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Family integrated care
There’s a great Leading article by Patel et al in the Blue journal (Archives) this month that should be of interest to FNN readers. You may have seen that the cluster randomised trial demonstrating the benefits of family integrated care was recently published in the Lancet (doi: 10.1016/S2352-4642(18)30039-7). Even before this, many units in the UK were moving in this direction and it is in this context that the Glasgow authors share with us the issues and difficulties they faced when implementing family integrated care, and the ways in which they overcame them. Crucially, it was the families first and foremost who found solutions to many of the perceived problems. Read, ponder, and implement.
Alcohol in pregnancy
I understand that when the population consumption of alcohol in the UK is calculated from surveys, it is only half as much as the alcohol that is known to have been sold. And although alcohol and pregnancy are a bad mix, it is known that quite a bit of alcohol gets consumed by pregnant women. But how many women? And how much? We clearly can’t rely on maternal report. At the end of this issue Hyperion alludes to some recent data from the USA suggesting between 1% and 5% population prevalence of fetal alcohol spectrum disorder in school children. My Editor’s choice is the paper by Mactier et al which both confirms the feasibility of determining fetal exposure on the basis of meconium analysis, and finds that in the West of Scotland the rate of significant fetal exposure to alcohol is at least 15%, or 1 in 7. How far this might result in FASD we don’t know, but fetal exposure on this scale can’t be good news. See page F216
Social inequity and survival
In Japan, Morisaki et al report that there seems to be a significant degree of socio-economic inequity in survival for the most preterm deliveries. This may well be the result of judgements, or biases, among attending clinicians and seems to operate around the time of delivery. The accompanying Editorial unpicks this issue in more detail. Complementary to this paper, Santhakumaran et al have used nationally collected neonatal data in England to give some information on current trends in the survival of very preterm infants, 2008–2014. Anyone involved in discussions with parents about survival of very preterm babies should take note of this, though the regional variations are considerable and there is limited value in applying national data to any particular neonatal network. In particular, even the most recent EpiCURE data look out of date. See pages F196, F202 and F208
‘Ligation’ of the duct from within
The intravascular approach to closure of the patent arterial duct could prove to be a neonatal game-changer. Morville et al report the use of the intravascular technique in a series of 18 babies, most of which were under 1000 g at the time of closure, and this adds to other reports of the successful deployment of intravascular occlusion using miniaturised equipment. More of the issues, relevant to the UK, are picked up in the Editorial. Cardiac units around the world are now looking to implement transcatheter duct treatment for very preterm babies, so it will be important that good data are collected. The catheter technique might well largely replace open surgery. Might it also replace medical treatment? There’s a need for some good trials, and now is the time to plan them. See pages F194 and F198
Anaesthesia, surgery and development
One issue that is not going to go away any time soon is the impact, if any, of anaesthesia and surgery on neurodevelopment. Although the GAS trial (Lancet 2016;387:239–50) was reassuring about infants around term (including ex-prems), it told us nothing about extremely preterm babies who received operations in very early life. Hunt et al have tried to fill this gap by reporting the outcomes of 3 cohorts, comprising 546 babies of whom 499 were assessed at age 8 years, and comparing the 1 in three who had surgery with the rest who did not. Even with these large numbers it was only the overall association with neurodevelopmental impairment that could be demonstrated: numbers were too small to make confident statements about specific conditions or operations, though the direction of effect was consistent. After adjustment for other risks, having any surgery was associated with more than a doubling of the chance of later impairment. See page F227
Drugs for intubation
Controlled intubations on neonatal units are generally undertaken using a combination of short acting paralysing agent, and a sedative or opiate, given intravenously. Conditions in the delivery room are rather different as there is no immediate intravascular access. The nasal route is the main alternative, but which agent is most effective? Milési et al investigated nasal midazolam versus nasal ketamine in a randomised trial and concluded that midazolam was the more effective of the two. It worked in 9 out of 10 cases, whereas ketamine was satisfactory in only 2 out of 3 cases. The authors pointed out that they could have used a higher dose of ketamine, but there are worries as with any anaesthetic agent that high doses may lead to neuronal apoptosis (see previous vignette). See page F221
Every so often an edition of FNN lives up to its name. We are pleased to carry the paper by Witlox et al which presents a cohort of 48 fetuses whose pleural effusions were treated by thoracocentesis, with or without shunt placement, in utero. There were 7 fetal and 10 neonatal deaths but there were 30 neonatal survivors. The outlook was much better if delivery took place after 32 weeks’ gestation. These data from the Netherlands are comparable with other recent series from Canada and California and contrast with the poor outlook historically for fetuses which are not treated. Even so the babies can be pretty challenging: six had severe pulmonary hypertension which needed nitric oxide for treatment. See page F245