Am Fam Physician. 2004 Jul 1;70(1):83-84.
Gowning in Newborn and Special-Care Nurseries
Does gowning attendants and visitors in newborn and special-care nurseries improve outcomes?
There is no evidence that gowning in newborn nurseries and neonatal intensive care units (NICUs) improves clinically important outcomes.
Gowns are an uncomfortable and not very fashionable fact of life at many newborn nurseries. It is thought that they reduce transmission of infection from clinicians to infants and limit the introduction of infectious agents by visitors from outside the nursery. Webster and Pritchard reviewed the literature and identified 12 relevant studies, four of which were excluded because they were not randomized or used historical controls (i.e., outcomes before and after a gowning requirement was begun or stopped were compared).
Three studies randomly assigned staff and visitors to a gown or no gown and observed their handwashing behavior (n = 2,285 infants). Five studies alternated periods when gowning was or was not required for all staff and visitors; all of these studies examined infants (n = 3,979) in special-care nurseries or NICUs. Not wearing a gown was associated with a lower death rate (relative risk, 0.84; 95 percent CI, 0.70 to 1.02) in the four NICU studies that studied this outcome.
The five NICU studies did not show any effect on the incidence of nosocomial infections such as septicemia, meningitis, necrotizing enterocolitis, or pneumonia. The relative risk of infection ranged from 0.62 (less infection with gowning) to 2.52 (more infection with gowning), but none of the differences between groups was significant, and the overall relative risk of 0.95 was not statistically significant. Four studies of localized nosocomial infection also found no benefit from gowning. Secondary outcomes such as length of hospital stay, likelihood that patients or clinicians would wash hands, or colonization rates did not differ between groups.
Webster J, Pritchard MA. Gowning by attendants and visitors in newborn nurseries for prevention of neonatal morbidity and mortality. Cochrane Database Syst Rev 2003;3:CD003670.
Intensive Management of Gestational Diabetes
Does intensive management of gestational diabetes improve outcomes?
There is not enough evidence to support dietary or drug treatment in patients with gestational diabetes.
Gestational diabetes and impaired glucose tolerance are associated with macrosomia and may be associated with increased risk for cesarean delivery, shoulder dystocia, and birth trauma. Although preexisting diabetes has been shown to increase the risk of poor perinatal outcomes, it is not clear that data relating to preexisting diabetes can be extrapolated to patients with gestational diabetes.
Tuffnell and colleagues searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Central Register of Controlled Trials, and bibliographies of relevant articles. They identified three studies of 223 women with impaired glucose tolerance; none of these studies was a randomized controlled trial comparing management strategies. Treatment of women with impaired glucose tolerance did not offer a statistically significant benefit over nontreatment in terms of abdominal operative delivery rates, neonatal intensive care admissions, or reduction in birth weight. Treatment may be associated with a reduced incidence of neonatal hypoglycemia. The trials had wide confidence intervals and methodologic shortcomings. The small number of patients studied means that a small but clinically meaningful benefit may have been missed.
In the face of limited and inconsistent research, the American College of Obstetricians and Gynecologists (ACOG) continues to recommend universal screening for gestational diabetes.1 It recommends that insulin therapy be considered in patients for whom nutritional therapy does not result in a fasting glucose level of less than 95 mg per dL (5.3 mmol per L), a one-hour postprandial glucose level of less than 130 to 140 mg per dL (7.2 to 7.8 mmol per L), or a two-hour postprandial glucose level of less than 120 mg per dL (6.7 mmol per L). ACOG also recommends that physicians consider elective cesarean delivery for women with gestational diabetes and an estimated fetal weight greater than 4,500 g (9 lb, 15 oz). ACOG does not make a recommendation for or against calorie restriction in obese women with gestational diabetes.
Intensive management of gestational diabetes is time-consuming and resource-intensive. Overall, evidence is insufficient to support therapy for gestational diabetes. However, universal screening is the standard of care in most communities. When faced with abnormal results, most family physicians will opt to follow the consensus opinion of our specialist colleagues.
Tuffnell DJ, et al. Treatments for gestational diabetes and impaired glucose tolerance in pregnancy. Cochrane Database Syst Rev 2003;3:CD003395.
1. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol. 2001;98:525-38
Copyright © 2004 by the American Academy of Family Physicians.
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