75 e-Letters

published between 2015 and 2018

  • CPAP and nasal injury

    Dilini I Imbulana and coworkers have published a good systematic review of nasal injuries in preterm infants receiving non-invasive respiratory support1. They included the early work by Robertson et al.2 but not the criticism from us3 or from the company selling the device4. At that time (1996), we had experiences of treatment of about 750 newborns with early versions of Infant Flow, including extremely preterm infants. We had not a single case of significant nasal injury. Imbulana et al. rightly write that it is important to chose correct size of nasal prongs (not too small). It is also crucial to avoid a hard pressure of the CPAP device on the nose. Moderate air leaks are acceptable. Several of the lesions published by Robertson and others are probable caused by attempts to avoid air leaks by a too tight connection between the CPAP device and the nose.
    Neonatal nurses from various hospitals and countries should meet face-to-face or via Skype to discuss and compare how they adapt CPAP devices to preterm newborns.
    Infant Flow was invented by the anaesthetists Drs Gunnar Moa and Kjell Nilsson at our hospital. We were the first paediatrician and neonatologist to use Infant Flow but we haven’t received any fees or other benefit for that.
    1. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Archives of Disease in Childhood - Fetal and Neonatal...

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  • Response to comments from Dr Mark W Davies and Drs Golumbek and Guidici

    Response to comment from Dr Mark W Davies:

    We agree that neurodevelopmental outcome may be an important outcome to measure following any neonatal surgery and would certainly welcome any study that reported this outcome in infants with gastroschisis. However following a rigorous consensus process as we have described, neurodevelopmental outcome was not selected as part of the core outcome set. We emphasise that the outcomes within the core outcome set are not the only outcomes that should be measured in future research but are the minimum recommended. Additional outcomes such as neurodevelopmental outcomes may of course be reported.

    Response to comment from Drs Golumbek and Guidici

    Drs Golumbek and Guidici are quite correct that characteristics of infants with gastroschisis, such as complexity of the condition at birth, may affect their prognosis. We are quite clear that this core outcome set should be used for observational studies which follow-up a cohort of infants based on these characteristics, as well as trials or observational studies which follow-up infants who have been managed using different surgical approaches. We agree that some of these outcomes are not specific to gastroschisis, but our aim was not to produce a core outcome set that had only gastroschisis specific outcomes within it, but one that contained the most important outcomes for infants with gastroschisis – some of which may apply equally to other infants. Growth at birth is not...

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  • To the editor

    Dear Nick Brown
    Editor in chief, Arch Dis Child Fetal Neonatal

    We read with interest the study titled “Development of a gastroschisis core outcome set” by Benjamin Saul Raywood Allin et al1, and we have several questions and comments.
    The aim of the authors is to design a core outcome set to be used in research in order to reduce outcome reporting heterogeneity and to help improve the clinical relevance of the research. The authors state that “Many gastroschisis studies investigate outcomes that are not relevant to patients or clinical practice”. However, they don´t clarify how they arrived to this hypothesis.
    This study has developed a gastroschisis core outcome set consisting of eight outcomes that are important to parents, people born with gastroschisis and clinicians.
    The eight outcomes are death, sepsis, growth, number of operations, time on parenteral nutrition, liver disease, number of severe gastrointestinal complications and quality of life. Regarding growth, it should be noticed that children born with gastroschisis are frequently intrauterine growth restricted, and therefore, this issue should be clarified - it is not always an outcome; gastrointestinal complications are also (up to 25% of gastroschisis population in some reports) a frequent component of the malformation itself, so this should be clarified when speaking of “complications”.
    In high income countries, adverse outcomes are related to the presence of complex gast...

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  • Development of a gastroschisis core outcome set: missed opportunity .

    Any surgery as a neonate carries increased risk of adverse neurodevelopmental outcomes and any neonatal study should include them. They are different from overall quality of life.

  • Practical advice on providing resuscitation of the neonate with an intact cord

    Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.

    Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.

    Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).


    1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001

    2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276

  • The value of accepting good with bad in moral distress: a response to Benjamin Hickox

    We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...

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  • Response to Hewson M, Resuscitation saturation targets

    We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.

    Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.

    We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).

    We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...

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  • Resuscitation saturation targets

    This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .

    The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.

    It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.

    The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).

    I suggest a target of 90...

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  • Moral distress is always a burden. Moral stress is not. The importance of a priori conceptual clarity.

    It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...

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  • Response: High flow nasal cannula versus NCPAP: No difference in time to full oral feeds

    We are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
    The first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstru...

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