Biomedical subjects

M W Davies

Publications and source records attributed to M W Davies.

At least 19 recordsLinked to original sources

PubMed2006

Disposable nappies for preventing napkin dermatitis in infants.

BACKGROUND: Napkin dermatitis is a common condition that occurs in otherwise healthy infants. It causes discomfort to infants, anxiety to parents and caregivers and contributes to the load on the health care system. A large variety of napkins, both disposable and non-disposable, are available. Evidence is required to assist carers and health care workers in making informed decisions when balancing the pros and cons of different napkin choices. OBJECTIVES: To assess whether disposable napkins prevent napkin dermatitis in infants. SEARCH STRATEGY: We searched the Skin Group Specialised Register (up to June 2003), the Cochrane Central Register of Controlled Trials in (The Cochrane Library, Issue 3, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to February 2003) and CINAHL (from 1982 to November 2004). We searched reference lists of articles. We contacted lead investigators in the area and companies that manufacture disposable napkins for access to unpublished trials. SELECTION CRITERIA: Randomised controlled trials in which disposable napkins were compared with other types of disposable napkins or non-disposable napkins, in infants up to two years of age, for preventing napkin dermatitis. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. The same two authors independently assessed trials for methodological quality. Attempts were made to contact trial authors of the trials identified for clarification of methods and results of published trials. MAIN RESULTS: We identified 28 studies of the effects of various napkin types on napkin dermatitis. Seventeen studies from nine reports were included. Eleven studies were excluded due to methodology that did not fit the inclusion criteria of this review. Due to the poor reporting of methodology and results of the studies found in this review, there were no quantitative data available for analysis (or meta-analysis). Although the included studies appeared to favour cellulose-core disposable napkins over cloth, absorbent gelling material over cellulose-only core napkins, breathable outer shell over occlusive outer shell napkins and linings impregnated with formulations over plain linings, all of these studies were open to bias due to flawed methodology. AUTHORS' CONCLUSIONS: There is not enough evidence from good quality randomised controlled trials to support or refute the use and type of disposable napkins for the prevention of napkin dermatitis in infants.

Diaper Rash↗

PubMed2005

Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants.

BACKGROUND: Napkin dermatitis (nappy or diaper rash) is a non-specific term used to describe inflammatory eruptions (rashes) in the napkin area. Most infants develop napkin dermatitis at least once during their infancy. Topical vitamin A has been suggested as a treatment for napkin dermatitis. OBJECTIVES: To determine if treatment with topical vitamin A is successful in either preventing napkin dermatitis, or producing resolution or decreasing the severity of napkin dermatitis. SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register (May 2005); Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005); Ovid MEDLINE from 1966 to August 2005; EMBASE (2003 to May 2005); Ovid OLDMEDLINE (1950 to 1965); and CINAHL (1982 to August 2005). We also searched reference lists of articles. SELECTION CRITERIA: Randomised controlled trials, where the topical application of medication containing vitamin A (or its derivatives) was compared with either placebo, no treatment or other topical medication, for the prevention or treatment of napkin dermatitis in infants aged from zero to two years. DATA COLLECTION AND ANALYSIS: Two authors (AJD and MWD) identified and checked titles and abstracts obtained from the searches, and reviewed the full text where necessary. They decided which trials met the inclusion criteria, and recorded their methodological quality. They assessed studies as either adequate, unclear or inadequate using the following key criteria: (a) randomisation (method of generation and concealment of allocation); (b) blinding; (c) loss to follow-up. MAIN RESULTS: We did not find any studies for the treatment of napkin dermatitis. We found only one study comparing the use of topical application of medication containing vitamin A, with another topical medication or placebo, to prevent napkin dermatitis. This included study, of 114 newborn infants, reported no significant differences between groups with regard to the severity or duration of napkin dermatitis. AUTHORS' CONCLUSIONS: For the treatment of napkin dermatitis there is no evidence to support or refute the use of topical vitamin A preparations. For the prevention of napkin dermatitis there is no evidence to suggest that topical vitamin A alters the development of napkin dermatitis. Further RCTs are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.

Administration, Topical↗

PubMed2005

Continuous infusion versus intermittent flushing to prevent loss of function of peripheral intravenous catheters used for drug administration in newborn infants.

BACKGROUND: The use of peripheral intravenous cannulae is common in newborn babies. Many of them require an intravenous line only for medications and not for fluid. Currently there is little uniformity in methods used to maintain cannula patency. OBJECTIVES: The object of this review was to determine which method was better for maintaining intravenous lines used in neonates for intravenous medication only: intermittent flushing or continuous infusion SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), CINAHL (from 1982 to June 2004) and MEDLINE (from 1966 to June 2004) . SELECTION CRITERIA: Randomised controlled trials comparing continuous infusion to intermittent flushing to maintain patency of intravenous cannulas. Units of randomisation might include individual catheters or individual babies. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Two studies were eligible for inclusion. In one study only one of our primary outcomes was available: the duration of cannula patency for the first cannula used per infant was slightly longer in the continuous infusion group, but not significantly so, with a mean difference of -4.3 hours (95% CI -18.2 to 9.7). In the second study, only one of our primary outcomes was available: the mean (SD) number cannulas used per infant in the first 48 hours was less in the intermittent flush group with a mean difference of -0.76 cannulas (95% CI -1.37 to -0.15). No results were available for any of our other primary outcomes: in the published report, results were reported per catheter rather than per infant, a number of infants received more than one intravenous catheter (39 infants received an unknown number of catheters). The overall duration of cannula patency was significantly longer in the intermittent flush group with a mean duration of patency in the intermittent flush group of 2.1 days (SD 1.0) compared with the continuous infusion group where the mean duration of patency was 1.0 days (SD 0.5) - Student's t test P value 0.0003. AUTHORS' CONCLUSIONS: It is difficult to draw reliable conclusions given the way the data were analysed and reported in the two included studies. The reliability of the results is uncertain. However, given the caution in interpreting these data, it should also be noted that the use of intermittent flushes was not associated in either study with a decreased cannula life or any other disadvantages, thus lending some support for the use of intermittent flushing of cannulas in a selected population in neonatal nurseries.

Catheterization, Peripheral↗

PubMed2005

Prophylactic antibiotics to reduce morbidity and mortality in neonates with umbilical venous catheters.

BACKGROUND: Umbilical venous catheters are often used in unwell neonates. Infection related to the use of these catheters may cause significant morbidity and mortality. The use of prophylactic antibiotics has been advocated for newborns with umbilical venous catheters in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm may outweigh benefit. Prophylactic antibiotics may be effective in preventing catheter-related blood stream infection, but may have the undesirable effect of promoting the emergence of resistant strains of micro-organisms. A policy of prophylactic antibiotic use should take into account this possibility, and has been used as a basis for arguing against its implementation. OBJECTIVES: The primary objective was to assess whether prophylactic antibiotics, in neonates with umbilical venous catheters, reduce mortality and morbidity. In separate comparisons, we planned to review two different policies regarding the prophylactic use of antibiotics in neonates with umbilical venous catheters: 1) Among neonates with umbilical venous catheters, a policy of prophylactic antibiotics for the duration of catheterisation (or other fixed duration of antibiotic treatment) versus placebo or no treatment; 2) Among neonates with umbilical venous catheters who had been started on antibiotics at the time of catheterisation, but whose initial cultures to rule out sepsis are negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: We searched MEDLINE (January 1966 to April 2005), CINAHL (1982 to April 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005). SELECTION CRITERIA: Randomised controlled trials or quasi-randomised trials in which newborn infants with umbilical venous catheters are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: One study, of poor quality, met the criteria for inclusion in this review. Twenty-nine term infants, who had umbilical venous catheters inserted specifically for transfusion procedures for hyperbilirubinaemia or polycythaemia, allocated non-randomly (quasi-randomised - alternate allocation) to treatment (n = 15) or control (n = 14) groups. Those in the treatment group received penicillin and gentamicin for three days. 5/15 infants given antibiotics and 5/14 control infants having positive blood cultures three days after catheter insertion. All positive blood cultures were considered contaminated, due to lack of corroborating clinical and haematological evidence of infection. Therefore, no infants were identified with evidence of septicaemia. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to support or refute the use of prophylactic antibiotics when umbilical venous catheters are inserted in newborn infants. There is no evidence to support or refute continuing antibiotics once initial cultures rule out infection in newborn infants with umbilical venous catheters.

Anti-Bacterial Agents↗

PubMed2004

Partial liquid ventilation for preventing death and morbidity in adults with acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Acute lung injury (ALI), and acute respiratory distress syndrome (ARDS), are syndromes of severe respiratory failure. Adults with ALI or ARDS have high mortality and significant morbidity. Partial liquid ventilation (PLV) may be better (i.e., cause less lung damage) for these patients than other forms of respiratory support. Uncontrolled studies in adults have shown improvement in gas exchange and lung compliance with partial liquid ventilation. OBJECTIVES: To assess whether partial liquid ventilation reduces morbidity and mortality in adults with ALI or ARDS. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Issue 2, 2004; MEDLINE (1966 to May 2004); and CINAHL (1982 to May 2004); intensive care journals and conference proceedings; reference lists and unpublished literature. SELECTION CRITERIA: Randomized controlled trials which compared partial liquid ventilation with other forms of ventilation, in adults (16 years old or greater) with ALI or ARDS, reporting one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit, or stay in hospital; infection; long term cognitive impairment or health related quality of life; long term lung function; or cost. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated the quality of the relevant studies and extracted the data from the included studies. MAIN RESULTS: Problems with the inadequacy of the primary report of the one included study do not allow us to report any quantitative results for patients with ALI or ARDS. The only outcome we considered to be of clinical significance and reported for all enrolled patients (i.e., patients with ALI and ARDS and less severe respiratory insufficiency) was 28 day mortality. There was no statistically significant difference between groups for this outcome with a relative risk for 28 day mortality in the PLV group of 1.15 (95% confidence intervals of 0.64 to 2.10). REVIEWERS' CONCLUSIONS: There is no evidence from randomized controlled trials to support or refute the use of partial liquid ventilation in adults with ALI or ARDS; adequately powered, high quality randomized controlled trials are still needed to assess its efficacy. Clinically relevant outcome measures should be assessed (especially mortality at discharge and later, duration of respiratory support and hospital stay, and long term cognitive and quality of life outcomes) and the studies should be published in full.

Adult↗

PubMed2004

Partial liquid ventilation for the prevention of mortality and morbidity in paediatric acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Acute lung injury, and acute respiratory distress syndrome, are syndromes of severe respiratory failure. Children with acute lung injury or acute respiratory syndrome have high mortality and significant morbidity. Partial liquid ventilation is proposed as a less injurious form of respiratory support for these children. Uncontrolled studies in adults have shown improvement in gas exchange and lung compliance with partial liquid ventilation A single uncontrolled study in six children with acute respiratory syndrome showed some improvement in gas exchange during three hours of partial liquid ventilation. OBJECTIVES: To assess whether partial liquid ventilation reduces either mortality or morbidity, or both, in children with acute lung injury or acute respiratory syndrome. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 2, 2003; MEDLINE (1966 to April 2003); and CINAHL (1982 to April 2003); intensive care journals and conference proceedings; reference lists and 'grey literature'. SELECTION CRITERIA: Randomized controlled trials which compared partial liquid ventilation with other forms of ventilation, in children (28 days - 18 years) with acute lung injury or acute respiratory syndrome, reporting one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit, or stay in hospital; infection; or long term cognitive impairment or neurodevelopmental progress or other long term morbidities. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated the quality of the relevant studies and extracted the data from the included studies. MAIN RESULTS: Only one study enrolling 182 patients (only reported as an abstract in conference proceedings) was identified and found eligible for inclusion: the authors report only limited results. The trial was stopped prematurely and therefore under-powered to detect any significant differences. The only outcome of clinical significance available was 28 day mortality: there was no statistically significant difference between groups with a relative risk for 28 day mortality in the partial liquid ventilation group of 1.54 (95% confidence intervals of 0.82 to 2.9). REVIEWERS' CONCLUSIONS: There is no evidence from randomized controlled trials to support or refute the use of partial liquid ventilation in children with acute lung injury or acute respiratory syndrome: adequately powered, high quality randomized controlled trials are still needed to assess its efficacy. Clinically relevant outcome measures should be assessed (mortality at discharge and later, duration of respiratory support and hospital stay, and long-term neurodevelopmental outcomes) and the studies should be published in full.

Adolescent↗

PubMed2004

Albumin infusion for low serum albumin in preterm newborn infants.

BACKGROUND: Intravenous albumin infusion to treat hypoalbuminaemia is used in intensive care nurseries. Hypoalbuminaemia occurs in a number of clinical situations including prematurity, the acutely unwell infant, respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotising enterocolitis (NEC), intracranial haemorrhage, hydrops fetalis and oedema. Fluid overload is a potential side effect of albumin administration. Albumin is a blood product and therefore carries the potential risk of infection and adverse reactions. Albumin is also a scarce and expensive resource. OBJECTIVES: The primary objective was to assess whether albumin infusions, in preterm neonates with low serum albumin, reduces mortality and morbidity. A secondary objective was to assess whether albumin infusion is associated with significant side effects. SEARCH STRATEGY: Searches were made of MEDLINE from 1966 to April 2004, CINAHL from 1982 to April 2004 and the current Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 1, 2004). Previous reviews (including cross references) and abstracts were also searched. SELECTION CRITERIA: All randomised controlled trials in which individual patients were allocated to albumin infusion versus control were included. Cross-over studies were excluded. Quasi randomised trials were excluded. Participants were preterm infants who had hypoalbuminaemia. Types of interventions included albumin infusion versus placebo (e.g. crystalloid) or no treatment. DATA COLLECTION AND ANALYSIS: The reviewers worked independently to search for trials for inclusion and to assess methodological quality. Studies were assessed using the following key criteria: blinding of randomisation, blinding of intervention, completeness of follow up and blinding of outcome measurement. MAIN RESULTS: Only two small studies were found for inclusion in this review and only one reported clinically relevant outcomes - it found no significant differences for our primary outcome measure of death (RR 1.5 [95% confidence interval 0.3 - 7.43]) or secondary outcome measures of intraventricular haemorrhage, patent ductus arteriosus, necrotising enterocolitis, bronchopulmonary dysplasia, duration of mechanical ventilation and duration of oxygen therapy. REVIEWERS' CONCLUSIONS: There is a lack of evidence from randomised trials to determine whether the routine use of albumin infusion, in preterm neonates with low serum albumin, reduces mortality or morbidity, and no evidence to assess whether albumin infusion is associated with significant side effects. There is a need for good quality, double-blind randomised controlled trials to assess the safety and efficacy of albumin infusions in preterm neonates with low serum albumin.

Albumins↗

PubMed2004

Transfer of preterm infants from incubator to open cot at lower versus higher body weight.

BACKGROUND: The use of incubators in helping to maintain a thermoneutral environment for preterm infants has become routine practice in neonatal nurseries. As one of the key criteria for discharging preterm infants from nurseries is their ability to maintain temperature, the infant will need to make the transition from incubator to open cot at some time before discharge. The timing of this transition is important because when an infant is challenged by cold, the infant attempts to increase its heat production to maintain body temperature. The increase in energy expenditure may affect weight gain. The practice of transferring infants from incubators to open cots usually occurs once a weight of around 1700-1800 g has been reached; however, this practice varies widely between neonatal units. This preferred weight mark appears to be largely based on tradition or the personal experience of clinicians, with little consideration of the infant's weight or gestational age at birth. OBJECTIVES: The main objective was to assess the effects on weight gain and temperature control of a policy of transferring preterm infants from incubator to open cot at lower versus higher body weight. SEARCH STRATEGY: Searches were undertaken of MEDLINE from June 2003 back to 1966, CINAHL from June 2003 back to 1987 and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. SELECTION CRITERIA: Trials in which preterm infants were randomly allocated to a policy of transfer from incubators to open cots at a lower body weight versus at a higher body weight. DATA COLLECTION AND ANALYSIS: Quality assessments and data extraction for included trials were conducted independently by the reviewers. Data for individual trial results were analysed using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, meta-analysis could not be undertaken. MAIN RESULTS: Four studies were identified as potentially eligible for inclusion in this review. Two studies were excluded as random allocation to the exposure was not employed. One study is pending, awaiting additional information from the authors. Therefore, one study involving 60 preterm infants, employing a matched-pairs design, which compared the transfer of infants to open cots at 1700 g versus 1800 g, is included in this review. Only two outcomes could be included from this study; return to incubator and daily weight gain. No statistically significant difference was shown for either return to incubator (RR 2.00, 95% CI 0.40 to 10.11) or daily weight gain [MD 4.00 g/day (95% CI -5.23, 13.23)]. Due to small numbers, effects on clinically important outcomes could not be adequately assessed. REVIEWERS' CONCLUSIONS: There is currently little evidence from randomised trials to inform practice on the preferred weight for transferring preterm infants from incubators to open cots. There is a need for larger randomised controlled trials to address this deficiency.

Body Temperature Regulation↗

PubMed2004

Prophylactic antibiotics to reduce morbidity and mortality in ventilated newborn infants.

BACKGROUND: Bacterial colonisation of the respiratory tract is associated with intubation and may increase the risk of acquiring infection. This may prolong the need for mechanical ventilation and increase the risk of chronic lung disease. The use of prophylactic antibiotics has been advocated for all mechanically ventilated newborns in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm may outweigh benefit. OBJECTIVES: To assess the effects of prophylactic antibiotics in reducing mortality and morbidity in intubated and ventilated newborn infants who are not known to have infection. In separate comparisons, we reviewed two different policies regarding the prophylactic use of antibiotics in intubated, ventilated infants: 1) among babies who are being intubated for mechanical ventilation, a policy of prophylactic antibiotics for the duration of intubation versus placebo or no treatment. 2) among intubated, ventilated babies who had been started on antibiotics at the time of intubation but whose initial cultures to rule our sepsis are negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: We searched MEDLINE (January 1966 to May 2003), CINAHL (1982 to May 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), the Cochrane Neonatal Group Specialised Register and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials of sufficient quality in which mechanically ventilated newborn infants are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: One study, of insufficient quality, met the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence from randomised trials to support or refute the use of prophylactic antibiotics when commencing mechanical ventilation in newborn infants, or to support or refute continuing antibiotics once initial cultures rule out infection in mechanically ventilated newborn infants.

Antibiotic Prophylaxis↗

PubMed2004

Prophylactic antibiotics to reduce morbidity and mortality in neonates with umbilical artery catheters.

BACKGROUND: Umbilical artery catheters are often used in unwell neonates. Infection related to the use of these catheters may cause significant morbidity and mortality. The use of prophylactic antibiotics has been advocated for all newborns with umbilical artery catheters in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm may outweigh benefit. OBJECTIVES: The primary objective was to assess whether prophylactic antibiotics, in neonates with umbilical artery catheters, reduce mortality and morbidity. In separate comparisons, we planned to review two different policies regarding the prophylactic use of antibiotics in neonates with umbilical artery catheters: 1) among neonates with umbilical artery catheters, a policy of prophylactic antibiotics for the duration of catheterisation (or other fixed duration of antibiotic treatment) versus placebo or no treatment; 2) among neonates with umbilical artery catheters who had been started on antibiotics at the time of catheterisation but whose initial cultures to rule out sepsis are negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: We searched MEDLINE (January 1966 to February 2004), CINAHL (1982 to February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), the Cochrane Neonatal Group Specialised Register and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials of adequate quality in which newborn infants with umbilical artery catheters are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: No study met the criteria for inclusion in this review. REVIEWERS' CONCLUSIONS: There is no evidence from randomised trials to support or refute the use of prophylactic antibiotics when umbilical artery catheters are inserted in newborn infants, or to support or refute continuing antibiotics once initial cultures rule out infection in newborn infants with umbilical artery catheters.

Antibiotic Prophylaxis↗

PubMed2004

Predicting the need for ventilation in term and near-term neonates.

OBJECTIVE: To determine whether the need for respiratory support can be predicted by oxygen requirement within the first 72 h in term and near-term infants. METHODS: To mimic the population of infants that would often be delivered outside a tertiary centre we studied a retrospective cohort of infants > or = 32 weeks requiring oxygen, divided into three groups: cot oxygen only, nasal continuous positive airway pressure (NCPAP) only, or intermittent positive pressure ventilation (IPPV). We recorded each infant's peak fraction of inspired oxygen (FiO2)--i.e. FiO2 in the first 72 h in the cot oxygen only group or maximum FiO2 prior to commencing the highest level of respiratory support. The peak FiO2 was used as a diagnostic test to predict any respiratory support or IPPV--sensitivity and specificity were calculated and receiver operating characteristic (ROC) curves plotted (FiO2 0.21-1.00) to identify the best balance point for prediction. RESULTS: The cohort included 592 infants: 516 cot oxygen only, 46 NCPAP only and 30 IPPV. The proportion ventilated increased with increasing peak FiO2--above 0.45 the proportion of infants ventilated exceeded 50%. To predict any respiratory support, the cut-point balancing sensitivity and specificity was a FiO2 > or = 0.35-58/136 required respiratory support (sensitivity = 0.76, specificity = 0.85, positive predictive value (PPV) = 43%, negative predictive value (NPV) = 96%). To predict IPPV the cut-point was a FiO2 > or = 0.5-28/47 treated with IPPV (sensitivity = 0.93, specificity = 0.97, PPV = 60%, NPV = 100%). CONCLUSION: The need for respiratory support can be predicted by oxygen requirement within the first 72 h in term and near-term infants with reasonable sensitivity and excellent specificity.

Blood Gas Analysis↗

PubMed2003

Epinephrine for the resuscitation of apparently stillborn or extremely bradycardic newborn infants.

BACKGROUND: Epinephrine is a cardiac stimulant with complex effects on the heart and blood vessels. It has been used for decades in all age groups to treat cardiac arrest and bradycardia. Despite formal guidelines for the use of epinephrine in neonatal resuscitation, the evidence for these recommendations has not yet been rigorously scrutinised. While it is understood that this evidence is in large part derived from animal models and the adult human population, the contribution from work in the neonatal population remains unclear. In particular, it remains to be determined if any randomised studies in neonates have helped to establish if the administration of epinephrine in the context of apparent stillbirth or extreme bradycardia might influence mortality and morbidity. OBJECTIVES PRIMARY OBJECTIVE: ~bullet~To determine if the administration of epinephrine to apparently stillborn and extremely bradycardic newborns reduces mortality and morbidity Secondary objectives: ~bullet~To determine the effect of intravenous versus endotracheal administration on mortality and morbidity ~bullet~To determine the effect of high dose versus standard dose epinephrine on mortality and morbidity, where high dose is defined as any dose greater than the current recommended standard dose of 0.1 to 0.3ml/kg of a 1:10,000 solution of epinephrine ~bullet~To determine whether the effect of epinephrine on mortality and morbidity varies with gestational age, i.e. term (greater than or equal to 37 weeks) versus pre-term (less than 37 weeks) SEARCH STRATEGY: Searches were made of Medline from 1966 to December 2002, CINAHL (from 1982), Current Contents (from 1988), EMBASE, and the Cochrane Controlled Trials Register (2002, issue 4). Bibliographies of conference proceedings were reviewed and unpublished studies were sought by hand searching the conference proceedings of the Society for Pediatric Research and the European Society for Pediatric Research from 1993 to 2002. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of newborns, both pre-term and term, receiving epinephrine for unexpected apparent stillbirth or extreme bradycardia. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: We found no randomised, controlled trials evaluating the administration of epinephrine to the apparently stillborn or extremely bradycardic newborn infant. Similarly, we found no randomised, controlled trials which addressed the issues of optimum dosage and route of administration of epinephrine. Current recommendations for the use of epinephrine in newborn infants are based only on evidence derived from animal models and the human adult literature. Randomised trials in neonates are urgently required to determine the role of epinephrine in this population.

Bradycardia↗

PubMed2003

Infant to staff ratios and risk of mortality in very low birthweight infants.

OBJECTIVES: To assess the effect that infant to staff ratios, in the first three days of life, have on the survival to hospital discharge of very low birthweight infants (<1500 g), having adjusted for initial risk and unit workload. DESIGN: In a retrospective analysis of a cohort of patients, the number of infants per nurse per shift were averaged for the first three days after admission and related to risk of mortality by logistic regression analysis. Infant to staff ratio was divided into terciles of low (1.16-1.58), medium (1.59-1.70), and high (1.71-1.97) infants per staff member. SUBJECTS: 692 very low birthweight infants admitted to the Intensive Care Nursery, Royal Women's Hospital, Brisbane over a four year period from January 1996 to December 1999. MAIN OUTCOME MEASURES: Survival to hospital discharge, adjusted for initial risk using the Clinical Risk Index for Babies (CRIB) score, and adjusted for unit workload using dependency scores. RESULTS: There were 80 deaths among the 692 babies analysed for the study period. The odds of mortality, adjusted for initial risk and infant dependency scores (unit workload), were improved by 82% when an infant/staff ratio of greater than 1.71 occurred, suggesting improved survival with the highest infant/staff ratio. The low and medium staffing levels corresponded with similar odds ratios for mortality. CONCLUSIONS: Infants exposed to higher infant to staff ratios have an improved adjusted risk of survival to hospital discharge.

Birth Weight↗

PubMed2003

Insertion distance of neonatal intercostal catheters using a 10 French Argyle trocar thoracic catheter.

OBJECTIVE: We believed that intercostal catheters were often inserted too far into the thoracic cavity in neonatal patients. The aim of this study was to determine the average distance from the catheter tip to the midline, of intercostal catheters inserted in our neonatal unit and the incidence of catheters that were inserted too far into the thoracic cavity. METHODS: During a two year period we examined the chest X-rays of all infants who had an intercostal catheter inserted using an Argyle 10 French trocar thoracic catheter for drainage of a pneumothorax. For each initial chest X-ray following the insertion of the intercostal catheter we measured the horizontal distance in mm from catheter tip to the midline. The tip to midline distance was zero if the tip was at the midline and negative if it crossed the midline. To standardise the tip to midline distance for different size infants we measured the distance in 'inter-vertebral' units. RESULTS: During the two year period, 13 of 24 intercostal catheters (54%) crossed the midline (i.e. were inserted too far). The mean (+/- SD) tip to midline distance was -1.29 (+/- 13.9) mm with a range varying between -40 to 34 mm with a calculated 'inter-vertebral' units mean (+/- SD) tip to midline distance of -0.32 (+/- 1.9) range -4.6 to 4.0. CONCLUSIONS: Fifty four percent of the intercostal catheters inserted in our unit were inserted too far. As the distance markings on the Argyle intercostal catheters are marked from the last side-hole rather than from the tip of the catheter, Argyle intercostal catheters may be inadvertently inserted two centimetres further than they should be.

Journal Article↗

PubMed2002

Tracheal gas insufflation for the prevention of morbidity and mortality in mechanically ventilated newborn infants.

BACKGROUND: Tracheal gas insufflation (TGI) is a technique where a continuous flow of gas is instilled into the lower trachea during conventional mechanical ventilation. TGI can improve carbon dioxide removal with lower ventilation pressures and smaller tidal volumes, potentially decreasing secondary lung injury and chronic lung disease (CLD). OBJECTIVES: To assess whether, in mechanically ventilated neonates, the use of tracheal gas insufflation reduces mortality, CLD and other adverse clinical outcomes without significant side effects. SEARCH STRATEGY: Searches were made of MEDLINE 1966 to December 2001, CINAHL 1982 to December 2001, the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001) and conference and symposia proceedings. SELECTION CRITERIA: Randomised controlled trials (RCT) that include newborn infants who are mechanically ventilated, and compare TGI during conventional mechanical ventilation (CMV) with CMV alone. Primary outcomes - mortality, CLD and neurodevelopmental outcome; secondary outcomes - air leak, intraventricular haemorrhage, periventricular leukomalacia, duration of mechanical ventilation, duration of respiratory support, duration of oxygen therapy, duration of hospital stay, retinopathy of prematurity, immediate adverse effects. DATA COLLECTION AND ANALYSIS: Each reviewer assessed eligibility, trial quality and extracted data separately. Study authors were contacted for additional information if necessary. MAIN RESULTS: Only one small study was found to be eligible. This study found no evidence of effect on mortality, CLD or age at first extubation. The total duration of ventilation was 9.3 days shorter in the TGI group (95% CI from 15.7 to 2.9 days shorter). The age at complete weaning from ventilation was 26 days shorter in the TGI group (95% CI from 46 to 6 days shorter). There was no evidence of effect on the total duration of respiratory support, oxygen therapy or hospital stay. REVIEWER'S CONCLUSIONS: There is evidence from a single RCT that TGI may reduce the duration of mechanical ventilation in preterm infants - although the data from this small study do not give sufficient evidence to support the introduction of TGI into clinical practice. The technical requirements for performing TGI (as performed in the single included study) are great. There is no statistically significant reduction in the total duration of respiratory support or hospital stay. TGI cannot be recommended for general use at this time.

Humans↗

PubMed2002

Rapid correction of early metabolic acidaemia in comparison with placebo, no intervention or slow correction in LBW infants.

BACKGROUND: Metabolic or mixed (metabolic and respiratory) acidosis are commonly encountered problems in the low birth weight (LBW) infant after delivery, and they may contribute to mortality and morbidity. Causes for the lactic acidosis are multiple and include maternal, placental and fetal factors. It is unclear whether metabolic acidaemia in the first 24 hours of life in LBW infants should be corrected by rapid infusion of alkali. OBJECTIVES: The main objective was to assess the short and long-term effects of the rapid correction of early (first 24 hours) metabolic acidaemia in LBW (<2500g birth weight) neonates. SEARCH STRATEGY: Searches were undertaken of MEDLINE from October 2001 back to 1966 and the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. SELECTION CRITERIA: Types of studies All randomised controlled trials where short or long term effects of treatment with alkalising agents by rapid infusion were compared with placebo or no treatment, or where rapid infusion of alkalising agents was compared with slow infusion. Types of participants Newborn infants with birth weight <2500g and less than 24 hours of age with proven metabolic acidaemia (on arterial blood gas). Types of interventions Rapid correction of acidaemia with alkalising agents (sodium bicarbonate and/or THAM) given as a bolus over 5 minutes or less compared with either placebo, no intervention or slow infusion (>5 minutes). Types of outcome measures 1) maximal oxygen requirement in first 24 hours 2) duration of oxygen therapy 3) need for and duration of assisted ventilation 4) intraventricular haemorrhage and/or periventricular leucomalacia 5) survival to discharge 6) long term survival (to 24 months of age) 7) neurological and developmental outcome at 24 months of age DATA COLLECTION AND ANALYSIS: Each reviewer assessed eligibility, trial quality and extracted data separately, then compared and resolved differences. Study authors were contacted for additional information if necessary. MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence available from randomised controlled trials to support or refute the rapid correction of metabolic acidaemia, in LBW infants in the first 24 hours of life, as compared with slow or no correction.

Acidosis↗

PubMed2002

Feed thickener for newborn infants with gastro-oesophageal reflux.

BACKGROUND: Gastro-oesophageal reflux (GOR) is common in newborn infants. A common first line management is the use of feed thickeners. OBJECTIVES: In newborn infants with GOR, to evaluate the use of feed thickeners in reducing signs and symptoms of GOR, acid episodes on pH monitoring and histological evidence of oesophagitis. SEARCH STRATEGY: We searched MEDLINE from 1966 to December 2001, the Cochrane Controlled Trials Register, The Cochrane Library, Issue 1, 2002. CINAHL from 1982 to December 2001, and conference and symposia proceedings published in Pediatric Research 1990 to 1994. We also searched conference proceedings for the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN) and the North American Society for Pediatric Gastroenterology and Nutrition (NASPGAN) from 1994 to December 2001. We did not restrict the searches to the English language. SELECTION CRITERIA: All randomised controlled trials that examine the effects of thickening formulas on treating gastro-oesophageal reflux in neonates. The eligible studies were to compare thickened feeds to no intervention (unthickened feeds). DATA COLLECTION AND ANALYSIS: Two independent reviewers identified potential studies from the literature search. Quality was independently assessed by two independent reviewers. MAIN RESULTS: No studies fulfilled the requirements for inclusion in the systematic review. REVIEWER'S CONCLUSIONS: There is no evidence from randomised controlled trials to support or refute the efficacy of feed thickeners in newborn infants with GOR. Given the absence of evidence, we cannot recommend using thickening agents for management of GOR in newborn infants.

Food Additives↗

PubMed2002

Ward reduction without general anaesthesia versus reduction and repair under general anaesthesia for gastroschisis in newborn infants.

BACKGROUND: Gastroschisis is a congenital anterior abdominal wall defect with the abdominal contents protruding through the defect. Reduction of the abdominal contents is required within hours after birth as the infant is at risk not only of water and heat loss from the exposed bowel but also of compromised gut circulation with ischaemia and infarction. To avoid the complications of general anaesthetic and mechanical ventilation it has been proposed that the reduction of abdominal contents can be achieved without endotracheal intubation or anaesthesia. OBJECTIVES: To determine which approach to the immediate surgical treatment of gastroschisis has the better outcomes: ward reduction without general anaesthetic or reduction and repair of the abdominal wall defect under general anaesthesia. SEARCH STRATEGY: Searches were made of MEDLINE from 1966 to March 2002, CINAHL from 1982 to March 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). Previous reviews including cross references, abstracts, and conference and symposia proceedings published in Pediatric Research (from 1990 to 1994) were also searched, especially for any unpublished data. SELECTION CRITERIA: Randomised, controlled trials (RCT) comparing ward reduction with reduction under general anaesthesia, for neonates with gastroschisis. Outcomes considered were: mortality, duration of total parenteral nutrition, time to full enteral feeds, need for a silo, infection, gastro-intestinal tract perforation, length of bowel lost/resected, need for a general anaesthesia, need for and duration of mechanical ventilation and respiratory support, duration of oxygen therapy, need for further operative procedure after initial reduction, duration of hospital stay, cosmetic outcome, nutritional status, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review. MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence from RCTs to support or refute the practice of ward reduction for the immediate management of gastroschisis. There is an urgent need for RCTs to compare ward reduction versus reduction under general anaesthesia in infants with gastroschisis. Initial trials would best be limited to those infants with uncomplicated gastroschisis (using pre-defined selection criteria excluding infants that are unstable, have gut perforation, necrosis or atresia, have other organs requiring reduction besides bowel, or are considered to need a silo prior to any reduction. Trials should use adequate pain relief and specify a pre-defined time period after which manual reduction is abandoned.

Anesthesia, General↗