survey using the Parents’ Perception of Primary Care questionnaire and evidence-based items from the Rourke Baby Record were used to measure parents’ satisfaction.

RESULTS

Of 200 questionnaires sent, 130 were returned. The mean number of children per family was 1.7±0.8 (mean ± SD). Sixty-six per cent of children received their primary care from general practitioners, 19% received their primary care from paediatricians, and 15% had no regular physician and identified other professionals (community nurses, midwives or chiropractors) as their primary care providers. Parents were questioned about their child’s hearing in 66% of cases. Only 41% of parents received guidance about breastfeeding, 37% about adequate sleeping position, 17% about the dangers of second-hand smoke and 16% about car safety seats. The level of satisfaction with communication, contextual knowledge and coordination of care was higher for families followed by general practitioners and paediatricians than for families followed by nonphysicians. According to the Parents’ Perception of Primary Care scores, the overall satisfaction with primary care was higher for care given by general practitioners and paediatricians than for care given by midwives or chiropractors, and intermediate when given by nurses.

CONCLUSION

In this survey, the majority of children received their primary care from physicians, most commonly general practitioners. Parents’ overall satisfaction regarding their infant’s primary health care was higher when it was delivered by physicians than by alternative health care providers. Evidence-based guidance recommendations were rarely followed.