Article Text
PDF
Statistics from Altmetric.com
Recognising uncertainty: an integrated framework for palliative care in perinatal medicine
This framework, developed collaboratively by the British Association of Perinatal Medicine (BAPM) and the Association of Paediatric Palliative Medicine (APPM), offers supportive guidance for all healthcare professionals working in perinatal medicine across antenatal and neonatal services. It acknowledges that palliative care is not just for babies who are dying or who will certainly die in early life. Incorporating a palliative approach into antenatal and neonatal care for all babies with an uncertain outcome can be particularly valuable. The framework provides guidance on recognising babies who may benefit from palliative care and outlines five key elements of perinatal palliative care: holistic family support, empowering parents to be parents, parallel planning, symptom management and loss and bereavement care. It provides recommendations for the delivery of palliative care services, advocating for a unified approach that involves all members of the perinatal team, supported by specialist services as needed. The framework calls on us to integrate palliative care into the everyday and to recognise and embrace the challenge of uncertain prognosis. See page F236
Macronutrient concentrations in human milk beyond the first half year of lactation
Jacqueline Muts and colleagues measured the macronutrient composition of 181 samples of expressed breast milk collected from 86 women between 5 weeks and 28 months post-partum. Fat content was stable through 8 months and then increased. Carbohydrate content was stable throughout. Protein concentration decreased during the first 8 months of lactation and then stabilised between 8 to 18 months before increasing again. Caloric density mirrored the pattern of the fat concentrations. This work strengthens the knowledge regarding milk composition beyond 6 months and provides reassurance to milk banks and their users regarding the suitability of donated milk over longer periods. See page F248
Perinatal medicine’s best treatment: how should we be using antenatal steroids?
Antenatal steroids are arguably the most effective treatment in perinatal medicine and the meta-analysis that established this paved the way for the neonatal community to embrace evidence-based medicine in the pursuit of better outcomes. This viewpoint by Katherine Pettinger and colleagues discusses important ways in which creeping practice change that is not well-evidenced may be altering their use, with potential for harm despite the good intention behind the change. Most preterm infants are exposed to some antenatal steroids before birth, but In order to be fully effective the treatment must have been started at least 24 hours before birth. Giving the second dose early when otherwise there would not be time is increasingly practiced and may be unintentionally encouraged by quality improvement targets but may be associated with increased risk of adverse outcome. The article also discusses the uncertainty regarding the balance of risks and benefits for repeat courses and the potential for different betamethasone preparations in use to have different effects because of their different degradation pathways affecting their durations of action. As the benefits of antenatal steroids begin to accrue soon after the first dose is given and then need 24 hours or more to become fully established it may be that focus on minimising delay before the first dose is administered would achieve the greatest benefits and adherence to the evidence. See page F245
Pre-medication before less invasive surfactant administration
Although the evidence base supports the use of Less Invasive Surfactant Administration (LISA) techniques as the favoured approach to surfactant treatment, there is uncertainty over the best approach to minimising the stress to the infant from the procedure. Claire Murphy and colleagues present a narrative review of the literature describing non-pharmacological and pharmacological approaches and measures of pain assessment. They identified two small randomised controlled trials and five observational studies with short term outcome measures. Consequently, previous meta-analyses have been limited in the conclusions that can be drawn and there is considerable variation in practice and international guidance. Ongoing studies may add further information but are studying a range of outcomes, mostly short term and are not focused on infants at highest risk of adverse long-term outcomes. There is a long way to go. See page F230
Cerebral injury and retinopathy as risk factors for blindness in preterm infants
Benjamin Honan and colleagues report the incidence and associated causal factors for bilateral blindness in 19 863 infants with birth weight 401–1000 g or gestation<29 weeks who were cared for in 28 Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers from 1994 to 2021. Overall, the outcome was thankfully uncommon—1% of children had bilateral blindness. Of blind children, 25% (53/213) had severe ROP only, 22% (47/213) had cerebral injury only, 40% (86/213) had both, and 13% (27/213) had neither. Hydrocephalus requiring shunt with concurrent other cerebral injury was associated with the greatest increase in the risk of blindness (aOR=12.7), followed by PVL (aOR=8.94). After 2006 cerebral injury had a stronger association with blindness than severe ROP (aOR 10.7 vs 6.2). See page F253
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.