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Infant Care

INFANTS WEIGHING 1·8-2·5 kg: SHOULD THEYBE CARED FOR IN NEONATAL UNITS OR

POSTNATAL WARDS?

C. WHITBY C. R. DE CATESN. R. C. ROBERTON

The Maternity Hospital, Mill Road, Cambridge

In 1972, Klaus et all published the first of a series of papersemphasising the importance of keeping mothers and theirnewborn babies together. Subsequently, the importance ofthis aspect of neonatal care has become increasinglyrecognised.2 Despite lip service to these notions, however, by1977, 20% of all newborn infants each year were admitted toneonatal units in England and Wales (Department of Healthand Social Security, unpublished figures for live-birthsdelivered in N.H.S. hospitals). Since it has been estimated3-5that only 1-3% of all newborn babies require intensive care,and the incidence of infants weighing less than 2. 5 kg is6.5—8% in most parts of the U.K., the majority of infantsadmitted to neonatal units must, therefore, be neither

seriously ill nor premature. Various reasons have been givento justify this high rate of admission to neonatal units:

1. Admission reduces neonatal mortality.Since neonatal mortality is primarily due to

malformation, severe asphyxia at birth, or illness ininfants weighing less than 1 - 5 kg at birth, it will not beaffected by the admission of healthy, unasphyxiatedinfants weighing more than 1 - 8-2’ 0 kg to neonatalunits.

2. The Sheldon report7 recommended that all infants

weighing less than 2’ 5 kg, and all breech, forceps, andcaesarean deliveries should be admitted to neonatal units.

In the face of a rising rate of forceps and caesareandeliveries, this idea is absurd: the object of surgical orinstrumental intervention is to prevent asphyxia andmorbidity, and maintain the baby’s healthy condition;if, on delivery, such infants are asymptomatic, they donot require admission to neonatal units.

3. Neonatal units are safer than postnatal wards; andpostnatal ward staff cannot be trusted to look after babies.

This is incorrect from a microbiological point ofview,8 and nonsense from a nursing point of view.Scant attention is paid, particularly at night, to large,healthy infants in neonatal units, when nurses arerushed off their feet caring for critically ill infants onventilators. On the postnatal ward, however, whererooming-in of babies with their mothers is allowed(and hopefully all maternity hospitals are sufficientlyenlightened for this to be the rule), the same largeinfant will receive uninterrupted special care from onedevoted nurse-his mother.

4. To justify the nursing establishment and placateadministrators, bed occupancy on neonatal units is kepthigh.

Hardly credible, but true!We have shown elsewhere9 that most infants with birth

weights over 2 - 5 kg can be managed safely on a postnatalward with their mothers, with the greatest of ease and withoutany extra provision (table I), and national figures now show areduction in neonatal unit admission. In 1980, only 14 - 7% ofall live-born infants in England and Wales were admitted.

When we started to become selective in admitting infantswith a birth weight less than 2 - 5 kg to the neonatal unit, andadmitted many instead to the.routine postnatal wards, levelsof anxiety among the midwifery staff began to rise. For thisreason, we arranged for such infants to be kept with theirmothers on just one of the four postnatal wards in CambridgeMaternity Hospital. Over a period of about 2 years, this wardhas developed into a highly successful unit, and this paperdescribes its functioning from March, 1979 to March, 1980.We do not wish to employ any such grandiose title as

transitional care unit, intermediate care unit, or mother/childunit, since the ward is none of these. It is simply a routinepostnatal ward taking all mother and infant pairs where thebaby weighs less than 2 - 5 kg, and also taking many healthyinfants weighing more than 2 - 5 kg.

The Ward

The ward is a 14-bed postnatal ward. When the new CambridgeMaternity Hospital is completed in 1983, we will use a 26-bedpostnatal ward next door to the neonatal unit. We have made noarchitectural adaptations to the existing ward, and the onlymodification was to introduce an old-fashioned radiant heater intothe nursery.

The StaffThe ward is staffed by midwives who rotate through all the other

departments of the Maternity Hospital. The daytime establishmentis 1 sister, 3 staff midwives, 1 state enrolled nurse, 1 nursery nurse,and 1 nursing auxiliary. The sister remains on the ward for 6 monthsand the staff midwives for 4 months. The nursery nurse, S.E.N.,and nursing auxiliary are permanent. This establishment was notincreased when the ward started to admit low birthweight infants.Midwives joining the ward staff overlap with those about to leavefor in-service orientation, which is supervised by the nursing officerfrom the neonatal unit. The night nursing establishment consists of1 staff midwife and 1 nursing auxiliary. The night rota has beenarranged to ensure that there is always a trained nurse in charge ofthe ward. We have found it a great advantage to have the neonatalunit nursing officer responsible for the ward so that she cansupervise the orientation of new staff, and is available for day to dayadvice on the management of the small baby. No extra medical staffis necessary; senior house officer and consultant advice is alwaysavailable from the paediatric staff in the Maternity Hospital.The nurses are expected to cope with routine Dextrostix

measurements for infants of diabetic mothers and small-for-datesinfants, to give tube feeds and supervise phototherapy, and tocomplete courses of intramuscular injections started on infantswhile they were on the neonatal unit. No infants on the ward receiveintravenous therapy, oxygen, or are nursed in incubators.

The Patients

There are only two routine criteria for admission to the neonatalunit in Cambridge: birth weight less than 1. 8 kg, or illness in theinfant. Asymptomatic infants weighing 1.82.5 kg, includingtwins or higher multiples, are nursed on the postnatal ward from thetime they leave the labour ward. They are cot-nursed, and rooming-in with their mothers is the rule for these infants, as it is for thenormal weight infants on the ward. Infants with malformationswhich are not life threatening, such as hare lip and cleft palate,Down syndrome, and dislocated hip are also nursed on the ward. Inaddition to asymptomatic infants 1.82.5 kg being admitted atbirth, infants of this birthweight admitted to the neonatal unit atbirth are transferred, on recovery, to be with their mothers.

RESULTS

Admissions

During the 13-month period studied, 269 infants weighing1 - 8 - 2 - 5 kg were delivered in Cambridge Maternity

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TABLE I-INBORN ADMISSIONS TO CAMBRIDGE SPECIAL CARE BABY

UNIT 1979-80

Hospital (see accompanying figure). It proved possible,immediately after delivery, to identify with a high degree ofaccuracy those requiring care in the neonatal unit, and thosewho could go straight on to the postnatal ward with theirmothers. Only 6 out of 181 infants admitted to the postnatalward subsequently needed to be transferred to the neonatalunit (see figure and tables III and IV). Of 88 infants admitted tothe neonatal unit at birth, 3 died, and 6 were transferred toother hospitals. 61 of the remaining 79 were transferred to thepostnatal ward with their mothers, and only 3 cases weresubsequently readmitted to the neonatal unit (figure andtables III and IV).Care on the Postnatal Ward

The clinical details of the procedures carried out on theinfants in the study are given in table II which excludes the 9babies who oscillated to and fro between the postnatal ward

Outcome of infants 1-8-2-5 kg born in Cambridge, March, 1979- -March, 1980 inclusive.

Of 256 infants who survived, 233 (90%) went home with their mothers, andof these 128 (55%) were making some attempt to breast feed.

Figures in parentheses refer to the number of babies breast feeding ondischarge.

and the neonatal unit. Details of these 9 infants are given intables III and IV. None of these infants came to any harm as aresult of admission to the inappropriate place, or transfer atan inappropriate time.

TABLE II-DATA OF INFANTS 1.8—2.5 kg BORN IN CAMBRIDGE MATERNITY HOSPITAL MARCH, 1979-MARCH, 1980

* Figures m parentheses = deaths.†The numbers do not add up to the total since in a few cases the method of feeding at discharge was not recorded.$This was the infant with congenital rubella who died 1 wk after discharge from the children’s ward, where her heart failure had been controlled.

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TABLE III-INFANTS ADMITTED TO POSTNATAL WARD AND SUBSEQUENTLY REQUIRING ADMISSION TO SCBU

T.T.N.-transient tachypnoea of the newborn G.B.S.-group B streptococcus N.E.C.-necrotising enterocolitis R.D.S.-respiratory distress syndrome

TABLE IV-INFANTS TRANSFERRED FROM S.C.B.U. TO POSTNATAL WARD AND SUBSEQUENTLY READMITTEDI I I I I I I

FeedingOne of the advantages of keeping mother and infant

together is the increase in the likelihood of establishinglactation.’° 55% of all infants weighing 1-8-2-5 kg wenthome breast feeding (see figure), although we do not know forhow long this was sustained.

DischargeThe age and weight at discharge is given in table II. No

feeding or management difficulties developed that mighthave suggested that discharge had occurred inappropriatelyearly. The subsequent rate of readmission to Addenbrooke’sHospital, for the first year of life of infants always on eitherthe postnatal ward or the neonatal unit, is unremarkable, andno different from the 10% of infants admitted to hospital inthe first year of life reported by Lloyd, Pursall, and Emery. 112 cases, however, are worthy of individual comment. 1 infantweighing 2 - 34 kg at a gestational age of 34 weeks, and neveradmitted to the neonatal unit, was transferred from thepostnatal ward to the maternity unit of a local militaryhospital on the second day of life, when she was perfectlywell; 5 days later, she was readmitted to the children’s ward ofAddenbrooke’s Hospital with Coxsackie B4 myocarditis,from which she died. It is unlikely that the outcome wouldhave been different had she stayed in Cambridge MaternityHospital until she became symptomatic. More worrying isthe 2 - 36 kg full-term infant who went home on the secondday feeding well, having passed as normal on a routineneonatal examination; she was readmitted to the children’sward at Addenbrooke’s, aged 3 months, with heart failure dueto a patent ductus arteriosus, and she was found to havecongenital rubella. Failure to detect murmurs in infants withcongenital heart disease is a recognised hazard in neonatalexaminations carried out in the first 24 - 48 hours of life, andthis child had none of the other stigmata of the extendedneonatal rubella syndrome to alert us. Had she stayed inlonger the murmur would undoubtedly have been detected,and the episode of heart failure averted perhaps by earlyprophylactic anti-failure therapy. Nevertheless, it is unlikelythat her subsequent cot death (when her heart condition wasunder control) could have been influenced by a longer stay onthe postnatal ward.

15 out of the 58 infants transferred from the neonatal unit tothe postnatal ward is a higher rate of readmission, but it is

comparable to the rate reported in ex-neonatal intensive carepatients. 12 Furthermore, none of the conditions necessitatingadmission in these 15 infants, except, perhaps, the infantadmitted 4 times for failure to thrive, were likely to haveoriginated in the neonatal period. In only one infant admittedwith a fracture, was there any suspicion of non-accidentalinjury, although the evidence was poor. No other cases ofN.A.I. were recognised. The 2 cot deaths occurred in infantsaged 4 and 6 months.

DISCUSSION

From this data it is clear that many infants weighing1’ 8 - 2’ 5 kg, presently separated from their mothers

immediately after birth and admitted to neonatal units, can bekept safely with their mothers on the postnatal ward. Thistype of ward is easy to run, and has proved popular withnursing staff as well as with mothers. Despite intense

pressure on postnatal maternity beds in CambridgeMaternity Hospital, the longer duration of stay for thesemothers has caused no difficulties as cooperation with theobstetric staff has been excellent. In only 2 cases (table IV) didthe mothers become sufficiently depressed, as a result of theirlong stay, for them to seek discharge, leaving their baby in theneonatal unit.As predicted, the infants suffered no medical harm as a

result of postnatal ward nursing. It is interesting to note thevery low incidence of asymptomatic hypoglycaemia, and thecomplete absence of symptomatic hypoglycaemia, in a largenumber of small-for-dates infants routinely screened byDextrostix, fed 60 ml/kg of milk on day 1, and 90 ml/kg ofmilk on day 2. Only 5 infants recorded Dextrostix levels lessthan 25 mg%, and they were promptly given an extra milkfeed; subsequent Dextrostix levels were normal. Thisincidence of asymptomatic hypoglycaemia is lower than the20% found in a comparable group of neonates at a time wheninadequate nutrition was given during the first 48 hours. 13.11We were particularly encouraged by the high rate of

breastfeeding in these infants (figure), which, although lowerthan the 70 - 80% figure found in full-term infants

discharged from Cambridge Maternity Hospital, seems to bea gratifying result of the extended mother/baby contact wewere able to achieve. It is difficult to ascertain whether theextended mother/child contact in the neonatal period is

responsible for only one case of non-accidental injury out of a

325

total of 256 infants. Since they all weighed less than 2’ 5 kg atbirth, and are consequently a high risk group, this maymerely reflect the overall low incidence of the problem inCambridge.This use of a postnatal ward means that the number of

infants requiring admission to a neonatal unit is reduced to afigure considerably below the national average. Table I showsthat during the last 2 years, only 6% of all deliveries wereadmitted to the Cambridge neonatal unit. It must be madeabsolutely clear, however, that the type of care for infantsweighing 1’ 8 - 2 - 5 kg described in this paper is not relevantto the provision of neonatal intensive care facilities. Duringthe 2 year period of this study, about 1/3 - 1/2 of all inbornadmissions to the Cambridge neonatal unit requiredintensive care. About 1/3 of these infants came from in-utero,antenatal transfers from other maternity hospitals in the EastAnglian region. This number of infants requiring intensivecare corresponds to the standard estimate that I - 3% of alldeliveries require intensive care, and is also in line with therecommendation that 1 cot for neonatal intensive care shouldbe provided for every 1000 live births.l5 This has not beenrealised anywhere in England and Wales, and our views onthe gross underprovision of neonatal intensive care facilitieshave been expressed elsewhere. 16-18We do believe, however, that on the basis of what is

described above, and elsewhere, the national provision forneonatal special care is excessive. For the neonatal specialcare work-load in the Cambridge Health District, we haveneeded in the last few years no more than 2 - 3 cots annuallyper 1000 deliveries, and we believe that this should be thestandard of cots provided in neonatal units of smaller

maternity hospitals. To provide 6 cots per 1000 deliveries,the minimum size of a neonatal unit set at 24 cots (H.M.S.O.1971) in a district general hospital (where 2000-2500deliveries or less take place annually, and those requiringneonatal intensive care are transferred to a regional unit), is,therefore, a massive overprovision. Perhaps some of themoney spent on building half-empty special care baby unitscould be diverted towards the provision of adequate neonatalintensive care facilities.

We would like to thank the nurses and medical staff of the neonatal unit andward 7B of the Cambridge Maternity Hospital, who have made the warddescribed so successful. We are also grateful to Dr Edmund Hey for theprovision of data on admission rates to Special Care Baby LJmtsRequests for reprints should be addressed to N. R. C. R.

REFERENCES

1 Klaus MH, Herauld R, Kreger NC, McAlpine W, Steffa M, Kennell JL. Maternalattachment importance of the first post-partum days N Engl J Med 1972, 286:460-63

2 Taylor PM, ed Parent-infant relationships. Semin Perinatol 1979; 3: 1-105.3. Fit for the future. Report of the Committee on Child Health Services Chaired by

Court S D M. London H.M Stationery Office, 1976, Para 8 32: 1224 British Paediatric Association/Royal College of Obstetricians and Gynaecologists

Liaison Committee. Recommendations for the improvement of infant care duringthe perinatal period in the United Kingdom. London. B.P A./R.C O G , 1978

5 2nd report from the Social Services Committee Perinatal and neonatal mortality.Chaired by Mrs Renee Short London H.M. Stationery Office, 1980; para 99: 35

6. McFarlane A, Chalmers I, Adelstein AM. The role of standardisation in the

interpretation of perinatal mortality rates. Health Trends 1980; 12: 45-507 Report of the expert group on special care for babies Chaired by Sir Wilfred Sheldon.

London. H.M Stationery Office, 1971; appendix 9· 33.8 Macquire GC, Nordin J, Meyers MG, Koontz FP, Hierholzer W, Nassif E Infections

acquired by young infants Am J Dis Child 1981, 135: 693-98.9. Richards MPM Roberton NRC Admission and discharge policies for special care

units In: Brimblecombe FSW, Richards MPM, Roberton NRC eds. Separationand special care baby units. London. Spastics International Publications withWilliam Heinemann, 1978: p. 82-110.

10 Richards MPM Possible effects of early separation on later development of children: areview In Brimblecombe FSW, Richards MPM, Roberton NRC, eds Separationand special care baby units London:Spastics International Medical Publicationswith William Heinemann, 1978 12-32.

11 Lloyd B, Pursall E, Emery JL Hospital mobidity pattern in children under 1 year of agein Sheffield 1975-76 Arch Dis Child 1981; 56: 36-9.

12 Hack M, DeMonterice D, Merkatz IR, Jones P, Fanaroff AA Rehospitalization of thevery-low-birthweight infant Am J Dis Child 1981; 135: 263-66

13. Raivio KO, Hallman N Neonatal hypoglycaemia 1. Occurrence of hypoglycaemia inpatients with various neonatal disorders Acta Paediat Scand 1968; 57: 517-21.

14. Lubchenco LO, Bard H Incidence of hypoglycaemia in newborn infants classified bybirthweight and gestational age Pediatrics 1971; 47: 831-38.

15. Simpson H, Walker G Estimating the cots required for neonatal intensive care. ArchDis Child 1981; 56: 90-3

16 Roberton NRC. Perinatal care and Government policy Lancet 1981; i: 9917 Roberton NRC Perinatal mortality Arch Dis Child 1981, 56: 48418 Roberton NRC Perinatal care and the Short committee Lancet 1981; i: 94

Screening for Disease

COMPARISON OF QUESTIONNAIRE ANDLABORATORY TESTS IN THE DETECTION OFEXCESSIVE DRINKING AND ALCOHOLISM

M. W. BERNADTC. TAYLOR

J. MUMFORDB. SMITH

R. M. MURRAY

Institute of Psychiatry, De Crespigny Park, London SE5

Summary A comparison was made between the efficacyof eight laboratory tests and three rapid

interviews in the detection of excessive drinking andalcoholism among 385 psychiatric patients. &ggr;-glutamyltranspeptidase, the best of the laboratory tests, detected onlya third of those consuming more than 16 "drinks" per day orindependently diagnosed as alcoholic. In contrast, the BriefMAST, the Cage, and the Reich interviews each identifiednine out often alcoholics, and the Cage and Reich interviewsdetected 93% and 98% of excessive drinkers respectively.The three interviews, each of which takes less than 1 min toadminister, have considerable potential for use in the routinescreening of high-risk groups, such as hospital patients.

INTRODUCTION

THE growing prevalence of alcohol-related disorders hasposed problems for medical, surgical, and psychiatricservices throughout the developed world. 1-4 In response,American researchers have devised a number of rapidinterview techniques for detecting alcoholism, the bestknown being the Michigan Alcoholism Screening Test(MAST)5-’ and Cage.8,9 The items of these interviews relateto abnormal drinking behaviour (e.g., drinking on waking)and alcohol-induced problems, rather than the amount ofalcohol consumed per se. In contrast, European researchers,mindful of the reputed tendency of heavy drinkers to denytheir problems, have concentrated on relating laboratorymeasures, such as ’serum-gamma-glutamyl-transpeptidase(y-GT)lo-’3 and mean corpuscular volume (MCV),12,14-16 tooverall alcohol consumption.There have been repeated calls for one or other of these

tests to be used for screening high-risk groups.4,17Unfortunately, many of the relevant studies were carried outin apparent ignorance of the principles of effective screeningfor disease, 18 and others have been severely criticised for theircircularity, small or biased samples, and failure to take intoaccount confounding variables. 19,20 In only a fewinstancesI3,20-22 were the putative screening tests comparedagainst valid consumption data. Finally, although four yearsago a World Health Organisation study group indicated23 theneed for "correlation of questionnaire and laboratory