Emerging Topics and Controversies in Neonatology

Contents
Part I: The Fetus
	Chapter 1: Pregnancy–Related Complications and Preterm Delivery
		Introduction
		Prematurity
			Risk Factors for Prematurity
			Cervical Length Screening
			Cervical Cerclage
			Vaginal Progesterone
		Preterm Birth: Intrapartum Care
			Magnesium Sulfate
		Threshold of Viability
		Non-cephalic Presentation
			Group B Streptococcus
			Stillbirth Prevention and Fetal Growth Surveillance
		International: ‘Ending Preventable Stillbirth’
			UK: Saving Babies’ Lives
			Each Baby Counts
		Fetal Growth Restriction
			Customised Growth Charts
			Fetal Dopplers
			Early Onset, Small for Gestational Age
			Late Onset SGA
			Dawes Redman CTG
			Impact on Neonates
		Conclusion
		References
	Chapter 2: Maternal Chronic Conditions and the Fetus
		Pre-conception Care
		Epilepsy
			Preconception Advice
			Maternal and Fetal Implications
			Delivery and Postnatal
		Cardiovascular Disease
			Preconception Advice
			Maternal and Fetal Implications
			Delivery and Postnatal
		Hypertension
			Preconception Advice
			Maternal and Fetal Implications
			Delivery and Postnatal
		Respiratory Disease
			Asthma
				Maternal and Fetal Implications
			Tuberculosis
				Maternal and Fetal Implications
				Postnatal
			Cystic Fibrosis
				Preconception Advice
				Maternal and Fetal Implications
		Gastro-Intestinal Disorders
			Inflammatory Bowel Disease
				Maternal and Fetal Implications
				Delivery and Postnatal
			Obstetric Cholestasis
				Maternal and Fetal Implications
				Delivery and Postnatal
			Chronic Renal Disease
				Maternal and Fetal Implications
				Delivery and Postnatal
		Connective Tissue Disorders
			Systemic Lupus Erythematosus
				Preconception Advice
				Maternal and Fetal Implications
				Delivery and Postnatal
		Rheumatoid Arthritis
			Maternal and Fetal Implications
		Antiphospholipid Syndrome
			Maternal and Fetal Implications
		Metabolic and Endocrine Disorders
			Diabetes
				Preconception Advice
				Maternal and Fetal Implications
				Delivery and Postnatal
		Endocrinology
			Hyperthyroidism
				Maternal and Fetal Implications
			Hypothroidism
				Maternal and Fetal Implications
			Pituitary Disease
				Maternal and Fetal Implications
				Postnatal Care
			Adrenal Disease
				Maternal and Fetal Implications
		Haematological Disorders
			Thrombocytopenia
				Maternal and Fetal Implications
				Delivery and Postnatal
			Anaemia
				Maternal and Fetal Implications
				Postnatal
			Sickle Cell Disease
				Preconception Advice
				Maternal and Fetal Implications
		Maternal Mental Health
			Maternal and Fetal Implications
		Dermatological Disorders
			Maternal and Fetal Implications
		Maternal Life Saving Therapies
			Extra-Corporeal Membrane Oxygenation (ECMO)
			Peri-Mortem Caesarean Section (Resuscitative Hysterotomy)
		Summary
		References
	Chapter 3: Artificial Gestation
		Introduction
		Definition
		Animal Models of Ectogestation
		Current State of Science
		Potential Applications of Ectogestation
		Ethical Questions
		Ectogestation: Research Ethics
			Who Should Be Enrolled in Trials?
			When Would Trials Be Ethical?
		Ectogestation: Clinical Ethics
			The Concept of Viability
			Viability and Neonatal Care
			Viability and Obstetric Care
		Conclusion
		References
Part II: The Term Infant: Evidence-Based Approach to Management
	Chapter 4: Management of the Depressed Newborn; to Cool or Not to Cool
		A Case Study
		Hypoxic-Ischaemic Encephalopathy
		Which Babies Will Most Benefit from Therapeutic Hypothermia?
		Secondary Energy Failure
		Why May Cooling Not Be Beneficial for All Babies Who Are Depressed After Birth?
		Why May Some Babies with HIE Not Benefit from Cooling?
		Severity of Encephalopathy
		Pattern of Brain Injury
		What Objective Early Bedside Biomarkers of Brain Injury Are Available That May Allow Us to Select Babies for Cooling?
		When Should Cooling Be Commenced? Switching Off the Overhead Heater
		Cooling Outside of Protocol, Cooling Longer, Deeper and Smaller
		Cooling After Sudden Unexpected Postnatal Collapse
		Therapeutic Hypothermia for Mild HIE
		Novel Biomarkers for Selecting Babies for Cooling?
		Back to the Case Study
		Conclusions
		References
	Chapter 5: Neonatal Hypotonia
		Features in the History
		The Anatomical Perspective: Central and Peripheral Hypotonia
		Clinical Examination
			Neurological Examination
		Investigations
			Genetic Investigations
			Cranial Imaging
			Nerve Conduction Studies/Electromyography
			Creatinine Kinase and Other Blood Investigations
			Muscle and Nerve Biopsy
			Lumbar Puncture
		Specific Conditions
			Spinal Muscular Atrophy
				Classification of SMA
				Genetics of Spinal Muscular Atrophy
				Specific Treatment for SMA
				Non-5q SMA
			Congenital Myotonic Dystrophy
				Myotonic Dystrophy: Clinical Features in the Mother
				Outcome of Congenital Myotonic Dystrophy
				Genetics of Congenital Myotonic Dystrophy
			Prader-Willi Syndrome
				Genetics of Prader-Willi Syndrome
		Neuromuscular Disorders by Anatomical Site
			Peripheral Nerve: Neuropathies
			The Neuromuscular Junction
			Muscle Disorders: Muscular dystrophies and Myopathies
			Congenital Muscular Dystrophies
			Congenital Myopathies
			Metabolic and Mitochondrial Disorders Presenting with Neonatal Hypotonia
		References
	Chapter 6: Critical Congenital Heart Disease
		Introduction
		Genetics
			Teratogens
			Chromosomal Microarray and DNA Analysis
			Genome Sequencing
			Modification of Short Term Outcome
				Prenatal Diagnosis
		Targets for Antenatal and Fetal Intervention
			Decreasing the Likelihood of Premature and Early Term Delivery
			Fetal Aortic Valvuloplasty
			In-Utero Stabilisation
			Maternal Hyperoxygenation Therapy
		Decision Making Around Surgical Approach
			Gestational Age and Birth Weight
			Surgical Strategy
			Hypoplastic Left Heart Syndrome and Variants: Staged Palliation for a Single Ventricle Circulation
		Outcome Data
			Mortality
			Survival
		Conclusions
		References
	Chapter 7: Evidence Based Approach to the Management of Persistent Pulmonary Hypertension of the Newborn (PPHN)
		Introduction
		What Is on the Horizon in this Area?
		Etiology and Risk Factors
		Pathophysiology
		Approach to a Diagnosis
		Delivery Room Resuscitation
		Supportive Measures
		Mechanical Ventilation
		Specific Management
		Inhaled Nitric Oxide
		Alternative and Newer Therapies
		Sildenafil
		Milrinone
		Prostacyclin
		Bosentan
		Magnesium Sulphate
		Vasopressin
		Extracorporeal Membrane Oxygenation
		Long Term Outcome
		Novel Therapies Under Investigation
		Conclusions
		References
	Chapter 8: Neonatal Surgical Conditions: Congenital Diaphragmatic Hernia and Short Bowel Syndrome
		Congenital Diaphragmatic Hernia
			Antenatal Imaging and Prognosis
				Genetic Testing
			Antenatal Intervention
			Neonatal Interventions
				Ventilatory Strategy
			Management of Pulmonary Hypertension
			Role of Extracorporeal Membrane Oxygenation
			Minimally Invasive Surgery (MIS)
		Short Bowel Syndrome
			Definition of Short Bowel Syndrome and Intestinal Failure
			Management of Short Bowel Syndrome
			Malabsorption and Dysmotility
			Intestinal Failure Associated Liver Dysfunction (IFALD)
			Central Venous Catheter Care
			Surgical Management
				Improve Absorptive Surface Area
				Overcome Dysmotility and Stasis
				Slow Down Intestinal Transit
			Long Term Outcome
				Survival
			Intestinal Transplant
			Adaptation and Enteral Autonomy (Growth, Development)
		Conclusion
		References
	Chapter 9: Managing the Difficult Airway in a Neonate
		Introduction
		Definition of a ‘Difficult Airway’
		Anticipation of a Difficult Airway
		Equipment to Manage a Difficult Airway
			Bougies
		Indirect Laryngoscopy
		Video Laryngoscopes for Neonatal Use
		Airtraq®
		Supra Glottic Airways
		iGel© Supraglottic Airway Device
		Digital Intubation
		Nasal Intubation
		Additional Airway Adjuncts
		Difficult Airway Kit
		Human Factors
			Organisational Factors
			Individual Factors
				Team Working
		Suggested Approach to the Patient with a Difficult Airway
		Conclusions
		References
	Chapter 10: Sudden Unexpected Postnatal Collapse
		The Challenges of Definition
		The Relationship Between SUPC and SUDI
		Extrinsic Risk Factors for SUPC
		Controversies in SUPC
			Skin to Skin Care (SSC) in the Post-partum Period
			Therapeutic Hypothermia After SUPC
		Medico-Legal Aspects of SUPC
		Improving Safety in the Early Postpartum Period
		Conclusion
		References
Part III: The Very Preterm Infant: Controversies in Postnatal Management
	Chapter 11: Mechanical Ventilation of the Preterm Infant
		Introduction
		Indications for Mechanical Ventilation
		Ventilation Modes
		Volume-Targeted Ventilation
		High Frequency Oscillatory Ventilation
		Positive End Expiratory Pressure and ‘Open Lung’ Ventilation
		Neurally Adjusted Ventilatory Assist
		Surfactant
		Medications for Neonatal Intubation
		Videolaryngoscopy for Teaching Neonatal Intubation
		Extubating Preterm Infants
		Conclusions
		References
	Chapter 12: Non-invasive Respiratory Support
		Non-invasive Respiratory Support for Neonates
			Perinatal Transition: From Breathing Liquid to Air
			Pulmonary Aeration: The Significance of Establishing the Functional Residual Capacity and Tidal Volume at Birth
		Respiratory Distress Syndrome in the Very Preterm Infant
		Mechanical Ventilation As a Risk Factor for Bronchopulmonary Dysplasia
		Developing the Concept of Nasal Continuous Positive Airway Pressure in Preterm Infants
		Different Modes of Non-invasive Respiratory Support
			Continuous Positive Airway Pressure
		Water-Lock, or “Bubble-CPAP”
		CPAP Devices with Variable Gas Flow
		Comparison of Constant Flow CPAP and Variable Flow CPAP
		Early Nasal CPAP from Birth
		Nasal High-Flow Nasal Cannula Therapy
		Rationale for Alternative Modes of Non-invasive Respiratory Support
		Definition of Non-invasive Positive Pressure Ventilation
		Clinical Applications of Non-invasive Positive Pressure Ventilation
		Non-synchronised and Synchronised NIPPV
		Nasal High-Frequency Oscillation Ventilation
		Chronological and Disease Specific Considerations
		What Could Be Next? A Glimpse at the Future
		References
	Chapter 13: Oxygen Management in Neonatal Care
		History
		Evidence from More Recent Trials
			Oxygen Therapy in the Later Weeks of the Clinical Course
			Oxygen Therapy in the Early Weeks of the Clinical Course
		Implications for Patients
		Achieved SpO2 Patterns
		International Guidelines
		Conclusions
		References
	Chapter 14: Patent Ductus Arteriosus: The Conundrum and Management Options
		Introduction
			Natural History of Closure of the PDA
		PDA Diagnosis
			Echocardiography Assessment
				Conventional Echocardiography
					Tissue Doppler Imaging and Speckled Tracking
			The Utility of Electrical Velocimetry: Non-invasive Cardiac Output Monitoring. (ICON(™) Monitor/NICOM) [16]
			Near Infra-Red Spectroscopy
			Utility of Perfusion Index
				Feasibility of Biomarkers at the Point of Care
				The Conundrum of PDA Management [32]
				Is Conservative Approach Always Safe?
				Restrictive Versus Liberal Fluids?
				Does Furosemide Cause Any Benefits or Harm?
				Does Choice of Respiratory Support Have Any Effect on the PDA?
				Does Use of Caffeine Affect PDA?
				Does Phototherapy Affect PDA?
		Prophylactic Approach: Should We Still Consider This?
		Early Targeted Approach for PDA Closure
		Symptomatic Approach
		Which Drug to Choose Amongst the Pharmacological Options?
			Indometacin Therapy
				Treatment Regimens
			Ibuprofen Therapy
			Paracetamol Therapy
		How Safe Are NSAIDS?
		Surgical Ligation: Is This Still an Option?
			Do Newer Surgical Techniques Offer Any Promise?
		The Influence of Genetics on Ductal Patency and Management
		Conclusions
		References
	Chapter 15: Glucocorticoid Treatment for Bronchopulmonary Dysplasia
		Introduction
		Corticosteroids: Mechanism of Action
		Corticosteroids and Inflammation
		Corticosteroids and the Lung
		Natural and Synthetic Corticosteroids
			Natural Corticosteroids
			Synthetic Corticosteroids
		Application of Glucocorticoids in Neonates
			Systemic Glucocorticoids
			Early Systemic Dexamethasone
			Early Systemic Hydrocortisone
			Late Systemic Glucocorticoids
			Inhaled Glucocorticoids
			Intratracheal Glucocorticoids
		Issues that May Be Important when Considering Glucocorticoids in Newborn Care
		Conclusions
		References
	Chapter 16: Feeding and Nutrition
		Introduction: The Nutritional Vulnerability of Preterm Infants
		Starting and Increasing Milk Feeds: What’s New?
		Parenteral Nutrition
		Milk Feeding and Necrotising Enterocolitis
		Donor Human Milk and NEC
		Probiotics and Risk of NEC or Sepsis
		Conclusions
		References
	Chapter 17: Blood Pressure Management in the Very Preterm Infant: More than Just Millimetres
		Introduction
		Etiology of Low Blood Pressure and/or Circulatory Failure
			During Transition
		Etiology of Circulatory Failure Beyond the Transitional Period
		Suggested Assessment Strategies
		Blood Pressure Intervention Standards
		Clinical Bedside Assessment
		Ancillary Investigations
		Echocardiography
		NIRS for the Assessment of Organ Oxygenation and Perfusion
		Non-invasive Cardiac Output Monitoring
		Perfusion Index for the Assessment of Peripheral Arterial Perfusion
		Treatment Options
			Volume Expansion
			Inotropes, Vasopressors and Inodilators
			Corticosteroids
		Proposed Intervention Strategies
		Future Perspectives
		References
	Chapter 18: Retinopathy of Prematurity
		Introduction
		ROP Imaging Modalities
			Fluorescein Angiography
			Ultra-Wide Field Imaging (UWFI)
			Optical Coherence Tomography (OCT) in Prematurity
		ROP Risk Algorithms and Tools
		Ocular Treatment Using Anti Vascular Endothelial Growth Factor
		Summary
		References
Part IV: Long Term Effects Following Extreme Prematurity
	Chapter 19: Neurodevelopmental Problems
		Introduction
		How Do Survival Rates Impact on Disability Rates?
		How Has Survival Changed over Time and What Impact Has This Had on Neurodevelopment?
		How Does Survival Change with Increasing Gestational Age and What Impact Does This Have on Neurodevelopment?
		What About Infants Born at 22/23 Weeks of Gestation and Infants Less Than 500 g Birthweight?
		Predicting Neurodevelopmental Problems: What Impact Do Factors Other Than Prematurity Have on Developmental Prognosis?
		Antenatal Factors
		Post-natal Factors
		Cerebral Palsy
		Cognitive Outcomes
		Challenges in Measuring Cognitive Outcomes in Preterm Birth
		What Are the Rates of Cognitive Impairment?
		What Is the Relationship Between Risk of Cognitive Deficit and Decreasing Gestational Age?
		What Is the Effect of Sex on Cognitive Outcomes?
		What Happens to the Cognitive Deficit as the Extreme Preterm Infant Gets Older?
		Improvement over Time?
		How Should We Screen for These Problems to Optimise the Chance of Early Recognition and Intervention?
		Adult Outcomes
		Collection and Use of Neurodevelopmental Outcome Data
		Individuals and Families
		Healthcare Systems
		Commissioning
		Conclusion
		References
	Chapter 20: Long Term Effects Following Extreme Prematurity: Respiratory Problems
		Definitions
		Lung Development
		Lung Pathology and Imaging
		Respiratory Infection and Morbidity
		Lung Function
		Unanswered Questions, Future Research Directions
			Phenotypes and Mechanisms of Disease
			Treatment: Infection
			Treatment: Inhaled Therapies
		Conclusion
		References
	Chapter 21: Behavioural and Educational Outcomes Following Extremely Preterm Birth: Current Controversies and Future Directions
		Introduction
		Attention, Social and Emotional Problems
		Mental Disorders
		Behavioural Outcomes: Current Controversies and Research Directions
		Academic Attainment and Special Educational Needs
		Developmental Delay or Developmental Deficit?
		Supporting the Learning of Children Born Preterm
		Delayed School Entry
		The Need for Theory Driven Research
		Summary
		References
Part V: The Infant Born Near Term
	Chapter 22: Early Outcomes in Babies Born Close to Term
		Introduction
		Definitions
		Neonatal Morbidity
		Breast Feeding
		Neonatal Respiratory Disease
		Obstetric Antecedents of Late Preterm and Early Term Birth
		Antenatal Corticosteroids in Late Preterm and Early Term Labour
		The Impact of Late Preterm and Early Term Birth on Families
		Burden on Health Care Services
		Implications for Clinical Practice
		Conclusions
		References
	Chapter 23: Long Term Outcomes in Moderate and Late Preterm Infants
		Introduction
		Neurodevelopment
			Infancy
			Pre-school and School Age
				Cognitive Functioning and School Performance
				Behaviour and Psychiatric Outcomes
			Adulthood
		Respiratory Outcomes
			Vulnerability of the MLP Lung
			Infancy and Childhood Outcomes
			Adolescence and Adulthood
			Lung Function Studies
			Hospitalisation and Health Services Use
		Functional and Other Outcomes
		Research Gaps
		Conclusion
		References
Part VI: General Principles in Neonatal Care
	Chapter 24: Delivery Room Stabilisation
		Introduction
		Management of the Umbilical Cord After Birth
			Re-introducing ‘Normal’ Cord Care
			Alternatives to Immediate Cord Clamping
			Updating the Guidelines
			Practicalities
		Temperature Optimisation
			Uncompromised Babies
			Instituting Therapeutic Hypothermia at the Right Time
		Monitoring of Resuscitation
			Heart Rate
			Respiratory Function Monitoring
		Airway Management
			Continuous Positive Airway Pressure With or Without Surfactant
			Sustained Lung Inflation
			Laryngeal Mask Airways
			Oxygen: How Much and When?
			Term and Near-Term Infants
			Preterm Babies (Below 37 Weeks of Gestation)
			Very Preterm Babies (Below 28 Weeks of Gestation)
		The Most Recent ILCOR Evidence Evaluation for Initial Oxygen Concentration in Babies Requiring Respiratory Support
		When Should We Stop Resuscitation?
		Resuscitation and Stabilisation of Infants Born at the Margins of Viability
			A Cautionary Note
				(…What you read today was accurate when written, but may not be accurate when you read it, and what is used today may become obsolete in future)
		References
	Chapter 25: Principles of Family-Oriented and Family-Integrated Care
		Introduction
		Parental Presence On Ward Rounds
			Negatives
			Why Should Parents Have 24/7 Access to Their Baby?
			Concerns Over 24 H Access
		Siblings on the Neonatal Unit
		Accountability and Delegation
		Conclusion
		References
	Chapter 26: Quality and Patient Safety in Neonatal Care
		Quality and Safety: Terminology and Frameworks
		Clinical Microsystems
		Assessing and Monitoring the Quality of Neonatal Care
		Quality Indicators for Comparative Performance Measures
		Quality Indicators for Improvement
		Improving the Quality of Care
		The Improvement Team
		Collaboration
		Aim: What Are We Trying to Accomplish?
		Measurement: How Will We Know That a Change Is an Improvement?
		What Changes Can We Make That Will Result in an Improvement?
		Plan-Do-Study-Act Cycles
		Ensuring Success and Sustainability of QI Projects
		Leadership and Unit Culture
		Why Is Quality Improvement Important in Neonatal Care?
		Examples of Quality and Safety Improvement in Neonatal Care
			QI Projects in Individual Units
		Collaborative QI Projects
		Conclusions
		References
	Chapter 27: Transport of the Sick Infant
		Introduction
		Physiological Effects of Transport on the Newborn
			Thermoregulation in Neonatal Transport
			Exposure to Vibration and Acceleration Forces
			Exposure to Sound
			Effect of Altitude
		Working in the Transport Environment
		Limitations of Transport Equipment to Deliver Mobile Intensive Care
			Respiratory Support During Neonatal Transport
		Managing the Baby with Difficult Oxygenation/Ventilation During Transport
		Transporting the Infant with Hypoxic Ischaemic Encephalopathy Requiring Therapeutic Hypothermia
		Communication Between Referring Unit, Receiving Unit and Transport Teams
		Decision Making Around Inutero and Exutero Transfers Is Complex
			In Utero Transfers
		Role of a “Flying-Squad” to Attend Births in Neonatal Transport
		Transport Team Skill-Mix
		The Challenges of Pre-transport Stabilisation by Referring Units
		Importance of a Robust Clinical Governance Programme to Reduce Risk in Neonatal Transport
		Summary
		References
	Chapter 28: Neonatal Pain
		Introduction
		Development of the Nociceptive Brain
		Cortical and Behavioural Measures of Pain
		Assessment of Neonatal Pain
		Long-Term Consequences of Neonatal Pain
		The Burden of Neonatal Pain
		Analgesic Treatment
			Nonpharmacological Interventions
				Prevention
				Sweet Solutions
				Swaddling, “Facilitated Tucking”, Touch, and Positioning
				Nonnutritive Sucking
				Skin-to-Skin Contact (Kangaroo Care)
				Breast Feeding Analgesia
			Pharmacological Treatment
				Opioids
					Morphine
					Fentanyl
					Remifentanil
		Paracetamol
		Topical Anesthetics
		Conclusions
		References
	Chapter 29: Neonatal Infection
		Neonatal Infection: Post Millennium But Still Not a Thing of the Past
		Diagnostic Techniques and Biomarkers: Improvements and Future Promise
			Molecular Tests
			Biomarkers
		Preventing Maternal to Infant Transmissions
		Vaccinations to Prevent Vertical Transmission
		Managing the Infant ‘At Risk’ of Early Onset Bacterial Infection
		Antibiotic Choice, Duration and Governance
		Treatment Adjuncts
		References
	Chapter 30: Withholding and Withdrawing Life-Sustaining Treatment
		Introduction
		Terminology and Biases
		‘Good’ Palliative Care: Multi-Dimensional and Integrative
		Optimal Delivery Models: Personalisation, Proximity and Trust
		Communication: Broadening Concepts
		Listening to Parents: Redefining Goals
		Summary: The Last Chapter
		References
	Chapter 31: Effective Training in Neonatal Medicine
		Simulation Based Training
		In-Situ Simulation
		Improving Fidelity
		Rapid Cycle Deliberate Practice
		Debriefing Techniques
		Plus Delta
		Advocacy with Enquiry
		Narrative Debrief
		Video Debriefing
		Gather, Analyse, Summarise (GAS)
			Debriefing: Moving from the Simulation Session to the Real World
			Maintaining Simulation Standards
			Technology Enhanced Learning: What Does the Future Hold?
		References
	Chapter 32: Genomics for the Neonatologist
		Introduction
		Important Concepts
		Genomic Testing
		Diagnostics
			Diagnostic Yield
			Effect on Management
			Time to Reporting
			Costs
		Microbiology
		Challenges for WGS on the Neonatal Unit
			Interpretation of Variants
			Incidental Findings
			Prognostic Uncertainty
			Rationing of Healthcare
			Consent
		Newborn Screening
		References
	Chapter 33: Research in the Newborn Period
		Introduction
		Informed Consent
			Parental Role and Responsibility for Providing Consent
			Validity of Informed Consent
				Voluntariness
				Information and Understanding
				Competence
			Different Forms of Consent
				Prospective Consent
				Waiver of Consent
				Antenatal Notification and Consent
				Deferred, Retrospective or Continuing Consent
				Zelen’s Method of Consent
				Opt-out
				Parental Views on Consent
		Research Outcomes
			Advantages of Using Primary Composite Outcome
				Statistical Efficiency
				Financial Benefit
				Importance of Individual Outcomes to Clinicians and Patients
			Disadvantages of Using Primary Composite Outcomes
				Selection of Components of a Composite Outcome
				Reporting of Composite Outcomes
				Contribution of Each Individual Component of the Composite Outcome
				Clinical Interpretation
		General Challenges in Delivering Research in the Neonatal Population
		Conclusion
		References
	Chapter 34: Parent Perspectives of Neonatal Intensive Care
		Initial Birth
		Early Days
		Communication
		Psychological Care
		Visitors
		Parents of Non-premature Babies
		Breastfeeding and Expressing
		Transfers
		Discharge
Index