BackgroundHyperglycaemia in extremely preterm infants can impact morbidity and mortality. To treat this, whilst optimising nutritional intake, insulin infusions are used widely on neonatal units.1 In February 2024, a new neonatal insulin monograph was introduced in response to an audit that illustrated poor adherence, with only 18% of patients reaching target blood glucose levels (BGL) within 6–12 hours of starting insulin. The new monograph made changes to recommended practice including starting insulin at a higher rate of 0.05 units/kg/hour, rather than a range of 0.02–0.05 units/kg/hour; and included comprehensive guidance regarding monitoring and rate titration, requiring clinicians to consider trends in BGL.AimTo audit neonatal insulin management against new local guidance and compare the results with previous audit results.MethodAll patients started on insulin infusions after implementation of the guidance were retrospectively audited. Data was collected to assess the following standards:100% of patients with two consecutive BGL of ≥12 mmol/L are initiated on a continuous intravenous insulin infusion.100% of patients are started on 0.05 units/kg/hour of insulin.100% of patients have BGL measured hourly for the first 4 hours of starting insulin or until BGL are stable.100% of patients have insulin titrated correctly in line with guidance.100% of patients reach a BGL of 3–10 mmol/L within 6-12 hours of initiating insulin.Results15 patients were audited with 17 episodes of insulin treatment. 53% of patients were born extremely preterm, 33% very preterm, 7% moderate-late preterm and 7% term.71% were started on insulin after two consecutive BGL of ≥12 mmol/L. The recommended starting rate of insulin was used in 65% of cases. Initial BGL monitoring was completed correctly 29% of the time. Insulin was titrated correctly 91% of the time. 71% of patients had BGL within range by 6–12 hours of starting insulin.DiscussionImplementation of the new monograph was accompanied by extensive communication with clinical teams and new electronic prescription templates using the new starting rate of insulin and with the titration table attached. 71% of patients were started on insulin correctly in relation to BGL, an improvement on the 47% previously found. Using the specified starting rate has increased by 15%, likely due to the new guideline using a fixed starting rate rather than a range. Previously, 18% of patients reached the required range within 6–12 hours of starting treatment, this audit saw an improvement to 71%. This may be due to the higher starting rate, which wasn’t used beforehand albeit part of the recommended range, and the prescriptive titration table allowing quicker titration of insulin when BGL were changing. This enhanced guidance on titration reflects the increased improvement of titration of insulin in patients from the previous 4.5%. Initial blood glucose monitoring is still only 29% and whilst better than the 0% found previously, the level is still low and therefore further investigation into this area is required.Limitations included the small patient cohort and lack of engagement with clinical staff for feedback. Staff engagement should be undertaken before further revisions of the insulin monograph and re-auditing.ReferenceMorgan C. The potential risks and benefits of insulin treatment in hyperglycaemic preterm neonates. Early Hum. Dev. 2015;91:655–659.

AimTo assess if there was an improvement in meeting the external bespoke parenteral nutrition (PN) ordering deadline following the pharmacy process being streamlined in August 2023 (data set 1). To assess if the implementation of a soft zero-tolerance policy to PN prescribing in January 2024 improved bespoke PN orders being sent on time (data set 2).MethodData was collected from the pharmacy PN key performance indicator (KPI) spreadsheet. For KPIs, on each day that bespoke PN orders are sent, the time that the last order was sent and the total number of bespoke orders sent are recorded.This data was collated and analysed for two periods of time: Data set 1: September to December 2023; pharmacy procedures to clinically screen and send the bespoke PN orders was streamlined.Data set 2: February to May 2024; a soft zero tolerance policy for PN prescribing, with a deadline of 1000h for PN to be prescribed by, was implemented across the hospital.Results was compared to baseline data collected in an audit conducted over 12 months in 2021/2022, where on average orders were sent by the deadline 77.8% of the time.ResultsData set 1Bespoke PN orders were sent on 82/84 days of the audit period; orders were sent on time on 84.1%(n=69) days. A total of 1238 orders were sent (average 15 orders/day). Following the process improvement of clinical screening, there was a marked improvement by 6.3%.Data set 2Bespoke PN orders were sent on 83/84 days of the audit period; orders were sent on time on 84.3%(n=70) days. A total of 961 orders were sent (average 12 orders/day). The improvement in meeting the deadline was sustained from data set 1.ConclusionThere was a notable improvement with the percentage of orders sent on time when the bespoke ordering process was streamlined in pharmacy.The implementation of the zero-tolerance policy for PN prescribing, with a 1000h deadline for prescriptions to be completed, did not significantly impact the percentage of orders sent on time. It is worth highlighting, that during the month of May 2024 there were multiple new staff members training in the pharmacy PN service. If May data was not included, 90% of orders were sent on time, which would have been a 5.9% increase from data set 2 and a 12.2% increase from baseline data.The data will be fed back to pharmacy and clinical teams to highlight the impact of the changes implemented in the service.

AimThere are no national standards to guide pharmacy staff on labelling dispensed paediatric medicines in the UK. A previous survey of hospital pharmacy staff reported considerable inconsistencies in how paediatric dosage instructions are communicated.1 It also identified variability in how the amount of liquid medicine to administer is expressed, and that this variability, along with confusion between units of measurement, poses a potential risk factor for dosing errors.1 This study aimed to explore parents’ and carers’ preferences for and interpretation of dosage instructions on dispensed paediatric medicines.MethodAn anonymous, paper-based, self-administered 9-item survey was conducted at 14 hospitals in England between March and April 2024. Each hospital received 25 questionnaires, which were distributed to a convenience sample of parents and carers (>18 years of age) during their child’s hospital visit. To assess preferences, participants were asked to select from a choice of two or four medicine labels that presented the same dosage instruction with different expression. Their understanding was assessed by asking them to illustrate their answers on a pictogram of a syringe. Participants’ demographics and educational characteristics were collected. Data were summarised using descriptive statistics. For group comparisons, the Mcnemar’s, Chi-square and Fisher’s exact tests were used. Analysis was conducted using Stata software.ResultsA total of 250 respondents (response rate = 71.4%) from 12 hospitals (including 3 district general hospitals) were included in the analysis. Of all respondents, 76% were female, 79.2% primarily spoke English, and 90.8% reported being very proficient in reading English. Respondents’ preferences for dose expression differ between those from healthcare and non-healthcare backgrounds. Among those from non-healthcare backgrounds, 72.8% preferred ‘...ml’ and 23.8% preferred ‘...ml (...mg)’, compared to 46.9% and 40.6% of respondents from healthcare backgrounds, respectively (p = 0.004). Similarly, a greater proportion of respondents from non-healthcare backgrounds preferred the numeric expression of ‘1 tablet’ (59.6% vs 33.3%; p = 0.005). For dosing frequency expression, 51.6% of respondents overall preferred ‘Give 5 ml twice a day’ as compared to ‘Give 5ml in the morning. Give 5 ml in the evening’ (25%), ‘Give 5ml in the morning and evening’ (16%), and ‘Give 5 ml two times a day’ (7.4%).Overall, 98.8%, 96.3% and 74.5% of the respondents marked the syringe image correctly when doses were expressed as ‘…ml’, ‘…ml (…mg)’ and ‘…mg (…ml)’, respectively (p < 0.05 for all pairwise comparison). The most common theme in the open-ended question on preferences was the need for clearer and simpler instructions (23% of all respondents).ConclusionThe results of this study show a preference among parents and carers for ‘…ml’ dosage instructions, and the use of simple wording for dosing schedules. The findings also suggest that how the amount of a liquid medicine to administer is expressed could influence parents’ and carers’ interpretation. This study underscores the need for standardising paediatric dosage instructions to support comprehension and appropriate use. Consideration of parents’ and carers’ preferences when developing labelling standards can improve the safe use of medicines for children.ReferenceLatheef F, Rashed A, Wignell A, et al. SP3 An exploratory study to characterise dosing instructions on dispensed paediatric medicines labels. BMJ Paediatrics Open 2024;8.

AimThe aim was to see if there was evidence of over and under prescribing of reflux medication once a child less than 1 year with a cardiac shunt dependent diagnoses has been discharged from hospital despite a close outpatient follow up by clinicians, and whether there was any relationship with patient growth.Gastroesophageal reflux disease (GORD) is common in infants with congenital heart disease (CHD) which is linked with poor growth and aspiration pneumonia in this cohort.1 Symptom management involves optimisation of enteral feeds and provision of pharmaceutical agents to support with gastric emptying and reduction of gastric acidity.2 Proton pump inhibitors (PPI) and prokinetic agents are often used as the first line treatment, but there are concerns they are commonly inappropriately and/or over-prescribed,3 which can be detrimental to patient care due to risks of cardiotoxicity.MethodA retrospective review was conducted looking at shunt dependant infants discharged from a regional children’s cardiac unit between 2020–2023. Growth, presence of reflux symptoms and anti-reflux medication prescribed were recorded at discharge from hospital and 3-months post-discharge. Medication doses were reviewed against the British National Formulary for Children.4Results94 patients included in the discharge data. 23 patients were readmitted into hospital or died before the 3-month point, leaving 71 patients to be included in the 3-month data.At discharge 30% (n=28) had reflux symptoms, 29% (n=8) of these had suboptimal anti-reflux prescriptions. Whilst 70% (n=66) had no reflux symptoms, and only one of these had suboptimal medication.At 3 months 28% (n=20) had reflux symptoms, and 70% (n=14) of these had suboptimal anti-reflux prescriptions. Whilst 72% (n=51) had no reflux symptoms, and 11% (n=6) of these had suboptimal medication.Overall, 24% (n=17) of infants had poor growth across the 3 months, with 35% (n=6) of these having a period reporting reflux symptoms and not on optimised anti-reflux medication.ConclusionReports of GORD symptoms and poor growth is common in infants with shunt dependant cardiac diagnoses. Treatment of GORD with pharmaceutical agents is high, but there is strong evidence of over-prescribing and under-prescribing, which increased over time post discharge. The lack of optimisation of reflux management could be linked with poor growth. Regular medication review from a specialist pharmacist at the point of discharge from hospital and in the outpatient setting would support both the symptom management of GORD and appropriate provision of potentially cardiac toxic medications.ReferencesGlassman M, George D, Grill B. Gastroesophageal reflux in children: clinical manifestations, diagnosis, and therapy. Gastroenterology Clinics of North America 1995;24:71–98.Indramohan G, Pedigo TP, Rostoker N, et al. Identification of risk factors for poor feeding in infants with congenital heart disease and a novel approach to improve oral feeding. Journal of Pediatric Nursing 2017;35:149–154.Naunton M, Peterson GM, Bleasel MD. Overuse of proton pump inhibitors. J Clin Pharm Ther 2000;25:333-340.British National Formulary for Children. (Accessed 15 January 2024).

IntroductionTransition between primary to secondary care and vice versa is identified as portraying a singularly unique risk to safe and effective care patient may receive, with a known 30 to 70% chance of medication related error(s) occurring.1 2 Effective communication between care providers as patients migrate between care setting to allow an accurate, safe, and timely medications reconciliation and clear understanding by care providers for the intended indications, is a hallmark of gold standard patient care.It has long been an NHS mandate that patients being admitted to hospital have an accurate medicines reconciliation conducted in timely manner. Similarly on discharge from secondary care, all patients should be discharged with an accurate discharge summary which should include medications that the patient is to continue. This should be received by primary care clinicians within 24 hours of discharge. Despite this community pharmacy contractors often struggle to be included in these communication cascade and so remain a single point at which safe care may fail. Discharge Medication Service (DMS) is a pharmacy led initiative established in 20213 to improve communication between secondary care and community pharmacy contractors.To support high risk transitions of care from a specialist tertiary paediatric hospital to community, a project commenced in 2023 to establish a discharge medicines service.AimFollowing completion of the initial project we proceeded to conduct a qualitative review of pharmacists completing referrals to understand barriers and facilitators to support DMS.MethodFrom April 2024 to July 2024, we interviewed 10 pharmacists across all bands and paediatric specialities. Thematic analysis of interviews was undertaken to identify commonly cited barriers and facilitators to making referrals.ResultsCommon thematic facilitators allowing the introduction of a DMS were: acknowledgement of meeting a trust target for a Commissioning for Quality and Innovation project associated with significant financial benefit; the ability to communicate on-going patient care to partner community pharmacy improving patient safety and care efficiency; enhancing the patient and family experience; improving and building patient and community relationships to support patient care; project leads supporting and driving projects and availabilities of key standard operating procedure.Barriers emerging were: completion of referral but without dedicated time required to allow referring pharmacists opportunity to achieve full benefits of information transfer; uncertainty around outcomes of referral; lack of feedback for rejections to tertiary centre referral, making it difficult to develop optimisation strategies for patients to refer.ConclusionOur evaluation highlights that DMS can be introduced, following development and implementation of an integrated database, supporting care for children and young people transitioning from a tertiary specialist care environment to primary care that can be further developed. The evaluation recognises the value to safe and effective patient care and allows a platform from which the pathways can be improved and refined to further develop safe and effective care transitions as well as improve communications provided to improve the seamless and effective care provision in primary care to children and young people.ReferencesNICE guideline [NG5] Published: 04 March 2015 Overview | Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes | Guidance | NICE (Accessed 1 June 2024)Keeping patients safe - getting the medicines right: Royal Pharmaceutical Society, FINAL REPORT, June 2012 Keeping patients safe transfer of care report.pdf (rpharms.com) (Accessed 1 July 2024)NHS Discharge Medicines Service [internet] NHS England » NHS Discharge Medicines Service (Accessed 1 June 2024)

AimThe aim of KidzMedz Cymru was to teach Welsh paediatric patients, aged 4 years and above, how to safely swallow tablets and capsules in a structured environment. The project also sought to transition children from liquid medications to tablets or capsules; thus, improving convenience for families and reducing liquid medication prescribing. KidzMedz Cymru was inspired by successful pill schools in England.1 2MethodIn October 2022, the project was awarded funding from the health board charity and approved by the Youth Council.We created self-contained kits including sports cap drinks bottles (for ease of swallowing water), pill packs, information leaflet and a certificate. The dummy pill packs included sprinkles, Millions©, sunflower seeds, mint Tic-Tacs©, Skittles©and dummy capsules. To improve accessibility of the project the contents of the packs are vegan and halal, and the literature is available in both Welsh and English. Each kit also included a data collection form to be filled out by staff, and a parent/carer questionnaire accessible via a QR code. Staff could pre-order kits before a clinic or pick up a few on-demand kits if they needed it immediately.KidzMedz Cymru was rolled out in June 2023 to the respiratory, endocrine, and renal teams due to their close relationship with specialist pharmacists. Posters comparing the sizes of commonly prescribed medicines to the sweets in the kit were also created. Drop-in staff training was available before the launch, with the option for further training on request.ResultsOver the first year, 131 kits were distributed, 54 data collection forms were completed and returned (41% response rate). Of these 54 patients who received the training only 15 patients had medication changed to tablets or capsules (28% success rate). Although the number of patients successfully switched was small there were practical successes achieved including the paediatric gastroenterology department using it to train two patients for video capsule endoscopy, thus eliminating the need for more invasive procedures like endoscopy or colonoscopy. One patient on dialysis had 3 medicines switched from liquid to tablets which meant the patient was more adherent to their fluid balance as well as providing a cost saving of £592 per month. For the patient’s family it was beneficial as they had a smaller amount of medicines to store safely at home and could collect the medication from their local community pharmacy.Only 8 parents or carers completed the online questionnaire so we were unable to see how their beliefs on tablet taking and liquid medicines changed with the education provided. The low response rate may have been influenced by reliance on staff to return forms and the QR code for the questionnaire possibly being missed.ConclusionKidzMedz Cymru faced challenges with data collection. However, the project demonstrated its potential by successfully transitioning children to tablets and supporting non-invasive diagnostic procedures in paediatric gastroenterology. The next steps include expanding the project to ward settings by December 2024 and integrating into local university pharmacy programs.ReferencesRashed AN, Terry D, Fox A, et al. Feasibility of developing children’s Pill School within a UK hospital. Archives of Disease in Childhood 2021;106:705–708.Tse Y, Vasey N, Dua D, et al. The KidzMed project: teaching children to swallow tablet medication. Archives of Disease in Childhood 2020;105:1105–1107.

AimCreatinine needs transforming into estimated glomerular filtration rate (eGFR) to be useful: for medication adjustments, to monitoring acute kidney injury, and to communicate severity of kidney disease to families. This has been standard practice in adult primary and secondary care for many years.In 2019 our children’s hospital adopted electronic patient records. Where a height is available within the last 6 months, eGFR is automatic generated using the Bedside Schwartz 2009 formula1 which is internationally the most recognised and accepted for paediatric use. The result appears as a valve in an adjacent row to creatinine. We studied its utility.MethodObservational EPR study of eGFR measurements at our hospital of children 1 to 16 years between January 2022 and May 2023. Low eGFR was defined as <90 ml/1.73m2/min. In 2024, an online survey was sent to non-nephrology paediatric healthcare staff to gauge user understanding on how to assess kidney function in paediatric patients.Project was approved as a service evaluation by institutional clinical effectiveness register.ResultsOver 17 months 41,286 creatinines were measured. Height was available for 28,215 (68%) creatinines so auto-generating eGFR for 5,264 children. 58% were during 4,309 in-patient episodes, remainder were out-patient samples. 59%, 24%, 9% and 9% of children had one, 2–4, 5–9 or ≥10 eGFR results respectively.A quarter of eGFR measures were low with 13% 60-89, and 10% <60 ml/1.73m2/min. Low eGFR were most prevalent in nephrology (77%), intensive care (19%), cardiology/cardiac surgery (17%) and surgery (9%) samples.Analysis of 1463 children with ≥3 eGFR measures showed substantial eGFR changes between best and worse valves during study period. Of 1313 children with best eGFR ≥90 ml/1.73m2/min, 21% had worse eGFR 60–89 and 8% <60.We gauged clinician response to low eGFR using by reviewing random sample of 100 patients with eGFR <90 and only one or two measures. At follow up of minimum six months, in 74% creatinine was repeated, in 17% creatinine value was within range for age, 4% were adult sized adolescents, and no reason given in 4% which when later recalled returned normal eGFR.A survey of non-nephrology healthcare staff (n=42, 45% consultants, 24% pharmacists) shows a knowledge gap with 55% still preferring creatinine over eGFR for assessing kidney function in children. 80% who answered were unable to correctly identify what eGFR is considered low and only 55% could correctly identify formula used.ConclusionWith electronic patient records it is feasible to auto-generate paediatric height based eGFR in children of all subspecialties. Many had substantial changes in eGFR over 18 months. More education is required to upskill staff’s understanding. The next step will be to study its utility to aid medication renal dose adjustments, to detect acute kidney injury, and families’ understanding of eGFR.Hospitals with electronic patient records should consider incorporating paediatric eGFR for all subspecialities, like in adult practice. However, it is important to ensure staff education from inception.ReferenceSchwartz GJ, Muñoz A, Schneider MF, et al. New equations to estimate GFR in children with CKD. J Am Soc Nephrol. 2009;20:629–637.

ContextMedicines management training (MMT) is mandatory for clinical staff. Before the Covid-19 pandemic, paediatric MMT was delivered in person by the Women’s and Children’s (W&C) pharmacy team. Post-pandemic, adult services designed an e-learning package and assessment to enable clinical staff to complete their MMT. Due to various factors, the W&C pharmacy team was unable to follow suit resulting in paediatric staff completing the adult e-learning package. Whilst this legally fulfilled criteria of completing the MMT, it is not ideal, as paediatric specific information was not covered leading to increased risk in relation to medicine safety and a missed opportunity for relevant training for paediatric clinical staff (PCS).PurposeThis project aimed to work in collaboration with adult service partners to incorporate paediatric specific MMT programme content in an e-learning format on Learn®, the organisation’s e-learning platform partner. The paediatric training content was based on feedback from key stakeholders, The NHS Enduring Standards and National Never Events big data that collates learning from key medication safety incidents nationally.Strategies for ChangeSeveral project tools were used to fruitful effect for the purposes of completion of this project including;SIPOC Project Outline – to ensure a clear vision was set outProject Scorecard including Key Performance Indicators – to ensure project completion and success of project phasesPorter’s Five Forces Model to demonstrate the need for the projectStakeholder Mapping and the Salience Model to identify and classify stakeholders and engagement – this was done to engage key stakeholders including paediatric nurse educators, key members of the pharmacy team and medical team and to highlight any stakeholders that would need further negotiation to make the project outcome successful.Appreciative Inquiry Methods were used in facilitation sessions to ensure relevant information was extracted for the purposes of paediatric medicines management content designRACI matrices to delegate responsibilities to team membersRisk analysis to ensure any problems could be pre–empted, considered and acted uponChange management using Kotter’s 8 Step Change Model and consequent options appraisalConsequently, meetings were had with Senior Lead Pharmacists for Medicines Advisory, Governance and Safety and Clinical Services, Education and Training. Then adult and paediatric content was merged and taken to appropriate stakeholders including the Head of Core Skills and the Core Skills Governance Committee.One of the key issues at this point was limited slide space for all key paediatric MMT topics and thus an interactive adjunct teaching session for PCS was designed and piloted amongst nursing staff and feedback collated.Lessons LearnedThis project has given me the opportunity to lead by example and advocate good practice within my organisation benefitting patients and PCSProject management tools can enhance the efficiency and efficacy of clinical targets within the NHSWritten qualitative feedback from PCS with the new training format has been positiveMedication error rates will be analysed at 6 months post roll out to investigate whether new training package has had an impact

IntroductionIn the European Union, 66% of medicines lack a well-researched paediatric dose upon market entry,1 resulting in up to 75% of Neonatal Intensive Care Unit babies receiving unlicensed medicines.2 This is a stark contrast with the adult population, where unlicensed medicine usage is below 7%,3 and highlights the need for evidence-based paediatric medication. Paediatric medicines without specific licenses rely on high-quality evidence to support their use; however, a 2022 review revealed that only 14% of these medicines have such evidence.4 This knowledge gap exposes children to potential efficacy and safety risks and impacts patients, clinicians, and their parents/carers in making informed evidence-based treatment decisions.Patient and public involvement and engagement (PPIE) is an integral part of research. PPIE activities engage patients and the public (non-patients) to help with designing, prioritising, conducting, and disseminating research as well as promoting knowledge of the researched topic During a scoping exercise, young people (YP) recommended highlighting the inequality in evidence-based paediatric medicine to the public and provided insight into which format this might take. As a result, two clinical academic pharmacists collaborated with a production company to produce a short film (8 minutes) to educate and inform patients and the public about the complexity of children’s medicines and advocate for increased research.MethodAn engagement activity was conducted in late 2023 to gather inspiration from YP. They were informed about the challenges in paediatric medicine and contributed to the script inspiration. The production company developed and produced the script which underwent refinement with feedback from the YP’s Advisory Group at a large tertiary paediatric centre, ensuring language and content resonated with the intended audience.ResultsTo ensure wider impact, the team drafted a dissemination plan aiming to attract attention from the public to fulfil its purpose. A screening event was attended by esteemed guests including the Mayor of Camden and Islington, Trust executives and YP, and received words of support and encouragement from members of the British parliament, the Prime Minister and His Majesty The King. A subsequent roundtable discussion, involving politicians, clinicians and young people, explored avenues for youth involvement in medicine-related policymaking. This event also served as a platform for pharmacists and allied healthcare professions across London to showcase their research and gather feedback from attendees. The film received endorsements and dissemination support from the hosting centre and external stakeholders.ConclusionInvolving patients and YP is pivotal in creating accessible content on complex research topics. Their participation increased their own scientific knowledge and brought interest in future engagement events. The film production, though resource-intensive, provided a sustainable way to engage the public, healthcare professions and researchers with research into paediatric medicine. The film has been invited to various research meetings as a medium to generate discussion in how research and healthcare professions work together to make medicine better for children. A shorter version of the film (2 minutes) was made to help disseminating via social media to enhance public visibility.ReferencesToma M, Felisi M, Bonifazi D, et al. TEDDY European Network of Excellence for Paediatric Research. Paediatric medicines in Europe: the paediatric regulation—is it time for reform? Frontiers in Medicine 2021;2;8:593281.Vieira VC, Costa RS, Lima RC, et al. Prescription of off-label and unlicensed drugs for preterm infants in a neonatal intensive care unit. Revista Brasileira de Terapia Intensiva. 2021;33:266–75.Weda M, Hoebert J, Vervloet M, et al. Study on off-label use of medicinal products in the European union. Publications Office of the European Union; 2019.a.van der Zanden TM, Smeets NJ, de Hoop-Sommen M, et al. Off-label, but on-evidence? A review of the level of evidence for pediatric pharmacotherapy. Clinical Pharmacology and Therapeutics 2022;112:1243–1253.AcknowledgementsThe authors would like to acknowledge and thank their colleagues: Clare Dunn, Stuart Barter, Ofran Al-Mossawi, Kalindi Rajani, Sadhna Sharma, Keli Lambie, Paula Kelly, Snehal Bakrania, Isabel Clee, Dauda Bappa, Munsur Ahmed, Nikesh Gudka, Jennifer Milella

ObjectiveTo examine the distribution and time trends of admission temperature in very preterm infants, effects of temperature-preserving interventions and associations between hypothermia and outcomes.MethodsPopulation-based cohort study of infants <32 gestational weeks without lethal malformations admitted to a neonatal intensive care unit within 2 hours of birth between 1 January 2012 and 31 December 2021. Hypothermia was defined as mild (36.0°C–36.4°C), moderate (34.5°C–35.9°C) or severe (<34.5°C). Associations between admission temperature and outcomes were investigated using multivariate logistic regression, adjusting for sex, weight Z-score, gestational age, antenatal steroids, surfactant and hospital.ResultsIn total, 2457/4879 (50.4%) had normal admission temperatures between 36.5°C and 37.5℃, 1314 (26.9%) had mild hypothermia and 886 (18.2%) had moderate to severe hypothermia, with a significant interhospital variance of 7%–40%. Moderate to severe hypothermia decreased from 24% in 2012 to 16% in 2021 (ptrend<0.001). Measuring temperature before leaving the delivery unit correlated with lower incidence of moderate to severe hypothermia (42% vs 58%, p<0.001). Admission temperature was inversely associated with mortality (adjusted OR 1.5, 95% CI 1.1 to 2.0 for moderate and 2.4, 95% CI 1.1 to 4.9 for severe hypothermia) and with surgical necrotising enterocolitis or intestinal perforation (adjusted OR 1.7, 95% CI 1.1 to 2.7 for moderate and 3.1, 95% CI 1.3 to 7.7 for severe hypothermia).ConclusionsAlthough the incidence of hypothermia decreased during the study period, it remains a concern due to significant associations with adverse outcomes. Areas for further improvement include addressing interhospital variance and enhancing temperature monitoring in the delivery unit.