643 e-Letters

  • Physiology of umbilical blood flow with uetrotonics?; in reply

    Thank you for your interest in our study and your comment. When you read the 6th paragraph of the discussion of the article, you will find that we completely agree that Oxytocin could have influenced the observations. This was an observational study and moment of oxytocin was given to the discretion of the midwife. Nevertheless, we still observed umbilical circulation much longer than previously described. This study was performed in 2015, but our local guideline has recently been changed to administering oxytocin after cord clamping. A new study is currently undertaken using the same methodology.

  • RE: Hemoglobin discordances in twins: Still unanswered!!!

    We thank dr. Kumar and dr. Yadav for their interest in our study. We hope that by stating ‘delayed cord clamping may not be advisable in second-born MC twins after vaginal birth’, we expressed that gynecologists could consider to deviate from the international guidelines in some cases. It is possible that not all babies will benefit from placental transfusion in a similar way. However, we certainly agree with dr. Kumar and dr. Yadav that the optimal timing of umbilical cord clamping in twins warrants further investigation.

  • Physiology of umbilical blood flow with uetrotonics?

    Thank you for this interesting and highly needed piece of knowledge on physiological umbilical bllod flow. Just one remark: uterotonics were given to all women directly after birth. Oxytocin may alter umbilical blood flow due to modifications in timing and strength of contractions, and influence timing of placental disattachment. Possibly, true physiological blood flow may be still different (and continue for even longer), if medication were administered after clamping (quite possibly with no significant disadvantage for the parturient).

  • PreROP Trial - Intention to treat analysis and Hypoglycemia monitoring

    Dear Editor
    We genuinely appreciate the readers keen interest in our paper and critical comments.1 Here are our clarifications regarding their comments.
    1. The readers have perhaps misunderstood the concept of “intention to treat analysis” and “per protocol analysis”.2 Infants were analysed as they were randomized in their respective groups (intention to treat analysis). Per protocol analysis excludes the patients who deviate from the protocol. In our study, we needed to exclude the infants who were lost to follow-up and therefore their outcomes were not known. We did not exclude them because there was a protocol deviation or violation.
    2. Blood dextrose levels were monitored as per unit protocol and once stable on full enteral feeds they were done once a week along with weekly routine blood evaluations up to discharge. No additional testing for blood sugars was done for the study.
    3. We believe that propranolol at lower doses of 0.5mg/kg/dose 12 hourly is unlikely to affect the normal vascularization in other organs. This drug has been previously used in newborns including preterm newborns for different indications. Till date there have been no reports of deranged neuro-developmental outcome attributed to propranolol. However, we agree with the readers thoughts that long term neuro-developmental outcome would have been useful but this was beyond the scope of this study.
    4. In our study, for babies born at 31-32 weeks post menstrual age the...

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  • Neonatal ethanol/isopropanol exposure in isolettes


    We read Hsieh et al's paper with much interest. In an experimental study of ethanol introduction in an empty isolette, they conclude that neonates in isolettes are at risk of of inadvertent exposure to ethanol from hands cleaned with ethanol-based hand sanitiser.
    We would like to share with the readers of Arch Dis Child Fetal Neonatal, the results of a similar study conducted in 2011. Measurements of isopropanol/ethanol exposure were conducted for 9 neonates nursed in incubators1. We found very variable exposure profiles with peak isopropanol/ethanol value of 1982, respectively 906 ppm. A wide range of possible exposure situations were also investigated using a one-box dispersion model2. Both our clinical and experimental papers offered different approaches to reduce the potential isopropanol/ethanol exposure for neonates nursed in isolettes.
    We were delighted to read that the results from Hsieh et al. were concordant with our findings. We believe that this new publication gives further evidence and emphasis on the, unfortunately often underestimated, issue of neonatal exposure to gaseous pollutants.

    1 Paccaud et al. Hand-disinfectant alcoholic vapors in incubators. JNPM 4(1):15-19, 2011
    2 Vernez et al. Solvent vapours in incubators: a source of exposure among neonates? Gefahrstoffe -Reinhaltung der Luft 71 (5):209-214, 2011

  • Hemoglobin discordances in twins: Still unanswered!!!

    We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
    Despite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis an...

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

    We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
    Even though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
    Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of...

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  • Re: Haemoglobin discordances in twins: is "really" due to differences in timing of cord clamping? A consideration to Verbeek L and co-authors

    We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.

    Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]

    Reference List

    1. McDonald SJ, Middleton P, Dowswell T, Morris PS: Eff...

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  • Implementation of an automated oxygen Control system- Are we ready?

    We read with great interest the article by Van Zanten HA et al., published in this journal and found the results impressive.[1] However, we have certain observations about the conduct of the study
    Even though the authors state that this report was part of a quality improvement initiative in their NICU, the authors have neither reported the results in the format suitable for a quality improvement study nor have clearly stated the design; at the end of introduction they seem to mention that this was a retrospective data analysis; whereas, in the first line of the methods they state the design as a prospective observational study. Even though the automatic oxygen controller group would not have been affected much by any one of the design, the impact would have been in the manual group, keeping especially the training of the NICU staff in mind. It’s also worth emphasizing here that the authors mention about the local guidelines practiced for manual titration of supplemental oxygen based on the saturations, for the sake of external validity.[2]
    Minute wise data points used in this study may have significantly underestimated the hypoxemic episodes and thereby the proportion of times an infant remained in the ‘below target range’ saturations. In a logical sense, manual titration would have happened sooner than expected for a hypoxemic event and hence would not have been captured if more frequent data points are not considered. Using the same technology and a lesser in...

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  • congenital depression of skull

    I read with interest your article on spontaneous ping pong parietal fracture in newborns with impressive color images .The word 'fracture' can be quite traumatic to the parents and should avaoided if there is no radiological evidence of break in the cortex 1. It should then just be labelled as depression of skull bone without a fracture rather than labelling as DCF( depressed calvarial fracture) as mentioned in your article .You have also clearly demonstrated in your 3D CT image also that there was no break but only invagination of parietal bone .The management would also not change whether the depression is with or without fracture .
    References -
    Tayeh,et al.BMJCase Rep2016.doi:1136/bcr-2016-215437