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Two sacred cows of neonatal intensive care—Authors' response
  1. EDMUND HEY, Retired Consultant Paediatrician
  1. Newcastle, UK
  2. shey{at}easynet.co.uk

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    Editor—I am glad to have a chance to respond to Dr Roberton's assertion that the care of the babies nursed using oximeter settings of 70–90% was “negligent”, since I was responsible for these children, but time and space does not allow a full response. Neither does space allow me to respond to the criticism implicit in your own introductory statement that such care “breaches BAPM guidelines”.

    Dr Roberton says the cerebral palsy rate is “irrelevant”, but parents might not agree. Parents might also be glad that, while 4 children monitored using an oximeter alarm set at 88–98% went blind, no child in the other group went blind. They might also be glad that half were off the ventilator in 7 rather than 22 days, and out of oxygen in 4 rather than 10 weeks. The NHS might be equally grateful for the reduction in cost such an approach delivers. Post delivery growth in the conservatively managed group was only retarded half as much as in the comparator group, even though only a quarter ever received any parenteral nutrition. I am happy to leave parents to be the judge of whether this was “negligent” care.

    Babies were not “kept at 3.3–6.0 kPa for days and weeks”: target saturation delivered an arterial partial pressure of 5–11 kPa, but alarm settings were more generous than this to discourage staff from adjusting the ventilator every time saturation transiently fell below 80%. Nor was blood pressure monitored by oscillometry (a technique that is known to be unreliable),1 as a proper reading of the paper would reveal. Dr Roberton mistakenly calls our survival rate our mortality rate, compares survival for mostly black American with that of our white English children, compares survival to discharge with survival to one year, and says nothing about the reliability with which gestation was documented.2 The same issue of your journal contains a better review of survival.3 We have every intention of following these children, but felt it would be wrong to wait ten years before reporting the above findings.

    Dr Roberton mentions the outcome of a study of 38 children offered corrective surgery for transposition 6 months to 5 years after birth.4 Those operated on early had a better cognitive outcome, but Dr Roberton does not mention the fact that these children had a mean saturation of 68% before operation, and that 8 had a history of acquired central nervous system damage.

    However, the main thrust of Dr Roberton's letter is that lack of an arterial line subjected these babies to unnecessary pain. This overlooks the fact that morphine was given during early care, while early extubation greatly reduced the total number of blood samples eventually taken (as the differing transfusion needs confirm). Samples were not taken every 2–3 hours initially, but every 6–8 hours. In fact, Dr Roberton and I are at one in agreeing that minimising pain is a very valid reason for inserting an umbilical artery line in babies as immature as this; the limited use of lines was only mentioned because these have been considered necessary in the past to minimise the risk of severe retinopathy—a belief for which there is absolutely no controlled trial evidence.

    Finally, Dr Roberton asks if this approach ever had ethics committee approval. It did not, because it was merely a continuation of the non-invasive approach initiated by my predecessor Dr Neligan in the mid 1970s, aided by the arrival of transcutaneous gas monitoring. Neither was the introduction of pancuronium in Dr Roberton's own unit5 placed before an ethics committee.

    I can only conclude that someone ought to cull the two sacred cows Dr Roberton has been worshipping (along with all the other animals recently culled in the UK). In the absence of any other evidence based information, we need a proper controlled trial to address these issues.

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