High noise levels during nCPAP reported by Karam et al. demonstrate
the presence of a continuous exposition to audio trauma by the developing
ears of preterm infants.1
These levels were directly related to the flow through the circuits, but
not to the pressure generated, neither to the type of nCPAP device used.
To improve the patient-ventilator interface we developed a new device
(neonatal helmet CPAP) to administer C...
High noise levels during nCPAP reported by Karam et al. demonstrate
the presence of a continuous exposition to audio trauma by the developing
ears of preterm infants.1
These levels were directly related to the flow through the circuits, but
not to the pressure generated, neither to the type of nCPAP device used.
To improve the patient-ventilator interface we developed a new device
(neonatal helmet CPAP) to administer CPAP in preterm infants.2 In a short-
term physiological study, neonatal helmet CPAP appeared to be a feasible
method of supporting the breathing of preterm infants with a better
tolerability compared with conventional nCPAP.2 Furthermore, this new
device allows the delivery of accurate nitric oxide levels avoiding NO2
accumulation.3
In a bench study, we measured the noise levels generated by the neonatal
helmet CPAP. Measurements were performed on the C scale (using a C-
weighting filter). The phonometer (MK 5350, Mitek Industries, Inc,
Phoenix, AZ, USA) was positioned in the pressure chamber of the device
corresponding to the ear of the neonate (“ear zone”). The noise levels
were detected at different flow rates (8, 10 and 12 l/min), maintaining
the level of CPAP constant at 5 cmH2O.
Measurements for each flow rate lasted 15 minutes; the noise level was
calculated every 20 seconds. All measurements were obtained in the
Neonatal Intensive Care Unit (NICU) in the afternoon (3.00-5-00 p.m.).
In the neonatal helmet CPAP system, the mean (SD) noise levels were
significantly higher in comparison with those measured in the NICU
(60.4+0.7 dB) and within the baby compartment of the incubator (62.3+0.5
dB). Noise levels significantly changed with increasing flow rates in the
system: 8 l/min (69.9+0.5 dB); 10 l/min (71.5+0.2 dB); 12 l/min (73.5+0.3
dB). (Figure)
In agreement with Karam et al.,1 our results show that the CPAP
systems produce potentially dangerous noise levels for the developing ear
of a preterm infant. They are directly related to the flow rate through
the system, instead of the pressure level. The new CPAP devices need to
take into account this crucial aspect.
REFERENCES
1. Karam O, Donatiello C, Van Lancker E, Chritin V, Pfister RE,
Rimensberger PC. Noise levels during nCPAP are flow-dependent but not
device-dependent. Arch Dis Child Fetal Neonatal Ed 2008;93:F132-F134.
2. Trevisanuto D, Grazzina N, Doglioni N, Marzari F, Zanardo V. A new
device for administration of continuous positive airway pressure in
preterm infants: comparison with a standard nasal CPAP continuous positive
airway pressure system. Intensive Care Med. 2005;31:859-64.
3. Trevisanuto D, Doglioni N, Micaglio M, Zanardo V. Feasibility of
nitric oxide administration by neonatal helmet-CPAP: a bench study.
Paediatr Anaesth. 2007;17:851-5.
O'Donnell et al (1) explain the need for documenting neonatal resuscitation for audit and teaching purposes. Obstetricians make great efforts to monitor the fetus during labour in the hope of being able to intervene when signs of significant fetal hypoxia develop. Intermittent monitoring may be sufficient in low risk women but continuous monitoring is common in hospital units. If fetal distress is detected and the decisi...
O'Donnell et al (1) explain the need for documenting neonatal resuscitation for audit and teaching purposes. Obstetricians make great efforts to monitor the fetus during labour in the hope of being able to intervene when signs of significant fetal hypoxia develop. Intermittent monitoring may be sufficient in low risk women but continuous monitoring is common in hospital units. If fetal distress is detected and the decision for delivery by caesarean section is made, delivery is expected to occur within 30 minutes. (2) Discontinuing monitoring is not acceptable when fetal compromise is suspected but during this time preparations need to be made for delivery such as transfer to the operating theatre and commencing a spinal anaesthetic. Maintaining continuous and documented fetal monitoring is difficult and not usually maintained during these preparations. Once the caesarean is commenced all monitoring ceases. There may therefore be an interval of 15 to 30 minutes during which little is known and nothing is formally documented about the condition of the fetal heart rate. When the baby is delivered in good condition this gap in our knowledge seems of little consequence. However when the neonate requires resuscitation, we do not know whether this represents the condition of the baby when the decision to deliver was made or whether there has been a significant deterioration since then. Even after delivery there is a significant interval when we rely on clinical assessment of the baby. The heart rate is estimated clinically, as are respiration and oxygen levels. Blood pressure measurements are not usually practical in the first few minutes after birth or during resuscitation. Documentation, as O’Donnell et al (1) point out is retrospective and dependant on memory sometimes after a chaotic and stressful event. Therefore we are often faced with more than 45 minutes of poorly documented data on the condition of the fetus and baby to determine the possible causes of a poor outcome.
Similarly in spontaneous or assisted vaginal delivery there is an interval during which we lose documented evidence of the state of the baby. During the second stage continuous monitoring is still possible but requires careful and frequent adjustment of the transducer. Once the head is delivered monitoring is no longer possible. Normally the body will quickly follow a few minutes later but if there is shoulder dystocia this time may extend to over 5 minutes. Once again our lack of knowledge during resuscitation continues.
A review of fatal shoulder dystocia (3) showed that in 50% of these babies who died, there was less than five minutes delay between delivery of the head and body. In only 25% was there evidence of fetal distress. We do not know what happened to the baby’s heart rate from the moment the head delivered.
While it is true that nothing much more may be possible if urgent delivery is already underway, it is a time when we have no good knowledge of the state of the cardiovascular system. This will limit our understanding and opportunity for maximising the management of fetal distress. Video monitoring of resuscitation is one way of improving our understanding. There is a gap which is poorly recognised. With current technology it should be possible to monitor continuously the heart rate once the head is delivered and continue during resuscitation until standard neonatal monitoring is in place or the baby no longer needs it. The convenience of Bluetooth transfer of data from my mobile phone makes me wonder if monitoring need not have the restrictions of wires.
David J R Hutchon FRCOG
References
1. O’Donnell CPF, Omar C, Kamlin F, Davis PG, Morley CJ. Ethical and legal aspects of video recording neonatal resuscitation. Archives of Disease in Childhood - Fetal and Neonatal Edition 2008;93:F82-F84
2. National Institute for Clinical Excellence. Intrapartum Care Guideline September 2007
3. Hope, P., Breslin S, Lamont L, Lucas A, Martin D, Moore I, Pearson J, Saunders D, Settatree R. Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol, 1998. 105(12): p. 1256-61.
We agree with Dr Gandhi¡¯s view that a large, well designed study is
required to answer the important question about accuracy and feasibility
of pulse oximetry in the early neonatal period. However, we would like to
clarify the design of such a study particularly focussing on outcome
measures that should be investigated. It should be a test accuracy study
for prediction of congenital heart disease (...
We agree with Dr Gandhi¡¯s view that a large, well designed study is
required to answer the important question about accuracy and feasibility
of pulse oximetry in the early neonatal period. However, we would like to
clarify the design of such a study particularly focussing on outcome
measures that should be investigated. It should be a test accuracy study
for prediction of congenital heart disease (CHD).
Dr Gandhi states that 60% of CHD is non-cyanotic and pulse oximetry
would offer little, if any assistance in its detection. It is important to
remember that majority of acyanotic congenital heart diseases do not need
attention in the early neonatal period and therefore pulse oximetry
screening would focus on detecting critical, life threatening CHD. There
are controversies about sensitivity of pulse oximetry in detecting
critical acyanotic duct dependent lesions in the early neonatal period,
namely coarctation of aorta and hypoplastic left heart lesions. However
recording pre and post ductal differential saturations and using a cut-off
of ¡Ý3% was found to increase the performance of this test.(1; 2)
Dr Gandhi¡¯s one year review of practice at their local hospital
revealed that only neonates with low saturations had respiratory distress
and were subsequently found to have PPHN; they did not encounter
asymptomatic newborns with low saturations.
This is not our experience and may be due to various reasons. Firstly,
there may be relatively small numbers at one particular centre. Secondly,
as the author pointed out, clinical detection of cyanosis is highly
clinician dependent. In our experience at the Birmingham Children¡¯s
Hospital, we get referrals for neonates who are asymptomatic and have low
saturations. In this situation, our policy is to recommend prostaglandin
infusion pending further assessment. Dr Gandhi¡¯s comment about all the
babies with heart murmurs having normal saturations is again likely to be
due to small numbers and is contrary to our experience.
We hope to have some answers to these questions from a large
multicentre NHS HTA funded study currently underway in the West Midlands.
Further details are available from our website www.pulseox.bham.ac.uk
Yours faithfully
Dr Abhay M Bhoyar1,2
Dr John G C Wright2
Dr Ashish Chikermane2
Prof Khalid S Khan1,3
Dr Andrew K Ewer1,4
1. Division of Reproductive and Child Health, University of
Birmingham. 2. Department of Paediatric Cardiology, Birmingham Children¡¯s
Hospital. 3. Department of Obstetrics and Gynaecology, Birmingham Women¡¯s
Hospital. 4. Deaprtment of Neonatology, Birmingham Women¡¯s Hospital.
References
(1) de Wahl Granelli A, Mellander M, Sunnegardh J, Sandberg K,
Ostman-Smith I. Screening for duct-dependant congenital heart disease with
pulse oximetry: a critical evaluation of strategies to maximize
sensitivity. Acta Paediatrica 2005;94(11):1590-6.
(2) Hoke TR, Donohue PK, Bawa PK, Mitchell RD, Pathak A, Rowe PC,
Byrne BJ. Oxygen saturation as a screening test for critical congenital
heart disease: a preliminary study. Pediatric Cardiol 2002; 23(4):403-9.
We read with interest the original article by Wren et al about the
trends in diagnosis of major congenital cardiovascular malformations
published in the fetal and neonatal issue of the journal1. The paper
discusses the difficulties which we are still experiencing in diagnosing
the cardiovascular (CVS) abnormalities. It is evident that we continue to
miss life threatening abnormalities despite efforts to imp...
We read with interest the original article by Wren et al about the
trends in diagnosis of major congenital cardiovascular malformations
published in the fetal and neonatal issue of the journal1. The paper
discusses the difficulties which we are still experiencing in diagnosing
the cardiovascular (CVS) abnormalities. It is evident that we continue to
miss life threatening abnormalities despite efforts to improve our
detection rates.
The authors in their discussion suggest that better early diagnosis
of serious congenital cardiac malformations is likely to be achieved by
further improvements in antenatal diagnosis and more wide spread use of
routine pulse oximetry. Whether such is indeed the case is open to debate
and discussion.
Firstly how can we realistically advance the antenatal detection
rate? The current practice is to perform a detailed scan of the foetus at
around 19 weeks of gestation to look for foetal abnormalities. This is
done by trained sonogarphers who routinely do a 4- chamber view of the
heart. The additional view of the outflow tracts is still not routine
practice in all units and remains optional. It is envisaged that by
obtaining the latter view the detection rate of the CVS malformation would
be improved from 25 % to up to 75% as per the RCOG2 guidelines for mid-
trimester scans. The malformations which were noted to be undetected in
the author’s study include coarctation of the aorta, interruption of the
aortic arch, aortic valve stenosis and total anomalous pulmonary venous
connection. These malformations are unlikely to be detected on routine
anomaly scans and are likely to evolve as the foetus grows. Identifying
them may well need another scan later in gestation. This at present is not
a recommended practice and has considerable additional resource
implications. There is of course the alternative of seeking early input
from the experts in cardiac scanning, namely paediatric cardiologists with
expertise in foetal cardiac scanning. Again the resource implications make
this highly improbable if not impossible. Thus with the current system of
screening for foetal abnormalities, we are unsure how the antenatal
detection rates for CVS abnormalities can be improved.
Secondly there is paucity of high-quality evidence supporting the
role of pulse oximetery for early detection of congenital heart disease.
The report of the Tennessee task force, which the authors have referenced
in their discussion was based on the analysis of four major studies using
pulse oximetry screening3. The task force recommended against mandatory
implementation of screening and stated that a very large prospective study
is needed to define sensitivity and false positive rates of lower limb
pulse oximetry screening in asymptomatic newborn population. More recently
a systematic review identified pulse oximetery as a potentially useful
tool for diagnosis of congenital heart disease in asymptomatic neonates.
The reviewers however in addition concluded that although pulse oximetery
is highly specific it has highly variable sensitivity with wide confidence
intervals. They also commented on the quality of the various studies
included in the review stating that this was generally compromised due to
the differential verification used in identifying positive and negative
cases. Moreover the absence of blinding, and absent or poor description of
the test or reference standard was deemed to have affected the results of
the review. The reviewer’s conclusion was that large, well-conducted and
robust studies are essential to confirm the value of pulse oximetry as a
screening test, in isolation or in combination with clinical examination
to obtain precise estimates of its sensitivity4.
It may sound disappointing but it seems rather implausible that
detection rates of congenital heart disease in the foetal or neonatal
period are going to improve notably in the foreseeable future.
References
1. Wren C, Reinhardt Z, Khawaja K. Twenty-year trends in diagnosis of
life-threatening neonatal cardiovascular malformations. Arch Dis Child
Fetal Neonatal Ed 2008;93:F33-F35.
2. Ultrasound Screening for Fetal Abnormalities. Report of the RCOG
Working Party (2000). RCOG, London.
3. Liske MR, Greeley CS, Law DJ, et al. Report of the Tennessee task force
on screening newborn infants for critical congenital heart disease.
Pediatrics 2006; 118: e1250–6.
4. Thangaratinam S, Daneils J, Ewer AK, Zamora J, Khan KK. Accuracy of
pulse oximetry in screening for congenital heart disease in asymptomatic
newborns: as systematic review. Arch Dis Child Fetal Neonatal Ed
2007;92:F176-F180.
Your point of transillumination test to detect pneumoperitoneum in gastric perforation in a newborn is quite valid and shows the importance of simple bedside test to detect an early abdominal catastrophe.
Recently, we encountered a 35 weeker, No risk factors for sepsis,commenced on nasogastric feeds on day1,and on D2 had marked abdominal distension.X-ray abdomen showed dilated loops with no air under diaphragm, a repeat X-ray on...
Your point of transillumination test to detect pneumoperitoneum in gastric perforation in a newborn is quite valid and shows the importance of simple bedside test to detect an early abdominal catastrophe.
Recently, we encountered a 35 weeker, No risk factors for sepsis,commenced on nasogastric feeds on day1,and on D2 had marked abdominal distension.X-ray abdomen showed dilated loops with no air under diaphragm, a repeat X-ray on D3 confirmed as pneumoperitoneum.The baby did have a 2 cms gastric perforation that was succesfully repaired.
My point is that sometimes its possible to miss small pneumoperitoneum on Xrays.
My question is How reiablewould the transillumination test be in the early hours of gastric perforation?
Reynolds, like the majority of us neonatologists and obstetricians, would be unable to keep his nerve and delay three minutes before clamping and cutting the cord to be able to proceed with resuscitation. However maintaining a placental circulation may sometimes be all that is required as Aristotle (1) observed “Frequently the child appears to be born dead, when it is feeble and when, before the tying of the cord,...
Reynolds, like the majority of us neonatologists and obstetricians, would be unable to keep his nerve and delay three minutes before clamping and cutting the cord to be able to proceed with resuscitation. However maintaining a placental circulation may sometimes be all that is required as Aristotle (1) observed “Frequently the child appears to be born dead, when it is feeble and when, before the tying of the cord, a flux of blood occurs into the cord and adjacent parts. Some nurses who have already aquired skill squeeze (the blood) back out of the cord (into the child’s body) and at once the baby, who had previously been as if drained of blood, comes to life again.”
We do not recommend the patience described by Aristotle but some lateral thinking is required. When reversal of tracheal occlusion done in cases of severe congenital diaphragmatic hernias is needed at birth an EXIT (2) procedure is used. Essentially a functional placental circulation is maintained until the tracheal occlusion can be removed and the neonate ventilated.
Resuscitation before the placental circulation has ceased allows some warm oxygenated blood to return to the neonate and supplement oxygenation from the newborns lungs. Indeed as the pulmonary vasculature opens up drawing blood from the rest of the body, the deficit is replaced by redistribution of the returning placental blood. This effect is well recognised as the placental transfusion which occurs in a physiological third stage.(3)
Resuscitation before the cord is clamped and cut takes a little preparation and thought. We have developed a procedure at caesarean section to provide all the normal equipment for resuscitation without compromising the facilities for the neonate or the mother, so that ventilation and pulmonary respiration can be established while the cord remains intact. (4) Precise arrangements may need to be modified according to different theatre layouts. Essentially it involves bringing the resuscitaire up to the side of the operating table. Other approaches are possible. Preparation and cooperation between obstetrician, paediatrician and theatre staff is key to success. There are likely to be substantial benefits for babies with significant hypoxia. When fetal distress is due to cord compression such as with a nuchal cord, the fetus may already be hypovolaemic at birth. Delayed clamping allows time for the placental transfusion to correct the hypovolaemia.
References
1. Aristotle. History of animals. Transl by R Cresswell, London.1878
2. Bouchard S, Johnson MP, Flake AW, et al: The EXIT procedure: Experience and outcome in 31 cases. J pediatr Surg 37(3):418-426, 2002.
3. Linderkamp O. Placental transfusion: determinants and effects. Immediate cord clamping can result in hypotension, hypovolemia and anemia. Clinics in Perinatology 1982;9:559-592
4. Hutchon DJR and Thaker IM. How to resuscitate the neonate with the cord intact at caesarean section. 31st British Congress of Obstetrics and Gynaecology London 6 July 2007
áñ"ã
To the Editor,
We read with interest the article by McCrossan et al on selective
fluconazole prophylaxis. Reviewing the data presented in Table 2, in 3
out of 4 infants with positive blood culture, cephalosporin was involved.
A practical conclusion would be to eliminate the use of cephalosporin in
VLBW infants. Another measure would be to shorten empiric antibiotic use
to 3-4 days (if cultures prove to be negative)...
áñ"ã
To the Editor,
We read with interest the article by McCrossan et al on selective
fluconazole prophylaxis. Reviewing the data presented in Table 2, in 3
out of 4 infants with positive blood culture, cephalosporin was involved.
A practical conclusion would be to eliminate the use of cephalosporin in
VLBW infants. Another measure would be to shorten empiric antibiotic use
to 3-4 days (if cultures prove to be negative) or to 7 days if positive
cultures for bacteria or if the infant's clinical condition improves under
antibiotic coverage. Prevention rather than prophylaxis could be the
corner stone for minimizing invasive fungal infections.
As to the study methodology, prophylaxis was given at the discretion
of the caring neonatologist and thus only 14 of the 31 eligible infants
received prophylaxis. The right way to do it would have been to give
prophylaxis to all the 31 eligible infants, according to the eligibility
and risk factors set by the authors. In the pre-prophylaxis period, a
total of 6 of the 33 eligible infants developed proven fungal infection,
but the authors do not suggest which of these 33 infants (all with risk
factors) would have received prophylaxis. In the post-prophylaxis period,
17 eligible infants did not receive prophylaxis! Reading the manuscript,
one can not sure that these 17 infants did not have fungi in blood, urine
or other sites. In the "Results" section, second paragraph, row 4, 6%
should read 18% (6/33).
Bose and Laughon have clearly reviewed the lack of evidence for
current treatments of patent ductus arteriosus (PDA) in preterm
infants.[1] As highlighted, the general tendency to treat a clinically
relevant PDA for fear of adverse clinical outcome with either indomethacin
or surgery when indomethacin fails has caused a lack of information on the
natural history of symptomatic PDA. Spontaneous PDA closure has been
report...
Bose and Laughon have clearly reviewed the lack of evidence for
current treatments of patent ductus arteriosus (PDA) in preterm
infants.[1] As highlighted, the general tendency to treat a clinically
relevant PDA for fear of adverse clinical outcome with either indomethacin
or surgery when indomethacin fails has caused a lack of information on the
natural history of symptomatic PDA. Spontaneous PDA closure has been
reported beyond the first weeks of life.[2] Therefore, a more conservative
approach towards PDA treatment may be rational, even at a later stage. We
report successful closure of a symptomatic PDA several weeks postnatally
in a preterm baby after fluid restriction and diuretics.
A preterm boy of 28 weeks and one day received prophylactic
indomethacin 0.1 mg/kg/day once daily during the first three days of life.
At day 1, a unilateral IVH grade 2 was noticed. Despite ventilation and
surfactant, oxygenation problems persisted. A cardiac ultrasound at day 5
showed evidence of pulmonary hypertension and a functionally closed ductus
arteriosus. Nitric oxide was administered for a week and the boy was
weaned from the ventilator at three weeks of age. At one month of age a
cardiac murmur was noticed while oxygen need and CPAP dependency
persisted. Cardiac ultrasonography demonstrated ductus arteriosus patency
with significant left-to-right shunting. Despite a long course of
indomethacin (0.2 mg/kg/day during 6 days), ductal patency persisted as
shown by cardiac ultrasound. Treatment with fluid restriction (130
ml/kg/day) and diuretics (furosemide 1 mg/kg/day for 3 days followed by
triamterene and hydrochlorothiazide 2 mg/kg/day for 14 days) was
initiated. Adequate growth was maintained. During treatment, both nasal
CPAP and supplemental oxygen could be stopped. By ultrasound at the age of
7 weeks, the ductus arteriosus was shown to have closed.
This case underlines both the possibility of the ductus reopening
after indomethacin prophylaxis and the low probability of indomethacin to
induce ductal closure at several weeks postnatally. Recently,
Vanhaesebrouck and colleagues have presented data to suggest that fluid
restriction along with ventilatory adjustments is effective in closing a
symptomatic PDA diagnosed within 72 hours postnatally in preterm
infants.[3] Our case suggests potential efficacy of a similar conservative
approach to PDA beyond the first days to weeks after birth. We wish to
emphasize the possibility of a conservative approach as a treatment option
and an alternative to surgery in clinically relevant PDA beyond the first
weeks of life. Additional studies are needed to evaluate the efficacy of
conservative treatment of PDA as compared to indomethacin and surgical
closure, depending on the postnatal age.
1 Bose CL, Laughon MM. Patent ductus arteriosus: lack of evidence for
common treatments. Arch Dis Child Fetal Neonatal Ed. 2007;92(6):F498-502.
2 Koch J, Hensley G, Roy L et al. Prevalence of spontaneous closure
of the ductus arteriosus in neonates at a birth weight of 1000 grams or
less. Pediatrics. 2006;117(4):1113-21.
3 Vanhaesebrouck S, Zonnenberg I, Vandervoort P et al. Conservative
treatment for patent ductus arteriosus in the preterm. Arch Dis Child
Fetal Neonatal Ed. 2007;92(4):F244-7.
Peter Pharoah conducted a study comparing the livebirth prevalence of congenital anomalies in children with CP living in Merseyside UK to the prevalence of congenital anomalies in 8 UK EUROCAT population-based congenital anomaly registers 1. EUROCAT is a European network of population-based registries for the epidemiologic surveillance of congenital anomalies. Currently, the network consists of 39 active registries in 20 count...
Peter Pharoah conducted a study comparing the livebirth prevalence of congenital anomalies in children with CP living in Merseyside UK to the prevalence of congenital anomalies in 8 UK EUROCAT population-based congenital anomaly registers 1. EUROCAT is a European network of population-based registries for the epidemiologic surveillance of congenital anomalies. Currently, the network consists of 39 active registries in 20 countries covering 26% of the European birth population 2. The published article contained two misleading statements regarding EUROCAT data which we wish to clarify.
1. While it is true that our website data prevalence tables only display total birth denominators, livebirth denominators for the EUROCAT registers are available on request
2. Contrary to the statement published in Pharoah’s paper, EUROCAT records prevalence information for both congenital hip dislocation and talipes from 1980 onwards, available at http://www.eurocat.ulster.ac.uk/pubdata/tables.html.
Our website Prevalence Data Tables provide European prevalence information for 96 EUROCAT congenital anomaly subgroups.
1 Pharoah POD (2007). Prevalence and pathogenesis of congenital anomalies in cerebral palsy. Archives of Disease in Childhood 92 (6): F489-F493
2 Dolk H (2005). EUROCAT: 25 Years of European Surveillance of Congenital Anomalies. Archives of Disease in Childhood 90 (5): F355-F358
The study by McCrossan et al showed that fluconazole prophylaxis in a
selected group of preterm infants with birth weight less than 1,500 grams
decreases invasive fungal infection [1]. We agree that a carefully
delineated risk-factor approach to the prevention of Candida infection in
neonates may be a useful alternative to continuous fluconazole prophylaxis
and may decrease the risk of the emergence of fluconazole-resistan...
The study by McCrossan et al showed that fluconazole prophylaxis in a
selected group of preterm infants with birth weight less than 1,500 grams
decreases invasive fungal infection [1]. We agree that a carefully
delineated risk-factor approach to the prevention of Candida infection in
neonates may be a useful alternative to continuous fluconazole prophylaxis
and may decrease the risk of the emergence of fluconazole-resistant
species.
We recently reported our data on 3178 newborns, using a protocol
based on more restricted risk factors than that used by McCrossan et al.
We studied a 5 year period, comparing two and half years before (period 1)
and after implementation of the restricted risk factor guideline (period
2) to start anti fungal therapy. We showed a significant decrease in
culture proven Candida sepsis (1.1% and 0.4% in periods 1 and 2
respectively, p=0.027), and also in mortality due to Candida infection
(61% and 0% in periods 1 and 2 respectively, p=0.016), with no increase in
the use of anti fungal therapy (4.5% and 4.9% in periods 1 and 2
respectively, p=0.63) [2,3]. Feja et al showed that infants with birth
weight higher than 1,500 grams with risk factors for fungal infection are
in risk for Candida infection [4].
With the use of our protocol fewer infants will use fluconazole, and
it will also cover those with birth weight higher than 1,500 grams that
have risk factors for Candida sepsis.
References.
1. McCrossan BA, McHenry E, O'Neill F, et al . Selective fluconazole
prophylaxis in high-risk babies to reduce invasive fungal infection. Arch
Dis Child Fetal Neonatal Ed. 2007;92;F454-458
2.Procianoy RS, Enéas MV, Silveira RC. Empiric guidelines for
treatment of Candida infection in high-risk neonates. Eur J Pediatr
2006;165:422-3.
3.Procianoy RS, Silveira RC. Prophylactic Fluconazole in Preterm
Neonates. New Engl J Med 2007;357:1349
4. Feja KN, Wu F, Roberts K, et al. Risk factors for candidemia in
critically ill infants: a matched case-control study. J Pediatr 2005;
147:156–161
High noise levels during nCPAP reported by Karam et al. demonstrate the presence of a continuous exposition to audio trauma by the developing ears of preterm infants.1 These levels were directly related to the flow through the circuits, but not to the pressure generated, neither to the type of nCPAP device used. To improve the patient-ventilator interface we developed a new device (neonatal helmet CPAP) to administer C...
O'Donnell et al (1) explain the need for documenting neonatal resuscitation for audit and teaching purposes. Obstetricians make great efforts to monitor the fetus during labour in the hope of being able to intervene when signs of significant fetal hypoxia develop. Intermittent monitoring may be sufficient in low risk women but continuous monitoring is common in hospital units. If fetal distress is detected and the decisi...
Dear Editor
We agree with Dr Gandhi¡¯s view that a large, well designed study is required to answer the important question about accuracy and feasibility of pulse oximetry in the early neonatal period. However, we would like to clarify the design of such a study particularly focussing on outcome measures that should be investigated. It should be a test accuracy study for prediction of congenital heart disease (...
Sir
We read with interest the original article by Wren et al about the trends in diagnosis of major congenital cardiovascular malformations published in the fetal and neonatal issue of the journal1. The paper discusses the difficulties which we are still experiencing in diagnosing the cardiovascular (CVS) abnormalities. It is evident that we continue to miss life threatening abnormalities despite efforts to imp...
Reynolds, like the majority of us neonatologists and obstetricians, would be unable to keep his nerve and delay three minutes before clamping and cutting the cord to be able to proceed with resuscitation. However maintaining a placental circulation may sometimes be all that is required as Aristotle (1) observed “Frequently the child appears to be born dead, when it is feeble and when, before the tying of the cord,...
áñ"ã To the Editor, We read with interest the article by McCrossan et al on selective fluconazole prophylaxis. Reviewing the data presented in Table 2, in 3 out of 4 infants with positive blood culture, cephalosporin was involved. A practical conclusion would be to eliminate the use of cephalosporin in VLBW infants. Another measure would be to shorten empiric antibiotic use to 3-4 days (if cultures prove to be negative)...
Bose and Laughon have clearly reviewed the lack of evidence for current treatments of patent ductus arteriosus (PDA) in preterm infants.[1] As highlighted, the general tendency to treat a clinically relevant PDA for fear of adverse clinical outcome with either indomethacin or surgery when indomethacin fails has caused a lack of information on the natural history of symptomatic PDA. Spontaneous PDA closure has been report...
The study by McCrossan et al showed that fluconazole prophylaxis in a selected group of preterm infants with birth weight less than 1,500 grams decreases invasive fungal infection [1]. We agree that a carefully delineated risk-factor approach to the prevention of Candida infection in neonates may be a useful alternative to continuous fluconazole prophylaxis and may decrease the risk of the emergence of fluconazole-resistan...
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