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THERE'S MORE PRETERM BIRTH ABOUT THAN THERE WAS—OR IS THERE?
Everyone working in neonatal care in developed countries is aware of the increasing workload, even as birth rates decline. This suggests, among other possibilities, that the delivery of preterm babies may be increasing, which might in turn signify a plausible change in obstetric practices. However these changes are difficult to quantify if, as in England, information on gestation is not routinely collected on every birth. Craig et al are therefore to be congratulated on their study of more than one million births, over 20 years, in New Zealand. They are able to inform us with considerable precision about the changing patterns of preterm births: increased rates in the 20 to 28 week (more than 80%), and 33 to 36 week groups (nearly 40%), but strangely little change in the 29 to 32 week group. At least as interesting are their data demonstrating the near disappearance of the previous gradient for preterm delivery according to deprivation index. This is counterintuitive, given that many of the factors associated with premature birth are closely correlated with deprivation. However, the disappearance of the gradient is only evident since 1995, and most of the existing literature on epidemiological factors increasing the risk of preterm birth relates to earlier years. These findings will provoke much speculation, and should encourage further studies from other countries with comparable national data sets.
See p 142
TO TILT OR NOT TO TILT?
We carry two papers exploring different aspects of neonatal physiology. In one, the issue of improved oxygenation of babies in the prone position is explored, with infants assessed either prone or supine, and either tilted at 45° head up, or flat. Dimitriou et al hypothesised that the improved oxygenation in the prone position in convalescent infants might be explained by greater respiratory muscle strength, but this was not the case, since strength was actually greater in the supine than the prone position. For practical neonatologists, who are normally happy with babies nursed prone at about 10° from the horizontal, it is not entirely clear whether we should be trying to encourage steeper tilting or not, so as with all good papers we are left with at least as many questions as answers. Gournay et al took the contrasting view that tilting was perhaps too invasive and unphysiological for assessment of the ontogeny of the baroreflex, and avoided tilting altogether. Instead they used an indirect technique for assessing baroreflex sensitivity, so it will be interesting to see whether other physiologists are happy about the application of this technique to preterm infants. This paper is potentially an important addition to the literature, and will perhaps stimulate some controversy.
EXAMINATION OF THE NEWBORN
When apparently healthy newborn babies are given their first clinical examination, more should be going on than the mere mechanical examination of a tiny human being. In the first place, it is well recognised that it is a good opportunity for health promotion as well as for dealing with questions that a mother may legitimately have about her baby's health and future. Secondly, as with any intervention aimed at a whole population of presumptively well people, it is of extreme importance that it does no harm. Maternal satisfaction may seem a low value end point to some hard nosed doctors, but the perspective of mothers, and even doctors who are also mothers, may be somewhat different. The demonstration by Wolke et al that junior doctors performed significantly worse than midwives, primarily because they appeared not to prioritise the discussion of healthcare issues, should make us all pause to consider how and what we teach our senior house officers in relation to newborn examination. It should also make us consider which dimensions we should use to measure quality for this examination.
See p 155
Making the diagnosis of seizures in preterm babies is hard enough, but knowing how to treat them is even harder. Unfortunately Boylan et al do not give us much in the way of answers. They confirm that electrographic seizures persist when their clinical manifestations are abolished by anticonvulsants, and that phenobarbitone is a pretty useless drug for abolishing the abnormal electrical activity. Depressingly, they seem to confirm that we are no further forward than when Eyre et al made similar observations in this journal nearly 20 years ago.
See p 165