As part of the process of adopting the WHO standard in the United Kingdom, the Royal College of Paediatrics and Child Health (RCPCH) was commissioned by the UK Department of Health to design new UK-WHO growth charts. The working group for this project combined expertise ranging from statistics and graphic design to qualitative research, as well as paediatrics, nursing and dietetics. New charts for children under 4 years were published in 2009 and are now widely used in the UK and beyond (www.growthcharts.rcpch.ac.uk). This paper will describe what we have learned in general about the process of designing charts and how these principles were applied to the design of a novel chart designed specifically for sick and premature infants. A successful design first requires clarity about the exact purpose of the chart and who will use it. The layout of the chart can then be varied in many ways to fit that use and ensure users are not misled. Users need consistent and well-evidenced rules for chart use. Drafting the instructions serves as a powerful test of the validity and clarity of the design. However, charts need also to be formally evaluated, as expert views will not reflect those of the average user. The Neonatal and Infant Close Monitoring (NICM) chart included various novel design features, including date boxes for gestational age adjustment and low SD lines to help assess very small infants. It was evaluated at three stages using plotting exercises and each phase led to substantial design changes. Growth charts are conceptually very complex, with the capacity to mislead as well as inform and should always be formally evaluated before implementation.

AIM:This paper aims to identify health research priorities that could improve the rate of progress in reducing global neonatal mortality from preterm birth and low birth weight (PB/LBW), as set out in the UN's Millennium Development Goal 4.METHODS:We applied the Child Health and Nutrition Research Initiative (CHNRI) methodology for setting priorities in health research investments. In the process coordinated by the World Health Organization in 2007-2008, 21 researchers with interest in child, maternal and newborn health suggested 82 research ideas that spanned across the broad spectrum of epidemiological research, health policy and systems research, improvement of existing interventions and development of new interventions. The 82 research questions were then assessed for answerability, effectiveness, deliverability, maximum potential for mortality reduction and the effect on equity using the CHNRI method.RESULTS:The top 10 identified research priorities were dominated by health systems and policy research questions (eg, identification of LBW infants born at home within 24-48 hours of birth for additional care; approaches to improve quality of care of LBW infants in health facilities; identification of barriers to optimal home care practices including care seeking; and approaches to increase the use of antenatal corticosteriods in preterm labor and to improve access to hospital care for LBW infants). These were followed by priorities for improvement of the existing interventions (eg, early initiation of breastfeeding, including feeding mode and techniques for those unable to suckle directly from the breast; improved cord care, such as chlorhexidine application; and alternative methods to Kangaroo Mother Care (KMC) to keep LBW infants warm in community settings). The highest-ranked epidemiological question suggested improving criteria for identifying LBW infants who need to be cared for in a hospital. Among the new interventions, the greatest support was shown for the development of new simple and effective interventions for providing thermal care to LBW infants, if KMC is not acceptable to the mother.CONCLUSION:The context for this exercise was set within the MDG4, requiring an urgent and rapid progress in mortality reduction from low birth weight, rather than identifying long-term strategic solutions of the greatest potential. In a short-term context, the health policy and systems research to improve access and coverage by the existing interventions, coupled with further research to improve effectiveness, deliverability and acceptance of existing interventions, and epidemiological research to address the key gaps in knowledge, were all highlighted as research priorities.

The decision to adopt the new WHO standard in the UK necessitated substantial changes to the neonatal section of the chart, including separation of the preterm UK birth weight reference from the WHO standard. The evidence-based design process has led to several novel features that could be generally applied in other chart designs, and revealed uncertainties leading to inconsistencies in charting. Failing to plot the birth weight of term infants at age 0 can lead to spurious centile crossing in the early weeks of life, particularly among infants at the extreme of gestation. Users will need training to use the charts, but this should improve overall understanding and the use of charts.

Breastfeeding protects babies and mothers against many illnesses. Improving care in the NHS has led to more women starting to breastfeed, but care is still patchy and a lack of support across society means that many breastfeeding mothers encounter problems that force them to stop before they want to. Most of the barriers that prevent mothers from breastfeeding for as long as they want could be removed with access to well-trained health professionals, good quality social support in the community, a widespread understanding of the profound benefits of breastmilk, and an acceptance within society that breastfeeding is normal.

In order to assess the extent to which children in the UK will follow the UK-WHO head circumference standard, the authors used head circumference data from the Southampton Women's Survey (n=3159) and the Avon Longitudinal Study of Parents and Children (n=15 208) in children aged 0-36 months, converted into z-scores using both the UK-WHO and UK1990 references. Rapid head growth was defined as crossing upwards through two major centile bands (1.33 SD). The UK-WHO standard identified many more infants with heads above the 98th centile than to the UK1990 reference (UK-WHO: 6-16% of infants at various ages; UK1990: 1-4%). Rapid head growth in the first 6-9 months was also much more common using the UK-WHO standard (UK-WHO: 14.6-15.3%; UK1990: 4.8-5.1%). Practitioners should be aware of these findings to avoid unnecessary referrals.

Background: The adoption in May 2009 by the UK of the WHO 2006 standard necessitated the provision of UK-based birth centiles for pre-term infants. The pre-existing British 1990 reference birth centiles, used in the UK since 1995, had been biased by the inclusion of post-natal data.Aim: To describe the construction of new UK birth centiles for weight, length and head circumference, based on British 1990 reference data, but excluding post-natal data.Subjects and methods: Birth data from the five original studies, collected between 1983-1993, were pooled and analysed by the LMS method, for the sexes separately. In addition, sex-specific composite centiles were constructed for infants born at term (37-42 completed weeks).Results: The birth data included 9443 weights, 985 lengths and 1841 head circumferences, covering 23-44 weeks gestation. The analysis provided LMS tables defining reference centiles for weight and head circumference from 23-42 weeks and for length from 26-42 weeks. The term centiles are for use at age 0 on the post-natal 0-1 year chart.Conclusion: These new centiles, replacing those of the British 1990 reference, are more accurate than their predecessors which were biased due to the inclusion of post-natal data.

Pre-existing diabetes is one of the commonest medical conditions complicating pregnancy in the UK, and is associated with increased perinatal and neonatal mortality and morbidity. The prevalence of both type 1 and type 2 diabetes is increasing in the UK and worldwide, and management strategies to optimise health outcomes for mother and baby are of utmost importance. Since 2001, a number of United Kingdom national guidelines have been published which make clear recommendations for optimal maternal glycaemic control before and during pregnancy and for neonatal management. However, there is evidence that these recommendations are not being consistently achieved within the UK and some of the specific challenges are highlighted in this chapter.

Objectives: There is evidence that breastmilk feeding reduces mortality and short and long-term morbidity among infants born too soon or too small. The aim of this study was to evaluate the cost-effectiveness of enhanced staff contact for mothers with infants in a neonatal unit with a birth weight of 500–2,500 g from the perspective of the UK National Health Service.Methods: A decision-tree model linked clinical outcomes with long-term health outcomes. The study population was divided into three weight bands: 500–999 g, 1000–1,749 g, and 1,750–2,500 g. Clinical and resource use data were obtained from literature reviews. The measure of benefit was quality-adjusted life-years. Uncertainty was evaluated using cost-effectiveness acceptability curves and sensitivity analyses.Results: The intervention was less costly and more effective than the comparator in the base–case analysis for each birth weight group. The results were quite robust to the sensitivity analyses performed.Conclusions: This is the first economic evaluation in this complex field and offers a model to be developed in future research. The results provide preliminary indications that enhanced staff contact may be cost-effective. However, the limited evidence available, and the limited UK data in particular, suggest that further research is required to provide results with confidence.

Perspective on the paper by Boyd et al ( see page F169 ) Those caring for the newborn have long appreciated the contribution made by breast milk to short-term and long-term health. In this issue Boyd et al 1 report their systematic search for unbiased evidence comparing outcomes of very low birthweight babies fed donor human milk or formula. The paucity of data identified from such adequately controlled studies is remarkable, given that most very low birthweight infants cared for in the neonatal units of industrialised countries will receive formula at some point during their clinical course. Boyd et al nevertheless demonstrate that formula-fed very low birthweight babies are at significantly increased risk of necrotising enterocolitis (NEC) compared with those fed exclusively on breast milk. Particularly striking is the observation that the estimates of risk and associated confidence intervals were virtually identical—about a fivefold increase—in the studies cited, which were carried out on three continents. This, coupled with the observation that other indicators of feeding intolerance also occurred more frequently in those receiving formula, suggests that the increase in risk is real and not a chance finding. Mortality related to NEC and severity of morbidity among survivors make this important. The eleventh annual report of the British Paediatric Surveillance Unit cited an incidence of 2.1/1000 neonatal unit admissions, 65% of whom weighed under 1500 g at birth.2 Overall mortality was 22% but it was significantly lower in those fed human milk compared with those fed on formula (5% v 26%, p<0.05). Late morbidity among survivors was not reported but data from the USA3 suggest it is considerable. Despite these observations many neonatal paediatricians continue to cite concerns about the use of donor breast milk when mother’s own is not available. …

We have shown marked increases in the plasma amino acid concentrations of very low birth weight (VLBW) infants treated with dexamethasone (Arch Dis Child 1992; 67: 5-9). Ornithine, citrulline, alanine and glutamine increased most. We now report rates of urinary excretion Methods: 24-hour urine collections in 6 VLBW infants before and after 48 hours of dexamethasone (0.6 mg kg−1 d−1). Amino acids were measured by high performance liguid chromatography (HPIC). Results: Median values given (n=6 unless indicated). Conclusion: Increased excretion of both the end product and intermediate compounds of the urea cycle support the suggestion that changes in plasma amino acid concentrations result from catabolism rather than inhibition of nitrogen disposal.