Dear Editor

we would like to thank Drs Millman and Satodia for their considerate comments on our paper.[1] The randomised controlled trial reported in the Archives is part of a larger evaluation study of the implications and cost effectiveness of extending the role of midwives to include the routine (24 hour) examination of the newborn. The evaluation study includes, apart from the RCT, a longer term follow-up (safety and referrals), videotaped quality assessments and interviews with health professionals involved in the newborn assessment and with parents and all stakeholders (Royal Colleges, professional organisations and consumer groups). Furthermore a national survey of current practice was conducted. The findings have been written up in a number of papers that are submitted or in press and our full report will be published by the NHS Executive Research and Development Programme Health Technology Assessment Programme this year.

The questions raised by Millman & Satodia have been addressed in the interviews with senior house officers (SHOs) (and midwives, General Practioners (GPs), consultant paediatricians). The full findings from the interviews with the SHOs and GPs were fairly consistent and clearcut:

1. they value the neonatal examination to screen for major anomalies;
2. they value the examination to reassure the parents about the normality of their child;
3. there were mixed opinions of whether "a quick SHO check" provides opportunities for any health education. Some felt not confident of providing such information while others were pro-active in discussing history or baby care issues. In contrast midwives consider the examination as an ideal opportunity to discuss feeding and baby care issues.
4. SHOs reported that they received very little, if any, training and the usual procedure was to be shown once and let to get on with it.
5. SHOs did not feel comfortable about some aspects of the examination such as the hips, taking pulses or the red reflex. They would have liked more training by senior paediatricians and more supervision.
6. Many SHOs and GPs felt that doing the examinations was useful for their training but there were too many examinations and they were often rushed. Others reported that "doctors have more important things to do";
7. SHOs and GPs were broadly the view that any midwife, if trained, could do the newborn examination as well as the junior doctor. This concurred with mothers views who would be happy for midwives to examine babies, and some expressed they had more confidence in midwives than SHOs.

Taking the findings of our evaluation study together, it is apparent that a system of formal training for SHOs would be highly desirable to increase quality of examinations and parental satisfaction. The training would need to include, apart from technical components, education in communication skills and knowledge on child care issues. SHOs, and in particular those who progress to GPs require some experience with normal newborns. In a programme of training there should be enough opportunities for newborn examinations by SHOs alongside or together with midwives. However, as one GP expressed it: "ultimately, the examination should not be education for an SHO but for the benefit of the baby".

Reference

(1) Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. Routine examination of the newborn and maternal satisfaction: a randomised controlled trial. Arch Dis Child Neonatal Fetal Ed2002;86:F155-60.

Dear Editor

We read with interest the findings of Wolke et al.[1] regarding maternal satisfaction with routine examination of the newborn. Whilst appreciating their conclusions and those reached by others (Lee TWR et al.[2] and Walker D[3])we wish to provide further comment. Perhaps an equally valuable study would be one which explores the attitudes of senior house officers to performing this examination and assessing the perceived benefits to their professional development. Possible questions may include:

(i) Did you receive formal training from a senior paediatrician?
(ii) Do you feel comfortable performing this task and subsequently reassuring parents about their infant?
(iii) Do you feel competent to discuss aspects of general neonatal care and education with parents?
(iv) Do you think this task contributes positively to your training?

It is important to note that whilst not subjecting senior house officers to vast numbers of repetitive neonatal examinations, a formal system of training in all aspects of routine neonatal care followed by subsequent assessment might be educationally beneficial. It is surely questionable to expect paediatric senior house officers to progress to GPs and higher specialist trainees managing common problems in newborn infants if their previous experience is being reduced further. The correct balance between education and service provision is essential to prevent future deficiencies in general paediatric knowledge.

Guy C Millman
Prakash Satodia

References

(1) Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. Routine examination of the newborn and maternal satisfaction: a randomised controlled trial. Arch Dis Child Neonatal Fetal Ed 2002;86:F155-60.

(2) TWR Lee, R E Skelton, and C Skene. Arch Dis Child Fetal Neonatal Ed 2001;85:F100-4.

(3) Walker D. Role of routine neonatal examination. It probably makes more sense for other staff to carry out neonatal examinations [letter]. BMJ 1999;318:1766.