As an SHO, I bought the first edition of the Manual in 1982. It was a survival guide which provided safe certainties in the small hours of the night. It was small, light, and compact. There was no competition: the Roberton Manual was the book to have!

Nearly 20 years on, where has the 4th edition taken us? Bigger, certainly: a behemoth of a “small” manual with 550 pages. Not much taller or wider than its predecessors, but much thicker, the rather thin and closely typeset pages distinctly reminiscent of a Bible. Thirty four chapters and eight appendices. There’s an awful lot of information in here.

Road testing a book like this is quite a challenge. Clearly one should not ask it to perform in a manner for which it was not designed, and the authors helpfully explain in the preface that their aim “is to provide a guide for the management of the acute medical and surgical problems a resident is likely to encounter on a modern neonatal intensive care unit.” So I went for chapter 1, expecting it to plunge in where every resident is most nervous: resuscitation of the newborn.

Instead, I got “Organization of neonatal care”. Admittedly it is only six pages, but does a resident really need this in a practical manual? Especially since the big Roberton textbook is likely to be on hand in most neonatal units to provide this and much more detail on this subject. In the Manual, you have to wait until chapter 6 to get “Resuscitation”, with “Temperature control”, “Fluid & electrolytes”, “Enteral nutrition and parenteral nutrition”, all packed with science and physiology, coming first. How much physiology do you want or need in a practical manual? Not this much, I think.

So I tried again with the oxygenation index (OI). There must be many units where the OI is used as a pragmatic threshold for giving nitric oxide or high frequency oscillation, and of course for referring for extracorporeal membrane oxygenation (ECMO). The resident will want to find the page with the formula for calculating OI, and how to deal with mm Hg versus kPa for the oxygen tension. To the index then—but no entry for oxygenation index. To the glossary of abbreviations at the front: there, sure enough, is OI. But where is it in the text? I could not find it under PPHN, or RDS, or ventilation. Eventually, by close reading, I found it mentioned under Meconium aspiration, and also under ECMO, but nowhere could I find the formula for calculating it. By this time, the luckless resident will have been called away to the next problem, and if the formula is indeed there, he/she will have lost interest in finding it.

Residents are increasingly likely to be faced with ventilators that read out the tidal volume and minute volume, and display pressure-volume curves. They want to know how to use this information. They want to know what to do when babies on trigger ventilation drop their Pco₂ to embarrassingly low levels. They want the formula for calculating the fractional excretion of sodium. They need to know that separate chest and abdomen radiographs give much better radiological information than “babygram” pictures. Sadly, they will be disappointed if they try to find such information in this book.

The 4th edition of the Manual seems to have lost the values of its roots. It feels like a pared down version of the big Roberton book, repackaged between smaller covers. It contains a level of detail that is unnecessary given the alternative sources of the material. It can be hard to find in a hurry the things you need, and some of the things you want are not there at all—or at any rate, I couldn’t find them, which comes to the same thing. And the index is terrible. On the other hand, if you want a comprehensive introduction to the subject of neonatal intensive care medicine for under £20, look no further. This is your book.