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Safety culture and the NICU
Over recent years, we have carried a number of papers examining rates of adverse events in babies receiving intensive care. These have contained salutary reminders of the possible harms that can happen, and their frequency, but they have been less helpful in terms of generating and testing practical measures by which errors might be reduced. We would all sign up to the laudable aims of better education, tight and simple systems, and close monitoring of errors and learning from them when they occur, but even these do not reduce rates of error as far as we would all wish. So it is particularly valuable to have the paper by Lee et al bearing a very positive message by reporting the application of structured random safety audits (a system widely used in industry) to the NICU setting. In short: it demonstrably works, and other units should give serious consideration to emulating this system. See page F116
Feeding and NEC
You might have thought that the many published case control studies investigating risks for necrotising enterocolitis would have said everything that there is to say on the subject. Not so. Henderson et al, while confirming both that breast feeding was protective and starting early trophic feeding was not associated with any increased risk, found that higher rates of increase of enteral feeding (with both shorter duration of trophic feeds and earlier attainment of full feeds), was associated with increased risk. The challenge is now to design a simple pragmatic trial comparing two different rates of increase in enteral feeds, with NEC free survival as the endpoint. Since NEC is uncommon the trial would need to be large, but the question is important. See page F120
ECMO in the UK
Extracorporeal membrane oxygenation has now been an established mode of therapy in the UK since the findings of the UK trial were published in 19961, yet last year we carried a paper showing that there was still unexplained differential referral of babies for ECMO in the UK, begging the question as to whether all neonatologists are equally well informed about the potential benefits of ECMO therapy2. This month, Karimova et al report the results of ECMO from the UK registry for its first thirteen years, with outcomes very similar to those achieved in reports from around the world. This is good news, and should stimulate clinicians who may be reluctant to consider referral for ECMO to reconsider. See page F129
Developmental care through a looking glass
“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means what I choose it to mean—neither more nor less.” 3 So with ‘developmental care’. Maguire et al have shown that when you choose it to mean incubator covers and nesting, there is no demonstrable beneficial effect on babies’ outcomes. This is interesting as far as it goes, but we should be careful. First, as the authors acknowledge, this does not invalidate or contradict the studies demonstrating beneficial effects of more integrated and extensive developmental care (eg NIDCAP). Second, it does not mean that the babies did not have a ‘better’, or more pleasant, NICU experience—it just means that this dimension could not be measured using the rather crude tools at our disposal for measuring outcomes. The last word on this has to go to Lewis Carroll again: “Contrariwise,” continued Tweedledee, “if it was so, it might be; and if it were so, it would be; but as it isn’t, it ain’t. That’s logic.” 3 See page F92
Prone versus supine
How times have changed. The paper by Saiki et al demonstrates that the prone position has clear benefits in terms of respiratory function for preterm babies studied at around 36 weeks postmenstrual age. Thirty years ago such data would have been taken as good evidence that ex-prem babies would be ‘safer’ nursed prone than supine, and doubtless even more would have gone home with strict instructions to their parents to put them down to sleep on their tummies. How wrong we would have been (indeed, how wrong we were). Now, in the light of more sophisticated knowledge, we turn these results on their head, and conclude that relative impairment of lung function is not the reason that ex-prem babies are at higher risk of sudden unexplained death when placed prone, rather than supine, for sleep. See page F133
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