Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants

BMJ 1999;318:627-632 ( 6 March )

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Editorial by Hall

Cathryn M A Glazener, clinical research fellow, ^a Craig R Ramsay, research fellow, ^a Marion K Campbell, senior statistician, ^a Philip Booth, consultant paediatrician, ^b Paul Duffty, consultant paediatrician, ^b David J Lloyd, consultant in perinatal medicine, ^b Alison McDonald, project administrator, ^a J Anne Reid, associate specialist in medical paediatrics. ^b

^a Health Services Research Unit, Polwarth Building, Aberdeen AB25 2ZD, ^b Aberdeen Maternity Hospital, Aberdeen AB25 2ZL

Correspondence to: Dr Glazener c.glazener{at}abdn.ac.uk

Objective: To evaluate the effectiveness of one ratherthan two hospital neonatal examinations in detection ofabnormalities.
Design: Randomised controlled switchbacktrial.
Setting: Postnatal wards in a teaching hospital innorth eastScotland.
Participants: All infants delivered at the hospital betweenMarch 1993 and February1995.
Intervention: A policy of one neonatal screening examinationcompared with a policy oftwo.
Main outcome measures: Congenital conditions diagnosed in hospital;results of community health assessments at 8 weeks and 8 months;outpatient referrals; inpatient admissions; use of general practionerservices; focused analysis of outcomes for suspected hip and heartabnormalities.
Results: 4835 babies were allocated to receive onescreening examination (one screen policy) and 4877 to receivetwo (two screen policy). More congenital conditions were suspectedat discharge among babies examined twice (9.9 v 8.3 diagnosesper 100 babies; 95% confidence interval for difference 0.3 to2.7). There was no overall significant difference between thegroups in use of community, outpatient, or inpatient resourcesor in health care received. Although more babies who were examinedtwice attended orthopaedic outpatient clinics (340 (7%) v 289(6%)), particularly for suspected congenital dislocation of thehip (176 (3.6/100 babies) v 137 (2.8/100 babies); difference $-$ 0.8; $-$ 1.5 to 0.1), there was no significant difference in the numberof babies who required active management (12 (0.2%) v 15 (0.3%)).
Conclusions: Despite more suspected abnormalities, therewas no evidence of net health gain from a policy of two hospitalneonatal examinations. Adoption of a single examination policywould save resources both during the postnatal hospital stay andthrough fewer outpatientconsultations.

Key messages

Neonatal screening in hospital after delivery can be safely carried out once rather than twice
Introduction of this policy would save hospital resources, both during the postnatal period and subsequently through fewer outpatient consultations
Later surveillance is an essential complement to hospital screening (whether performed once or twice) to detect abnormalities missed in hospital and conditions which develop after discharge

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