After a Little Massage … Urine Business
The study
One hundred and twenty-seven full-term newborns admitted to a Turkish NICU, aged 3 to 30 days, were randomized into 1 of 2 clean catch urinary collection techniques to compare time to and success of urine collection. Both techniques included feeding 25 minutes before procedure, cleaning the genital area, holding the naked infant under his or her arms, providing nonnutritive sucking or sucrose syrup during the procedure, and waiting up to 5 minutes for voiding. In addition, infants in the experimental group received alternating suprapubic finger tapping and lumbar paravertebral massage until micturition. Infants were excluded for poor feeding, dehydration, oliguria/anuria, treatment with nephrotoxic drugs, and illnesses affecting mobility. The majority of enrolled infants underwent urine collection in the context of fever or hyperbilirubinemia.
The key findings
Compared with the control group (n = 64), the experimental group (n = 63) had a lower median time to void (60 vs 300 seconds, P < .01) and a higher percentage of successful voiding within 5 minutes (78% vs 33%, P < .01). The proportion of contaminated samples did not differ between the 2 groups (24% vs 29%, P = .77).
Why Do We Care?
The current study offers a noninvasive alternative to infant urine collection. Contamination rates for this method are similar to reported rates for bag-collected specimens and clean catch specimens in older children. One advantage of this technique over bag specimens is the rapidity with which urine was obtained. The need for 3 individuals to collect the specimen (presumably 1 person each to hold, massage, and collect) is a limitation, although the authors speculate that 2 staff members may be acceptable.
Traditional dogma dictates that infant urine samples should be obtained via catheterization or suprapubic aspiration, owing to the higher rate of contamination for less invasive methods. Given emerging evidence for the high sensitivity of pyuria for infant UTI and the possibility of catheter-inflicted urogenital damage and catheter-introduced pathogens, an argument can be made for starting with noninvasive urine collection. The AAP UTI guidelines support such an approach among children 2 to 24 months of age. (Pediatrics. 2011;128(3):595–610)
Words from the expert…
“This study demonstrates that urine can be obtained fairly reliably and expeditiously in neonates using noninvasive techniques. Other than ‘crying in all babies’ (a previously undescribed and somewhat unexpected adverse effect of massage!), the ‘cost’ appears to be a fairly high rate of contaminated specimens. The authors unfortunately do not comment on urinalysis [UA] results; we are increasingly appreciating that the urine culture results should be interpreted in the context of the UA, even in the youngest infants. Incorporation of the UA should mitigate some of the concerns about a high contamination rate.”
—Alan Schroeder, MD
Citation: Altuntas N, Tayfur AC, Kocak M, Razi HC, Akkurt S. Midstream clean-catch urine collection in newborns: a randomized controlled study. Eur J Pediatr. 2015;174(5):577–582
Agree to Disagree
The study
Investigators measured intraobserver (same examiner, repeat evaluations) and interobserver (different examiners) variation in the clinical assessment of dyspnea in children. Five pediatricians and 4 pediatric nurses, all with at least 5 years of experience, reviewed 2- to 3-minute digital video segments of 27 children, aged 0 to 8 years, presenting to a Dutch emergency department with acute mild to moderate dyspnea and wheeze. Observers were shown videos of each child before and after bronchodilator treatment (blinded to which was pre and which was post) and asked to record clinical signs of dyspnea (retractions, nasal flaring, etc) and an overall dyspnea score for each recording. Assessments were then repeated by each observer for the same recordings at least 2 weeks later, for a total of 972 assessments.
The key findings
Intraobserver assessments of clinical signs of dyspnea showed moderate to substantial agreement (κ 0.49–0.84), whereas interobserver assessments showed slight to moderate agreement (κ 0.12–0.46). Because of the substantial variation for overall dyspnea assessment, only 5.8% of observations were both statistically significant and clinically relevant. In other words, almost all observed changes in respiratory status could not be distinguished from measurement error.
Why Do We Care?
This study has both research and clinical ramifications. The authors point out that research studies relying on respiratory assessment must be explicit about the number of observers and suggest that more objective measures, such as oxygen saturation and lung function evaluations, should be considered to improve reliability.
Clinically, respiratory scores for a patient in mild to moderate distress might only be reliable if made by the same observer. Even then, comparing assessments made by the same observer, substantial variation remains for certain clinical signs (wheeze and intercostal retractions, according to the current study). Perhaps bedside handoffs should be practiced more frequently to ensure that providers are using the same words to describe the same patients.
Words from the expert…
“The implications are substantial. If a novel intervention is deemed efficacious in a clinical trial, it is critical that reliable and objective measures are used to avoid biased conclusions. Clear reporting in clinical care and research as to who and how many people are involved in respiratory scoring, in addition to presentation of reliability measures when publishing research findings, is essential.”
—Todd A. Florin, MD, MSCE
Citation: Bekhof J, Reimink R, Bartels IM, Eggink H, Brand PL. Large observer variation of clinical assessment of dyspnoeic wheezing children. Arch Dis Child. 2015;100(7):649–653
Footnotes
FINANCIAL DISCLOSURE: The authors has indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2015 by the American Academy of Pediatrics
