Intended for healthcare professionals

Papers

Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infantsCommentary: “Switchback” allocationdangerous bends ahead!

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7184.627 (Published 06 March 1999) Cite this as: BMJ 1999;318:627

Abstract

Objective: To evaluate the effectiveness of one rather than two hospital neonatal examinations in detection of abnormalities.

Design: Randomised controlled switchback trial.

Setting: Postnatal wards in a teaching hospital in north east Scotland.

Participants: All infants delivered at the hospital between March 1993 and February 1995.

Intervention: A policy of one neonatal screening examination compared with a policy of two.

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 practioner services; focused analysis of outcomes for suspected hip and heart abnormalities.

Results: 4835 babies were allocated to receive one screening examination (one screen policy) and 4877 to receive two (two screen policy). More congenital conditions were suspected at discharge among babies examined twice (9.9 v 8.3 diagnoses per 100 babies; 95% confidence interval for difference 0.3 to 2.7). There was no overall significant difference between the groups in use of community, outpatient, or inpatient resources or in health care received. Although more babies who were examined twice attended orthopaedic outpatient clinics (340 (7%) v 289(6%)), particularly for suspected congenital dislocation of the hip (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 number of babies who required active management (12 (0.2%) v 15 (0.3%)).

Conclusions: Despite more suspected abnormalities, there was no evidence of net health gain from a policy of two hospital neonatal examinations. Adoption of a single examination policy would save resources both during the postnatal hospital stay and through fewer outpatient consultations.

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

Footnotes

    • Accepted 9 November 1998

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

    1. Cathryn M A Glazener (c.glazener{at}abdn.ac.uk), clinical research fellowa,
    2. Craig R Ramsay, research fellowa,
    3. Marion K Campbell, senior statisticiana,
    4. Philip Booth, consultant paediatricianb,
    5. Paul Duffty, consultant paediatricianb,
    6. David J Lloyd, consultant in perinatal medicineb,
    7. Alison McDonald, project administratora,
    8. J Anne Reid, associate specialist in medical paediatricsb
    1. aHealth Services Research Unit, Polwarth Building, Aberdeen AB25 2ZD
    2. bAberdeen Maternity Hospital, Aberdeen AB25 2ZL
    3. NHS/ICRF Centre for Statistics in Medicine, Institute of Health Sciences, Oxford OX3 7LF
    1. Correspondence to: Dr Glazener
    • Accepted 9 November 1998

    Abstract

    Objective: To evaluate the effectiveness of one rather than two hospital neonatal examinations in detection of abnormalities.

    Design: Randomised controlled switchback trial.

    Setting: Postnatal wards in a teaching hospital in north east Scotland.

    Participants: All infants delivered at the hospital between March 1993 and February 1995.

    Intervention: A policy of one neonatal screening examination compared with a policy of two.

    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 practioner services; focused analysis of outcomes for suspected hip and heart abnormalities.

    Results: 4835 babies were allocated to receive one screening examination (one screen policy) and 4877 to receive two (two screen policy). More congenital conditions were suspected at discharge among babies examined twice (9.9 v 8.3 diagnoses per 100 babies; 95% confidence interval for difference 0.3 to 2.7). There was no overall significant difference between the groups in use of community, outpatient, or inpatient resources or in health care received. Although more babies who were examined twice attended orthopaedic outpatient clinics (340 (7%) v 289(6%)), particularly for suspected congenital dislocation of the hip (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 number of babies who required active management (12 (0.2%) v 15 (0.3%)).

    Conclusions: Despite more suspected abnormalities, there was no evidence of net health gain from a policy of two hospital neonatal examinations. Adoption of a single examination policy would save resources both during the postnatal hospital stay and through fewer outpatient consultations.

    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

    Footnotes

      • Accepted 9 November 1998

      Commentary: “Switchback” allocationdangerous bends ahead!

      1. Jonathan J Deeks (j.deeks{at}icrf.icnet.uk), medical statistician
      1. aHealth Services Research Unit, Polwarth Building, Aberdeen AB25 2ZD
      2. bAberdeen Maternity Hospital, Aberdeen AB25 2ZL
      3. NHS/ICRF Centre for Statistics in Medicine, Institute of Health Sciences, Oxford OX3 7LF
          View Full Text