Dear Editor

French and Evans have pointed out several limitations of our study which we had already discussed within the original paper. As there was no randomistaion performed, it is not possible to conclude that one group was better or worse than another at resuscitating preterm babies. The concerns expressed about the accuracy of retrospectively collected data are equally valid.

However, this was not intended to be a randomised controlled trial intended to determine whether ANNPs are 'better' or 'worse' than junior medical staff at resuscitating preterm babies at birth. As stated in the article, this was an audit of current clinical practise within our service. The conclusion we have reached is that there is no evidence that ANNPs are less proficient than junior medical staff at resuscitating preterm babies.

There were some differences between the two groups. These tended to be in favour of the ANNP group, but given the well described limitations of the study, it is not possible to reach any conclusions from these differences. These sorts of observations are only useful for hypothesis generation. As French and Evans have pointed out, it would be possible to test such a hypothesis with a randomised controlled trial using the design they propose. However, it would be a fairly sterile exercise which would not address the other clinical benefits of utilising ANNPs or address the impact of ANNPs on medical training and we do not intend to perform such a study.

Dear Editor

Aubrey and Yoxall conclude that Advanced Neonatal Nurse Practitioners (ANNPs) are effective in the resuscitation of preterm infants at birth [1]. The authors are careful not to conclude that ANNPs are more effective than medically led teams but they have made a comparison nevertheless. The data presented suggest that the infants resuscitated by ANNP led teams were intubated more quickly, received surfactant earlier, and were less likely to be hypothermic on admission to the neonatal unit.

We believe such comparisons are not justified because of two major sources of bias: failure to use randomisation and contamination.

Firstly, the study allocated the infants to ANNP or medically led resuscitation on the basis of existing practice, rather than by randomisation. The ANNPs worked exclusively during the daytime. A greater proportion of medically led resuscitation therefore occurred out of normal working hours. During these times, infants would be more likely to be born at short notice and the medical staff would have less time to prepare for the delivery, particularly if they have co-existing commitments on a neonatal unit with lower night-time staffing levels (no ANNPs, less medical and nursing staff). This hurried preparation, combined with lower night-time ambient temperatures, may explain the observed differences.

Secondly, the infant groups were determined by who wrote the resuscitation notes. Thus, an ANNP led resuscitation that required senior medical help might then be classed as a medically led resuscitation (and vice versa). The infants need to be analysed in groups according to initial resuscitation team. This second point also highlights the problem of trying to record precise data (such as time to intubation) from retrospective written accounts of the resuscitation.

Both these sources of bias were not quantified and therefore could not be corrected through multivariate analysis.

We welcome the fact that the authors have made efforts to evaluate ANNP led resuscitation of preterm infants. Before any conclusions are to be drawn about the relative merits or deficiencies in ANNP or junior doctors training, however, further comparisons need to use more rigorous methodology. Future prospective studies might compare only infants born during the daytime and allocated to a resuscitation team by randomisation.

References
(1) Aubrey WR, Yoxall CW. Evaluation of the role of the neonatal nurse practitioner in resuscitation of preterm infants at birth. Arch Dis Child Fetal Neonatal Ed 2001;85:F96-F99.

Dear Editor,

The paper by Aubrey and Yoxall[1] concludes that Advanced Neonatal Nurse Practitioners (ANNPs) are effective in the resuscitation of preterm babies at birth. In the same edition, Lee et al.[2] show that ANNPs in East Yorkshire are significantly more effective in detecting abnormalities during the neonatal check.

Neither of these results surprise me. ANNPs are intelligent, motivated and most importantly, trained for these relatively self contained tasks. Quite rightly, they can expect a structured training programme and will have to show competence in these tasks before being allowed to operate independently of direct supervision.

Paediatric SHOs on the other hand receive an 'ad hoc' training with no demonstration of competence. In my experience, preparation for the neonatal examination usually involves a half-hour lecture and a brief demonstration by the registrar before being pointed in the direction of the postnatal ward.

Neonatal resuscitation receives slightly more weight. Junior paediatricians are usually accompanied to deliveries 'until they can intubate'. They learn by a supervised apprenticeship. There is usually middle grade cover to ensure safety, but in no way is this comparable to the way ANNPs or anaesthetists are trained.

Changes in staffing and service delivery will undoubtedly occur as Trusts are forced to make posts compliant with both the New Deal[3] and the European Working Time Directive[4]. This will make it both attractive and necessary to employ ANNPs to carry out these tasks in place of doctors.

The implications are rather worrying. Are paediatricians to lose their technical resuscitation skills? Similarly, are SHOs to be denied the necessary (if at times slightly tedious) experience of the new born examination?

These studies demonstrate that junior paediatricians suffer as a result of their traditional 'service based training'. They need a proper, structured education with an assessment of competence before complementing the work of the ANNPs on both the labour and postnatal wards.

Dr Ieuan Davies
SpR Paediatrics
University Hospital of Wales

References
(1) Aubrey WR, Yoxall CW. Evaluation of the role of the neonatal nurse practitioner in resuscitation of preterm infants at birth. Arch Dis Child Fetal Neonat Ed 2001;85:F96-F99.
(2) Lee TWR, Skelton RE, Skene C. Routine neonatal examination: effectiveness of trainee paediatrician compared with advanced neonatal nurse practitioner. Arch Dis Child Fetal Ed 2001;85:F100-F104.
(3) NHS Management Executive. Junior Doctors-The New Deal. London: Department of Health;1991.
(4) European Working Time Directive. 93/104/EEC.