J3I
~S 1717 I T
SATURDAY 21 OCTOBER 1978 j[LONDON, HJ
MEDICAL JOURNAL Caring for babies of very low birth weight Over two-thirds of all deaths in the first week of life occur in babies of low birth weight (less than 2500 g) who are perfectly formed. Most have been born too soon, and pulmonary immaturity and intraventricular haemorrhage are the leading causes of death. Some are mature but have grown poorly in the uterus and are vulnerable to perinatal asphyxia. A few low-birthweight babies suffer the dual disadvantage of being premature and malnourished. Among the many developments in neonatal intensive care in the past 10 years one of the most important has been mechanical ventilation for very small babies. The most common indication is incipient or established respiratory failure associated with severe respiratory distress syndrome or recurrent apnoeic attacks. These very ill neonates also need nutritional support by transpyloric feeding or total intravenous alimentation; frequent measurements of blood glucose, bilirubin, and electrolyte concentrations; monitoring for coagulopathy and small fresh blood transfusions or exchange transfusions; and prompt recognition and treatment of sepsis and the estimation of serum concentrations of antibioticswhile all the time the staff must encourage close contact and interaction between the mother and her child. Many centres have reported improved neonatal survival rates in babies of very low birth weight since intensive-care facilities were introduced.1 2 In babies with birth weights of 750-1000 g and 1001-1500 g the survival rates have now risen (in good units) to 50%/' and over 7000 respectively.2-6 We should, however, interpret neonatal survival statistics cautiously and only in the light of data on neonatal morbidity and on the population from which the sample of babies is drawn. Longterm follow-up studies of babies of very low birth weight who were born before the era of intensive care showed that over half the survivors were severely incapacitated by cerebral palsy,7 8 most often spastic diplegia.9-11 Serious visual handicap, usually the result of retrolental fibroplasia, was found in 10-30%/" of survivors,8 9 11 and the incidence of sensorineural hearing loss was about 100%.8 Since the introduction of intensive care, the frequency of all these types of major handicap in surviving babies of very low birth weight has decreased.12 13 The most dramatic fall has been in the incidence of cerebral palsy,14-'8 which is now only 0-5%/O. But the results reported from specialised neonatal intensivecare units do not reflect the experience of conventional specialcare baby units-where most low-birthweight babies are ¢) BRITISH MEDICAL JOURNAL 1978. All reproduction rights reserved.
nursed in Britain. The hallmark of good neonatal care is anticipation and prompt intervention before a baby's condition so far deteriorates that full-scale intensive care is needed to reverse cardiorespiratory failure. The ominous signs associated with a high mortality rate in very small babies include the delayed onset of respiration at birth, recurrent apnoeic episodes, respiratory distress, and hypothermia; clinical deterioration may be measured in minutes and hours rather than days. Clearly, then, the neonatal care in any maternity hospital catering for low-birthweight babies has certain basic requirements-for example, staff skilled in resuscitation of the newborn (not merely someone who can intubate) immediately available round the clock, and facilities for continuous temperature monitoring of the baby, with scrupulous attention to preventing heat loss; monitoring for apnoea with reliable respiration and heart-rate recorders; and measuring ambient oxygen concentration and arterial Po2, Pco2, and pH. This degree of supervision, essential in any intensive-care unit, requires nurses and doctors to have some knowledge of neonatal pathophysiology and an almost obsessional attitude to fine details of nursing and medical care. Such standards do not apply in most British maternity hospitals. A recent survey'9 of babies of very low birth weight (under 2000 g) born in three South-east London boroughs during 1970, 1971, and 1973 emphasised the influence on neonatal mortality of the babies' condition at birth, the temperature of infants on admission to the special-care baby unit, and the presence of respiratory diseases. There were appreciable differences in mortality rates between individual special-care baby units, and these appeared to be related to deficiencies in medical and nursing staffing, particularly at night and weekends. For example, temperatures were not recorded in nearly one-third of neonates nursed in the special-care baby unit with the lowest staff:cot ratio-and the greatest mortality. Most special-care baby units cannot and should not develop the facilities required for an efficient mechanical ventilation service. A conventional special-care baby unit cannot become an intensive-care unit overnight by the purchase of one or two mechanical ventilators, nor is the recipe for improved neonatal mortality and long-term morbidity rates found within the wrappings of high technology. Regional neonatal intensive-care units can provide a safe transportation service for sick babies from maternity hospitals-as has been shown already in several parts of Britain.20 This is the right solution NO 6145 PAGE 1105
1106
BRITISH MEDICAL JOURNAL
-so long as the emergence of intensive-care units does not lead to declining standards of care in special-care baby units. Instead, intensive- and special-care units should be organised in parallel, and both must maintain high standards, albeit with a different emphasis, appropriate to their babies' needs. Rawlings, G, et al, Lancet, 1971, 1, 516. Usher, R, Seminars in Perinatology, 1977, 1, 309. 3Pape, K E, et al,,Journal of Pediatrics, 1978, 92, 253. 4Pomerance, J J, et al, Pediatrics, 1978, 61, 908. 5Sarasohn, C, Pediatric Clinics of North America, 1977, 24, 619. 6 Stewart, A L, and Reynolds, E 0 R, Pediatrics, 1974, 54, 724. 7Drillien, C M, Archives of Disease in Childhood, 1969, 44, 562. 8 Lubchenco, L 0, et al' American Journal of Diseases of Children, 1963,106, 2
101.
Drillien, C M, The Growth and Development of the Prematurely Born Infant. Edinburgh, Livingstone, 1964. 0 Lubchenco, L 0, et al, journal of Pediatrics, 1972, 80, 501. 1 McDonald, A, Children of Very Low Birthweight. London, Heineman, 1967. 12 Davies, P A, and Stewart, A L, British Medical Bulletin, 1975, 31, 85. 13 Franco, S, and Andrews, B F, Pediatric Clinics of North America, 1977, 24, 639. 14 Bjerre, I, Acta Paediatrica Scandinavica, 1975, 64, 859. 15 Churchill, J A, et al, Developmental Medicine and Child Neurology, 1974, 16, 143. 16 Davies, P A, and Tizard, J P M, Developmental Medicine and Child Neurology, 1975, 17, 3. 17 Fitzhardinge, P M, and Ramsay, M, Developmental Medicine and Child Neurology, 1973, 15, 447. 18 Sabel, K G, Olegard, R, and Victorin, L, Pediatrics, 1976, 57, 652. 19 Stanley, F J, and Alberman, E D, Developmental Medicine and Child Neurology, 1978, 20, 300. 20 Blake, A M, et al, British 1975, 4, 13.
Medical_Journal,
The telephone in general practice Should the telephone be used more widely for consultation in general practice ? Reactions among doctors vary from guarded to enthusiastic. A common opinion seems to be that the telephone is a useful tool when doctors take the initiative but a nuisance when used by patients wanting to speak to their doctor. No one, however, seems to have asked patients for their views. Any theoretical legal hazards of telephone consultation are not apparently reflected in litigation by disgruntled patients'at any rate in Britain. Most published comments on experience with telephone consultation have come from North America, where (partly perhaps because distances are greater) home visiting is less frequent than in Britain. Katz et a12 described a telephone care system using medical auxiliaries, and reported that their assistants resolved 92% of the paediatric problems without intervention by a doctor and that 90% of the parents were satisfied with this system. This represents a much cheaper method of delivering medical care and advice to the community; indeed, Westbury3 commented in his Canadian study that "the telephone practice accounts for about 20% of the total practice workload ... the use of the telephone for medical purposes saves much time for the paying agency." Reports have also appeared of nursing by telephone,4 a comparison between television and the telephone in the remote consultation,5 and the use of Mediphone,6 which is a medical information and consulting service for doctors. In Denmark there is a well-established telephone time when patients know they can speak to a doctor in the practice-though once again this is a fee-paying service. Nearer to home, Watts7 pointed out seven years ago that by making so little use of the telephone in psychiatric medicine we were "neglecting a
21 OCTOBER 1978
powerful tool which costs so little beyond time, sympathy and a listening ear." The telephone, then, whatever its limitations, is a convenient aid: why are the British so reluctant to use it ? One reason must be ignorance of its potential. Doctors in training could and should be taught the correct use, the limitations, and the advantages and disadvantages of- the telephone in general practice. The organisation of the. practice needs rethinking to take account of this aspect of doctor-patient contact. How many handsets and how many lines would be needed, which lines would be for outgoing rather than incoming calls, who would screen the calls (if they are to be screened), how would the doctors allocate the time to deal with the calls, and would the doctor keep a record of what was said on the telephone? The list is long, with many ramifications, but the problems are not insuperable. Without publicity many doctors already have good systems whereby patients know when to telephone if they wish to speak to a doctor, even their "own" doctor. In rural practices the telephone has thrived as public transport has declined, so that both follow-up and consultations by telephone have become commonplace, though undocumented in journals. Even in urban practices many doctors already encourage their patients to telephone for laboratory results, repeat prescriptions, and follow-up information about an illness in the family. -Neither the ethical nor the legal pitfalls of these uses of telephone consultation have been given any publicity, but that should not in any way discourage its further growth. In other countries the telephone is used more readily because of demand from patients. They know that consulting the doctor by telephone is cheaper and more convenient than asking him to visit. In Britain, by contrast, patients know that doctors will visit or that they will be seen in the surgery, and therefore persuading and educating them to use the telephone might not be easy. There are still old people who think that the doctor should visit every two weeks. Yet the telephone can give the patient contact with the doctor more quickly and more easily than any other method, to the benefit of all concerned. With appointment systems, multistorey health centres, practice nurses, receptionists, and the whole panoply of the primary care team our patients could be forgiven for thinking that general practitioners are becoming increasingly distant, detached, and unapproachable. Using the telephone to its full potential could help to reverse that trend. Defence Union, unpublished information. 'Medical 2 Katz, H P, Pozen, J, and Mushlin, A I, American Journal of Public Health,
1978, 68, 31. Westbury, R C, Canadian Family Physician, 1974, 20, 69. Murphy, D, and Dineen, E, American Journal of Nursing, 1975, 7, 1137. Moore, G T, et al, New England Journal of Medicine, 1975, 292, 729. 6 Bellows, J G, New York State Journal of Medicine, 1974, 1, 1082. 7 Watts, C A, British MedicalJournal, 1971, 3, 419. 3 4 5
Crohn's disease-40 years on Despite the fact that it is relatively common, ileocaecal Crohn's disease has no specific treatment. Indeed, its management is comparable with that of tuberculosis in prestreptomycin days. The disease usually presents with diarrhoea, abdominal pain, and loss of weight. Less often the first symptoms are due to malnutrition, intra-abdominal abscesses, fistula formation, or anal lesions, all of which are commonly seen in established disease. Supportive medical care (especially ensuring adequate
~S 1717 I T
SATURDAY 21 OCTOBER 1978 j[LONDON, HJ
MEDICAL JOURNAL Caring for babies of very low birth weight Over two-thirds of all deaths in the first week of life occur in babies of low birth weight (less than 2500 g) who are perfectly formed. Most have been born too soon, and pulmonary immaturity and intraventricular haemorrhage are the leading causes of death. Some are mature but have grown poorly in the uterus and are vulnerable to perinatal asphyxia. A few low-birthweight babies suffer the dual disadvantage of being premature and malnourished. Among the many developments in neonatal intensive care in the past 10 years one of the most important has been mechanical ventilation for very small babies. The most common indication is incipient or established respiratory failure associated with severe respiratory distress syndrome or recurrent apnoeic attacks. These very ill neonates also need nutritional support by transpyloric feeding or total intravenous alimentation; frequent measurements of blood glucose, bilirubin, and electrolyte concentrations; monitoring for coagulopathy and small fresh blood transfusions or exchange transfusions; and prompt recognition and treatment of sepsis and the estimation of serum concentrations of antibioticswhile all the time the staff must encourage close contact and interaction between the mother and her child. Many centres have reported improved neonatal survival rates in babies of very low birth weight since intensive-care facilities were introduced.1 2 In babies with birth weights of 750-1000 g and 1001-1500 g the survival rates have now risen (in good units) to 50%/' and over 7000 respectively.2-6 We should, however, interpret neonatal survival statistics cautiously and only in the light of data on neonatal morbidity and on the population from which the sample of babies is drawn. Longterm follow-up studies of babies of very low birth weight who were born before the era of intensive care showed that over half the survivors were severely incapacitated by cerebral palsy,7 8 most often spastic diplegia.9-11 Serious visual handicap, usually the result of retrolental fibroplasia, was found in 10-30%/" of survivors,8 9 11 and the incidence of sensorineural hearing loss was about 100%.8 Since the introduction of intensive care, the frequency of all these types of major handicap in surviving babies of very low birth weight has decreased.12 13 The most dramatic fall has been in the incidence of cerebral palsy,14-'8 which is now only 0-5%/O. But the results reported from specialised neonatal intensivecare units do not reflect the experience of conventional specialcare baby units-where most low-birthweight babies are ¢) BRITISH MEDICAL JOURNAL 1978. All reproduction rights reserved.
nursed in Britain. The hallmark of good neonatal care is anticipation and prompt intervention before a baby's condition so far deteriorates that full-scale intensive care is needed to reverse cardiorespiratory failure. The ominous signs associated with a high mortality rate in very small babies include the delayed onset of respiration at birth, recurrent apnoeic episodes, respiratory distress, and hypothermia; clinical deterioration may be measured in minutes and hours rather than days. Clearly, then, the neonatal care in any maternity hospital catering for low-birthweight babies has certain basic requirements-for example, staff skilled in resuscitation of the newborn (not merely someone who can intubate) immediately available round the clock, and facilities for continuous temperature monitoring of the baby, with scrupulous attention to preventing heat loss; monitoring for apnoea with reliable respiration and heart-rate recorders; and measuring ambient oxygen concentration and arterial Po2, Pco2, and pH. This degree of supervision, essential in any intensive-care unit, requires nurses and doctors to have some knowledge of neonatal pathophysiology and an almost obsessional attitude to fine details of nursing and medical care. Such standards do not apply in most British maternity hospitals. A recent survey'9 of babies of very low birth weight (under 2000 g) born in three South-east London boroughs during 1970, 1971, and 1973 emphasised the influence on neonatal mortality of the babies' condition at birth, the temperature of infants on admission to the special-care baby unit, and the presence of respiratory diseases. There were appreciable differences in mortality rates between individual special-care baby units, and these appeared to be related to deficiencies in medical and nursing staffing, particularly at night and weekends. For example, temperatures were not recorded in nearly one-third of neonates nursed in the special-care baby unit with the lowest staff:cot ratio-and the greatest mortality. Most special-care baby units cannot and should not develop the facilities required for an efficient mechanical ventilation service. A conventional special-care baby unit cannot become an intensive-care unit overnight by the purchase of one or two mechanical ventilators, nor is the recipe for improved neonatal mortality and long-term morbidity rates found within the wrappings of high technology. Regional neonatal intensive-care units can provide a safe transportation service for sick babies from maternity hospitals-as has been shown already in several parts of Britain.20 This is the right solution NO 6145 PAGE 1105
1106
BRITISH MEDICAL JOURNAL
-so long as the emergence of intensive-care units does not lead to declining standards of care in special-care baby units. Instead, intensive- and special-care units should be organised in parallel, and both must maintain high standards, albeit with a different emphasis, appropriate to their babies' needs. Rawlings, G, et al, Lancet, 1971, 1, 516. Usher, R, Seminars in Perinatology, 1977, 1, 309. 3Pape, K E, et al,,Journal of Pediatrics, 1978, 92, 253. 4Pomerance, J J, et al, Pediatrics, 1978, 61, 908. 5Sarasohn, C, Pediatric Clinics of North America, 1977, 24, 619. 6 Stewart, A L, and Reynolds, E 0 R, Pediatrics, 1974, 54, 724. 7Drillien, C M, Archives of Disease in Childhood, 1969, 44, 562. 8 Lubchenco, L 0, et al' American Journal of Diseases of Children, 1963,106, 2
101.
Drillien, C M, The Growth and Development of the Prematurely Born Infant. Edinburgh, Livingstone, 1964. 0 Lubchenco, L 0, et al, journal of Pediatrics, 1972, 80, 501. 1 McDonald, A, Children of Very Low Birthweight. London, Heineman, 1967. 12 Davies, P A, and Stewart, A L, British Medical Bulletin, 1975, 31, 85. 13 Franco, S, and Andrews, B F, Pediatric Clinics of North America, 1977, 24, 639. 14 Bjerre, I, Acta Paediatrica Scandinavica, 1975, 64, 859. 15 Churchill, J A, et al, Developmental Medicine and Child Neurology, 1974, 16, 143. 16 Davies, P A, and Tizard, J P M, Developmental Medicine and Child Neurology, 1975, 17, 3. 17 Fitzhardinge, P M, and Ramsay, M, Developmental Medicine and Child Neurology, 1973, 15, 447. 18 Sabel, K G, Olegard, R, and Victorin, L, Pediatrics, 1976, 57, 652. 19 Stanley, F J, and Alberman, E D, Developmental Medicine and Child Neurology, 1978, 20, 300. 20 Blake, A M, et al, British 1975, 4, 13.
Medical_Journal,
The telephone in general practice Should the telephone be used more widely for consultation in general practice ? Reactions among doctors vary from guarded to enthusiastic. A common opinion seems to be that the telephone is a useful tool when doctors take the initiative but a nuisance when used by patients wanting to speak to their doctor. No one, however, seems to have asked patients for their views. Any theoretical legal hazards of telephone consultation are not apparently reflected in litigation by disgruntled patients'at any rate in Britain. Most published comments on experience with telephone consultation have come from North America, where (partly perhaps because distances are greater) home visiting is less frequent than in Britain. Katz et a12 described a telephone care system using medical auxiliaries, and reported that their assistants resolved 92% of the paediatric problems without intervention by a doctor and that 90% of the parents were satisfied with this system. This represents a much cheaper method of delivering medical care and advice to the community; indeed, Westbury3 commented in his Canadian study that "the telephone practice accounts for about 20% of the total practice workload ... the use of the telephone for medical purposes saves much time for the paying agency." Reports have also appeared of nursing by telephone,4 a comparison between television and the telephone in the remote consultation,5 and the use of Mediphone,6 which is a medical information and consulting service for doctors. In Denmark there is a well-established telephone time when patients know they can speak to a doctor in the practice-though once again this is a fee-paying service. Nearer to home, Watts7 pointed out seven years ago that by making so little use of the telephone in psychiatric medicine we were "neglecting a
21 OCTOBER 1978
powerful tool which costs so little beyond time, sympathy and a listening ear." The telephone, then, whatever its limitations, is a convenient aid: why are the British so reluctant to use it ? One reason must be ignorance of its potential. Doctors in training could and should be taught the correct use, the limitations, and the advantages and disadvantages of- the telephone in general practice. The organisation of the. practice needs rethinking to take account of this aspect of doctor-patient contact. How many handsets and how many lines would be needed, which lines would be for outgoing rather than incoming calls, who would screen the calls (if they are to be screened), how would the doctors allocate the time to deal with the calls, and would the doctor keep a record of what was said on the telephone? The list is long, with many ramifications, but the problems are not insuperable. Without publicity many doctors already have good systems whereby patients know when to telephone if they wish to speak to a doctor, even their "own" doctor. In rural practices the telephone has thrived as public transport has declined, so that both follow-up and consultations by telephone have become commonplace, though undocumented in journals. Even in urban practices many doctors already encourage their patients to telephone for laboratory results, repeat prescriptions, and follow-up information about an illness in the family. -Neither the ethical nor the legal pitfalls of these uses of telephone consultation have been given any publicity, but that should not in any way discourage its further growth. In other countries the telephone is used more readily because of demand from patients. They know that consulting the doctor by telephone is cheaper and more convenient than asking him to visit. In Britain, by contrast, patients know that doctors will visit or that they will be seen in the surgery, and therefore persuading and educating them to use the telephone might not be easy. There are still old people who think that the doctor should visit every two weeks. Yet the telephone can give the patient contact with the doctor more quickly and more easily than any other method, to the benefit of all concerned. With appointment systems, multistorey health centres, practice nurses, receptionists, and the whole panoply of the primary care team our patients could be forgiven for thinking that general practitioners are becoming increasingly distant, detached, and unapproachable. Using the telephone to its full potential could help to reverse that trend. Defence Union, unpublished information. 'Medical 2 Katz, H P, Pozen, J, and Mushlin, A I, American Journal of Public Health,
1978, 68, 31. Westbury, R C, Canadian Family Physician, 1974, 20, 69. Murphy, D, and Dineen, E, American Journal of Nursing, 1975, 7, 1137. Moore, G T, et al, New England Journal of Medicine, 1975, 292, 729. 6 Bellows, J G, New York State Journal of Medicine, 1974, 1, 1082. 7 Watts, C A, British MedicalJournal, 1971, 3, 419. 3 4 5
Crohn's disease-40 years on Despite the fact that it is relatively common, ileocaecal Crohn's disease has no specific treatment. Indeed, its management is comparable with that of tuberculosis in prestreptomycin days. The disease usually presents with diarrhoea, abdominal pain, and loss of weight. Less often the first symptoms are due to malnutrition, intra-abdominal abscesses, fistula formation, or anal lesions, all of which are commonly seen in established disease. Supportive medical care (especially ensuring adequate
