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Neonatal intubation training: the patient comes first
THE EDITORS’ PERSPECTIVES Neonatal intubation training: the patient comes first — Robin H. Steinhorn, MD
“Loose joints” — Thomas R. Welch, MD
October 2016
P
remature babies that require resuscitation are highly vulnerable to poor outcomes, including death, intraventricular hemorrhage, and neurodevelopmental impairment. As a result, the early minutes of neonatal resuscitation are viewed as a “golden hour” requiring technical precision and choreographed teamwork. Sauer et al used their large database of resuscitation data to show that multiple intubation attempts, particularly in the smallest babies, dramatically increased rates of intraventricular hemorrhage. As trainees typically require more attempts while learning intubation, the data from Sauer et al also suggest that delivery room resuscitation of extremely preterm babies is a poor training environment for pediatric residents. Yet, the Accreditation Council for Graduate Medical Education continues to mandate proficiency in neonatal intubation, even as the number of opportunities fall and the stakes associated with the procedure rise. Although simulation can provide some support in learning intubation mechanics, it does not fully build competency. It is time to re-examine which trainees will truly require this skill and develop novel approaches to build expertise. In the meantime, intubation training should be confined to more mature, stable, and sedated neonates. Article page 108 ▶
“
B
enign joint hypermobility syndrome” (BJH) is increasingly being mentioned in the pediatric literature, and the term is being introduced to our readers in an article by Chelimsky et al in this volume of The Journal. BJH is an objective entity, diagnosed by specific physical findings (the Brighton criteria). It has been recognized that BJH overlaps with a number of childhood chronic pain syndromes, such as functional gastrointestinal disorders. It is not clear whether BJH contributes to the development of these other functional complaints, or is simply a comorbid finding with them. One way in which BJM could actually contribute to chronic pain syndromes is through autonomic dysfunction. It has already been shown that BJM may be associated with autonomic dysfunction, such as postural tachycardia syndrome. To assess this possibility, Chelimsky et al examined a group of children from their clinical programs providing care for children with chronic pain syndromes. All of the children had both formal autonomic testing and Brighton scoring. There was no difference in the frequency of abnormal autonomic testing between children with and without BJH. Thus, it seems less likely that the autonomic dysfunction is the driver of chronic pain syndromes in children with BJH. Although this study focuses on a very narrow question, this report provides a very nice introduction to an exciting area of interest in these very difficult children. Article page 49 ▶
3
“Loose joints” — Thomas R. Welch, MD
October 2016
P
remature babies that require resuscitation are highly vulnerable to poor outcomes, including death, intraventricular hemorrhage, and neurodevelopmental impairment. As a result, the early minutes of neonatal resuscitation are viewed as a “golden hour” requiring technical precision and choreographed teamwork. Sauer et al used their large database of resuscitation data to show that multiple intubation attempts, particularly in the smallest babies, dramatically increased rates of intraventricular hemorrhage. As trainees typically require more attempts while learning intubation, the data from Sauer et al also suggest that delivery room resuscitation of extremely preterm babies is a poor training environment for pediatric residents. Yet, the Accreditation Council for Graduate Medical Education continues to mandate proficiency in neonatal intubation, even as the number of opportunities fall and the stakes associated with the procedure rise. Although simulation can provide some support in learning intubation mechanics, it does not fully build competency. It is time to re-examine which trainees will truly require this skill and develop novel approaches to build expertise. In the meantime, intubation training should be confined to more mature, stable, and sedated neonates. Article page 108 ▶
“
B
enign joint hypermobility syndrome” (BJH) is increasingly being mentioned in the pediatric literature, and the term is being introduced to our readers in an article by Chelimsky et al in this volume of The Journal. BJH is an objective entity, diagnosed by specific physical findings (the Brighton criteria). It has been recognized that BJH overlaps with a number of childhood chronic pain syndromes, such as functional gastrointestinal disorders. It is not clear whether BJH contributes to the development of these other functional complaints, or is simply a comorbid finding with them. One way in which BJM could actually contribute to chronic pain syndromes is through autonomic dysfunction. It has already been shown that BJM may be associated with autonomic dysfunction, such as postural tachycardia syndrome. To assess this possibility, Chelimsky et al examined a group of children from their clinical programs providing care for children with chronic pain syndromes. All of the children had both formal autonomic testing and Brighton scoring. There was no difference in the frequency of abnormal autonomic testing between children with and without BJH. Thus, it seems less likely that the autonomic dysfunction is the driver of chronic pain syndromes in children with BJH. Although this study focuses on a very narrow question, this report provides a very nice introduction to an exciting area of interest in these very difficult children. Article page 49 ▶
3