The paper by Wardle et al brings the interesting concept of use of
peripheral fractional oxygen extraction to guide the blood transfusion in
preterm infants in clinical practice[1]. The clinical dilemma of deciding
when to and when not to transfuse preterm neonates is always a major
topic of debate amongst professionals involved in caring preterm neonates.
There is a great deal of variation among...
The paper by Wardle et al brings the interesting concept of use of
peripheral fractional oxygen extraction to guide the blood transfusion in
preterm infants in clinical practice[1]. The clinical dilemma of deciding
when to and when not to transfuse preterm neonates is always a major
topic of debate amongst professionals involved in caring preterm neonates.
There is a great deal of variation amongst Neonatologists about the cut
off of hemoglobin or hematocrit levels to be used for transfusions in
preterm babies. There are not many randomised studies in literature to
address this issue, and of the few we know, they have either
methodological limitations or are not published in their full form [2,3,4,5,6].
Therefore, as Wardle et al state, there is no doubt that we need
more studies to produce evidence-based guidelines for blood transfusion in
preterm neonates[1]. These studies should not only look at number of
transfusions, acute mortality and morbidity but also developmental
outcomes at 2-3 years of age.
Can a more serious consideration of physiologic basis assist us in
deciding us about when to transfuse? These might have postulated benefits
in terms of oxygen delivery to the tissues[7].
The risks and benefits of
transfusion include those of maintaining a high or low hemoglobin and some
additional risks and benefits of the transfusion itself. A high hemoglobin
level, maintained by frequent transfusion, enhances arterial oxygen
content and oxygen transport to the tissues. But this is usually far in
excess of need, and so oxygen delivery (equal to oxygen uptake or
consumption) is not limited by hemoglobin content. However, in chronic
ischemic or hypoxic hypoxia, where oxygen delivery may be limited by
oxygen transport, a high hemoglobin may be required to maintain oxygen
delivery to the tissues. Expected consequences of chronic anemic hypoxia
might be thought to be poor growth or impaired neurodevelopmental outcome.
On the other hand, if allowing the hemoglobin to fall to lower levels has
no critical or limiting effects on oxygen delivery, growth and development
will continue unimpaired without the potential adverse effects of blood
transfusion, such as transfusion-borne infection or iron overload. Even
further complicating these physiologic considerations is the decrease in
oxygen affinity of hemoglobin with postnatal age, which increases the
ability of the blood to deliver oxygen, and the effect of transfusion of
adult hemoglobin, which enhances this effect.
While reading the paper by Wardle et al raised several questions in
my mind.
(1) In the abstract of article it is stated that the primary outcome
measures were number of transfusion received, rate of weight gain, and
postmenstrual age at discharge. In contradiction to this in the main
methodology details of article authors state single primary outcome
measure as, “number of transfusions received after randomization”, and all
other were secondary outcome measures.
(2) The first criterion stated in Group 1 (Conventional Group) for
transfusion, “ transfused at Hb of 140g/L if inspired oxygen concentration
>0.35 or mean airway pressure >6 cm of water” appears liberal.
(3) It is stated that one of the transfusion criterion set for Group 2
(NIRS Group), “ transfused at FOE >0.47”. In “blinding” paragraph it is
stated that, “forearm FOE measurements were made on all infants in both
groups, these results were only available to researchers and not to the
clinical team”. This statement implies that clinicians were not aware or
notified of the FOE values even in “NIRS Group”.
(4) The frequency of Hb measurement by authors is described as, “daily in
first week of monitoring, then about 4 times a week until the infant was
30 weeks postconceptional age, and then about twice a week”. Going through
the paper it is evident that these infants were enrolled in to study when
they were not ventilated or ventilated with FIO2 <_40 and="and" the="the" postnatal="postnatal" median="median" age="age" at="at" randomization="randomization" was="was" _5days.="_5days." taking="taking" these="these" two="two" facts="facts" in="in" to="to" account="account" i="i" think="think" frequency="frequency" of="of" hb="hb" monitoring="monitoring" during="during" study="study" very="very" frequent="frequent" contributing="contributing" excess="excess" iatrogenic="iatrogenic" blood="blood" loss.br="loss.br"/>
(5) In the footnote of Table 1, it is mentioned that the results are
given as “median (range)”. For example, birthweight in grams in NIRS group
1200 (range1004-1373). The reader will interpret this as the baby in this
group with lowest weight at 1004 gram. But as you go through the table
later it is mentioned that 9 infants were £ 1000 gram. It is left to the
poor reader to make a serious thoughtful effort to interpret this “range”
in reality means ‘interquartile range”.
(6) In discussion authors state that many infants in NIRS group were
transfused on by clinicians because of low Hb or clinical symptoms, even
though FOE was not >0.47. Authors state that these clinical symptoms
could have been due to clinical reasons other than anemia such as
infection. It would have been useful if authors had given us some data
about infection rate differences in two groups knowing that this is a
prospective study.
References
(1) Wardle SP, Garr R, Yoxall CW, Weindling AM. A pilot randomised
controlled trial of peripheral fractional oxygen extraction to guide blood
transfusions in preterm infants. Arch Dis Child Fetal Neonatal Ed 2002;
86:F22-27.
(2) Blank JP, Sheagren TG, Vajaria J, Mangurten HH, Benawra RS,
Puppala BL. The role of RBC transfusion in the premature infant.
Am.J.Dis.Child. 1984; 138:831-833.
(3) Ransome OJ, Moosa EA, Mothebe FM, Spector I. Are regular 'top-up'
transfusions necessary in otherwise well, growing premature infants? S Afr
Med J. 1989; 75:165-166.
(4) Connelly RJ, Stone SH, Whyte RK. Early vs. late red cell transfusion in
low birth weight infants. Pediatr Res 1998; 43: 170A.
(5) Bell EF, Strauss RG, Widness JA, Mahoney LT, Mock DM, Seward VJ, et al.
Choice of hematocrit threshold for erythrocyte transfusion in preterm
infants. Pediatric Res.2000; 47:389A.
(6) Bifano EM, Bode MM, D’Eugenio DB. Prospective randomized trial of high
vs. low hematocrit in ELBW Infants: One-year growth and neurodevelopmental
outcome. Pediatr Res 2002; 51:325A.
(7) Andersen C. Critical haemoglobin thresholds in premature infants. Arch
Dis Child Fetal Neonatal Ed. 2001; 84:F146-148.
We read with interest the paper by Dimitriou et al.,[1] in which it
was confirmed again that head up tilting to 45 degrees results in better
oxygenation in stable preterm neonates. However compared to our study,[2]
in which the same effect was observed, there is a (probably) significant
difference. Their infants were studied in the horizontal prone, in the
horizontal supine and in the 45 degre...
We read with interest the paper by Dimitriou et al.,[1] in which it
was confirmed again that head up tilting to 45 degrees results in better
oxygenation in stable preterm neonates. However compared to our study,[2]
in which the same effect was observed, there is a (probably) significant
difference. Their infants were studied in the horizontal prone, in the
horizontal supine and in the 45 degree head up tilt supine position
whereas in our study all infants were studied in the prone position
including the 45 degree head up tilt. We had then hypothesised that the
combination of the prone position and the 45 degree head up tilt could
facilitate diaphragmatic activity.
I do not think that this hypothesis can be totally dismissed by the
results of Dimitriou et al.,[1] as suggested by the authors, since their
infants were studied in different positions (i.e. supine in their study and
prone in our study)
I should be grateful for the authors' views
H.D. Dellagrammaticas
References
(1) Dimitriou G, Greenough A, Pink L, McGhee A, Hickey A, Rafferty GF.
Effect of posture on oxygenation and respiratory muscle activity in
convalescent infants. Arch Dis Child Fetal Neonatal Ed 2002;86:F147-50.
(2) Dellagrammaticas HD, Kapetanakis J, Papadimitriou M, Kourakis G.
Effect of body tilting on physiological functions in stable very low
birthweight neonates. Arch Dis Child 1991;66:429-32.
we would like to thank Drs Millman and Satodia for their considerate
comments on our paper.[1] The randomised controlled trial reported in the
Archives is part of a larger evaluation study of the implications and cost
effectiveness of extending the role of midwives to include the routine (24
hour) examination of the newborn. The evaluation study includes, apart
from the RCT, a longer term follow-up (...
we would like to thank Drs Millman and Satodia for their considerate
comments on our paper.[1] The randomised controlled trial reported in the
Archives is part of a larger evaluation study of the implications and cost
effectiveness of extending the role of midwives to include the routine (24
hour) examination of the newborn. The evaluation study includes, apart
from the RCT, a longer term follow-up (safety and referrals), videotaped
quality assessments and interviews with health professionals involved in
the newborn assessment and with parents and all stakeholders (Royal
Colleges, professional organisations and consumer groups). Furthermore a
national survey of current practice was conducted. The findings have been
written up in a number of papers that are submitted or in press and our
full report will be published by the NHS Executive Research and
Development Programme Health Technology Assessment Programme this year.
The questions raised by Millman & Satodia have been addressed in
the interviews with senior house officers (SHOs) (and midwives, General
Practioners (GPs), consultant paediatricians). The full findings from the
interviews with the SHOs and GPs were fairly consistent and clearcut:
1. they value the neonatal examination to screen for major anomalies;
2. they
value the examination to reassure the parents about the normality of their
child;
3. there were mixed opinions of whether "a quick SHO check"
provides opportunities for any health education. Some felt not confident
of providing such information while others were pro-active in discussing
history or baby care issues. In contrast midwives consider the examination
as an ideal opportunity to discuss feeding and baby care issues.
4. SHOs
reported that they received very little, if any, training and the usual
procedure was to be shown once and let to get on with it. 5. SHOs did not
feel comfortable about some aspects of the examination such as the hips,
taking pulses or the red reflex. They would have liked more training by
senior paediatricians and more supervision. 6. Many SHOs and GPs felt that
doing the examinations was useful for their training but there were too
many examinations and they were often rushed. Others reported that
"doctors have more important things to do"; 7. SHOs and GPs were broadly
the view that any midwife, if trained, could do the newborn examination as
well as the junior doctor. This concurred with mothers views who would be
happy for midwives to examine babies, and some expressed they had more
confidence in midwives than SHOs.
Taking the findings of our evaluation study together, it is apparent
that a system of formal training for SHOs would be highly desirable to
increase quality of examinations and parental satisfaction. The training
would need to include, apart from technical components, education in
communication skills and knowledge on child care issues. SHOs, and in
particular those who progress to GPs require some experience with normal
newborns. In a programme of training there should be enough opportunities
for newborn examinations by SHOs alongside or together with midwives.
However, as one GP expressed it: "ultimately, the examination should not
be education for an SHO but for the benefit of the baby".
Reference
(1) Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. Routine
examination of the newborn and maternal satisfaction: a randomised
controlled trial. Arch Dis Child Neonatal Fetal Ed2002;86:F155-60.
In a recent issue of the journal, Ng et al.
described the endoscopic view of an
congenital epiglottic cyst. We report the recently discovered antenatal vallecular cyst (VC). [1]
The incidence of VC is low.[2] We discovered this case of
congenital VC at 25 weeks of gestation, diagnosed on routine
ultrasound survey for polyhydramnios. An axial scan of the
oropharyngeal region showed a cystic mas...
In a recent issue of the journal, Ng et al.
described the endoscopic view of an
congenital epiglottic cyst. We report the recently discovered antenatal vallecular cyst (VC). [1]
The incidence of VC is low.[2] We discovered this case of
congenital VC at 25 weeks of gestation, diagnosed on routine
ultrasound survey for polyhydramnios. An axial scan of the
oropharyngeal region showed a cystic mass (35 x 30 mm) that
appeared to be intimately attached to the base of the tongue,
and a colour Doppler study showed that there was no
neovasularisation. A diagnosis of VC was
suggested. At 33 weeks, on the basis of an important
polyhydramios, a caesarean section was carried out. Just after birth, the baby could not cry. The cyst was partly
drained with a syringe and the airway was stabilised with
intubation. Marsupialisation of the VC using nasotracheal
intubation was performed on the 10th of life.
An awareness of the existence of VCs is important because they
can cause upper airway obstruction.[3] The widespread use of
prenatal ultrasound can lead to an earlier diagnosis of a VC and
allows for appropriate counselling and preparation at
delivery and for the proper preparation of staff and
equipment in the management of these neonates.[4,5] It allows the obstetrician to collaborate with the neonatologist,
paediatric surgeon, and paediatric otolaryngologist in order to
plan for perinatal management. It also allows an explanation to
be given to the parents, the time and place of delivery to
be decided, and planning for resuscitative efforts to be
organised in advance.
References
(1) Ng SK , Abdullah VJ, van Hasselt CA. Congenital epiglottic cyst. Arch Dis Child Fetal Neonatal Ed 2002;86:F134.
(2) Amagasu M, Lee D, Bluestone CD. Imaging quiz case
one. Vallecular cyst. Arch Otolaryngol Head Neck 1999;125:592-5.
(3) Myer CM. Vallecular cyst in the newborn. Ear Nose
Throat J 1988;67:122-4.
(4) Gluckman PG, Chu TW, Van Hasselt CA. Neonatal
vallecular cysts and failure to thrive. J Laryngol Otol 1992;106:448-9.
(5) Oluwole M. Congenital vallecular cyst: a cause of
failure to thrive. Br J Clin Pract 1996 Apr-May;50(3):170.
We read with interest the findings of Wolke et al.[1] regarding maternal
satisfaction with routine examination of the newborn. Whilst appreciating
their conclusions and those reached by others (Lee TWR et al.[2] and Walker
D[3])we wish to provide further comment.
Perhaps an equally valuable study
would be one which explores the attitudes of senior house officers to
performing this examinat...
We read with interest the findings of Wolke et al.[1] regarding maternal
satisfaction with routine examination of the newborn. Whilst appreciating
their conclusions and those reached by others (Lee TWR et al.[2] and Walker
D[3])we wish to provide further comment.
Perhaps an equally valuable study
would be one which explores the attitudes of senior house officers to
performing this examination and assessing the perceived benefits to their
professional development. Possible questions may include:
(i) Did you receive formal training from a senior paediatrician?
(ii) Do you feel comfortable performing this task and subsequently
reassuring parents about their infant?
(iii) Do you feel competent to discuss aspects of general neonatal care
and education with parents?
(iv) Do you think this task contributes positively to your training?
It is important to note that whilst not subjecting senior house
officers to vast numbers of repetitive neonatal examinations, a formal
system of training in all aspects of routine neonatal care followed by
subsequent assessment might be educationally beneficial. It is surely
questionable to expect paediatric senior house officers to progress to GPs
and higher specialist trainees managing common problems in newborn infants if their
previous experience is being reduced further. The correct balance between
education and service provision is essential to prevent future
deficiencies in general paediatric knowledge.
Guy C Millman
Prakash Satodia
References
(1) Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. Routine examination of the newborn and
maternal satisfaction: a randomised controlled trial. Arch Dis Child
Neonatal Fetal Ed 2002;86:F155-60.
(2) TWR Lee, R E Skelton, and C Skene. Arch Dis Child Fetal Neonatal Ed 2001;85:F100-4.
(3) Walker D. Role of routine neonatal examination. It probably makes
more sense for other staff to carry out neonatal examinations [letter].
BMJ 1999;318:1766.
Armstrong and Simpson’s letter in May’s edition of Archives of Disease in Childhood highlights the difficulties encountered by junior medical staff when examining the
neonatal palate.[1] Their concern is echoed by a presentation at the recent Royal
College of Paediatrics and Child Health spring meeting. Habel et al. presented the
results of their audit revealing that 31 % of isolated cleft pal...
Armstrong and Simpson’s letter in May’s edition of Archives of Disease in Childhood highlights the difficulties encountered by junior medical staff when examining the
neonatal palate.[1] Their concern is echoed by a presentation at the recent Royal
College of Paediatrics and Child Health spring meeting. Habel et al. presented the
results of their audit revealing that 31 % of isolated cleft palate (ICP) cases over a ten-year period were missed in the first 24 hours.[2] Neither of these authors describe the
circumstances of the routine neonatal examination.
It is recommended that the examination be performed under direct vision with a torch
and spatula. Our experience is that this is only possible if the paediatrician performs the examination with an assistant. We discovered this when we introduced a clinic
setting for all weekday routine neonatal examinations to overcome the problems
created by early maternity discharges. The paediatric Senior House Officer is assisted
by a nurse whom can then support the baby’s head with the neck extended whilst
placing a finger on the baby’s chin. The paediatrician is then able to examine the
whole palate without difficulty with torch and spatula. Examinations not performed in
the clinic setting, usually at the weekend, encounter the difficulties described by
Armstrong and Simpson. Failing in the neonatal examination can result from the
circumstances in which it is performed rather than the examination itself.
Christopher S. James
Peter J. Todd
Department of Paediatrics
Arrowe Park Hospital
Arrowe Park
Wirral CH49 5PE
UK
References
(1) H Armstrong and R M Simpson. Examination of the neonatal palate. Arch Dis Child Fetal Neonatal Ed 2002;86:F210.
(2) Habel A, Elhadi N, Sommerlad B. Delay in detection of cleft palate, an audit of newborn clinical examination. Arch Dis Child 2002;86(suppl 1):A59.
We read the article by Reece et al [1] and closely followed the responses
to it. We even went ahead to carry out a study looking at identification
of the tip of the long lines using inversion of image technique on PACS
(picture archiving and communication system).
Background: Positioning of long lines into the heart has serious
consequences including death due to cardiac tamponade.[2] The...
We read the article by Reece et al [1] and closely followed the responses
to it. We even went ahead to carry out a study looking at identification
of the tip of the long lines using inversion of image technique on PACS
(picture archiving and communication system).
Background: Positioning of long lines into the heart has serious
consequences including death due to cardiac tamponade.[2] The tip of long
lines is accurately visible in only 50 % of plain radiographs.[1]
Identification of the line using radio opaque contrast media requires
caution. The use of an insufficient volume of contrast will falsely
identify the tip in an apparently more proximal position, whereas a film
taken during active injection may cause the line to appear longer due to a
jet of contrast issuing from the tip of the line. Bernard I and Banerjee
I, from Glan Clwyd Hospital, wrote in their E-letter on the use of PACS in
their hospital to identify the tip of the long lines.[3] Ultrasound may be
of value but it requires expertise to perform and interpret.[2]
Methods: At Hinchingbrooke Hospital, Huntingdon, X-rays are taken on a
phosphor plate which are later processed through PACS and image is
available on computer terminal on the Special care baby unit. The Hospital
use Frame wave dicom view version 3.0 software that allows for image
inversion, image magnification and image sharpening. Using the technique
of image inversion supplemented by image magnification and sharpening of
image, the tips of the long line are much better seen than on plain X-rays. Our this observation lead us to carry out a study looking at the
tips of the long lines on plain X-ray and then on the same image on PACS
with image inversion. Three investigators including an experienced SHO, a
consultant paediatrician and a consultant neonatologist participated in
this study. The study was retrospective and included the long lines
inserted between the periods of January 2000 to July 2001.
Results:
Observer
Tip visible on plain X ray
Tip visible on inverted image
Improvement
A
06/24 (25%)
15/24 (63%)
38%
B
12/23 (52%)
17/23 (74%)
22%
C
40/69 (58%)
65/69 (94%)
36%
Conclusions: Inversion of image on PACS is better than plain
radiograph in identifying the tip of the long lines. Although there is
inter observer variation, with experience of using PACS, this may be
minimized. It is important to note that there is improvement in
recognition of line tip by each observer.
Recommendations: We recommend that units having facility of PACS should
use them to identify the long line tips and there is a need for
prospective randomized study comparing contrast study v/s image inversion
technique on PACS, before accepting contrast as the only way of
identifying the tips of long lines.
Other uses of PACS with regards to neonatal long lines:
1. Accurate line manipulation. Once it is noted that the long line is in
right atrium, one can measure the distance on the image by which it should
be pulled back to be in acceptable place, rather than guessing the
distance by which line is pulled back.
2. Monitoring of long line on subsequent X rays: Most unit that uses
contrast to identify the long line tip does it only once to confirm the
position and subsequently look at the plain X rays (taken for other
clinical indications) to see the long line position. We know that long
lines do migrate over a course of time and plain X rays are less sensitive
to detect the tip accurately. The use of PACS allows each image to be
reviewed with same accuracy as first image. This can detect the potential
line migration and allows adjustments in line position to be made.
References
(1)Reece A et al. positioning long lines: contrast versus plain
radiography. Arch Dis Child Fetal Neonatal Ed 2001; 84:F129-30.
(2) Review of four neonatal deaths due to cardiac tamponade associated with
the presence of a central venous catheter: Recommendations and department
of health response. June 2001.
(3) Bernard I, Banerjee I. E-letter. Arch Dis Child 14th May 2001.
I am familiar with the work of Dr Shehadeh et al. There may indeed
be a place for insulin in infant formula. However, before such a step is
taken, I believe that it is imperative that appropriate prospective
studies be done, including safety monitoring. Although our human pilot
study and animal studies suggest there may be a benefical effect of oral
insulin, much more work needs to be done...
I am familiar with the work of Dr Shehadeh et al. There may indeed
be a place for insulin in infant formula. However, before such a step is
taken, I believe that it is imperative that appropriate prospective
studies be done, including safety monitoring. Although our human pilot
study and animal studies suggest there may be a benefical effect of oral
insulin, much more work needs to be done and recommending its use now is,
to my mind, not appropriate. [1]
Reference
(1) RJ Shulman. Effect of enteral administration of insulin on intestinal development and feeding tolerance in preterm infants: a pilot study. Arch Dis Child Fetal Neonatal Ed. 2002;86:F131-3.
I read with great interest the article by Shulman.[1] Indeed, orally
administered insulin may have a positive effect on gut maturation and
mucosal enzyme expression in preterm infants. We have recently
demonstrated that human milk is rich in insulin (mean = 60.2 micro U/ml),
and that insulin is barely detected in infant formulas.[2] Moreover, we
have hypothesized that insulin content of human milk may ha...
I read with great interest the article by Shulman.[1] Indeed, orally
administered insulin may have a positive effect on gut maturation and
mucosal enzyme expression in preterm infants. We have recently
demonstrated that human milk is rich in insulin (mean = 60.2 micro U/ml),
and that insulin is barely detected in infant formulas.[2] Moreover, we
have hypothesized that insulin content of human milk may have an important
role in the primary prevention of type 1 diabetes, by inducing active
cellular machanisms that suppress the development of autoimmune diabetes,
and by reducing intestinal transmission of 'triggering' dietary peptides.[3]
We suggest to add human insulin to infant formulas in a concentration
similar to insulin concentration present in human milk. This addition may
lead to the following beneficial effects: It will make infant formula
similar to human milk; it may fasten gut maturation; and it may protect
from the development of type 1 diabetes.
References
(1) Shulman RJ. Effect of interal administration of insulin on
itestinal development and feeding tolerance in preterm infants: a pilot
study. Arch Dis Child Fetal Neonatal Ed 2002;86:F131-3.
(2) Shehadeh N, Gelertner L, Blazer S, Perlman R, Solovachik L, Etzioni
A. Importance of insulin content in infant diet: suggestion for a new
infant formula. Acta Pediatr 2001;90:93-5.
(3) Shehadeh N, Shamir R, Berant M, Etzioni A. Insulin in human milk
and the prevention of type 1 diabetes. Pediatric Diabetes 2001;2:175-7.
I read with interest the report by Al-Dahhan and colleagues on the
beneficial effect of NaC1 supplementation of preterm infants during the
neonatal period on their later neurodevelopmental outcome. They found
better memory, learning, language and educational performances at the age
of 10-13 years in prematures who were given 4-5 mMol/day NaC2 when
compared to those not receiving NaC1 supplement.[1] In th...
I read with interest the report by Al-Dahhan and colleagues on the
beneficial effect of NaC1 supplementation of preterm infants during the
neonatal period on their later neurodevelopmental outcome. They found
better memory, learning, language and educational performances at the age
of 10-13 years in prematures who were given 4-5 mMol/day NaC2 when
compared to those not receiving NaC1 supplement.[1] In this regard, it is
relevant to mention our most recent findings describing a new aspect of
the relationship of neonatal sodium homeostasis to central nervous system
function. Namely, we demonstrated that hyponatraemia is one of the most
significant risk factors for development of sensorineural hearing
impairment detected by transient evoked otoacustic emission and confirmed
by auditory brainstem response.[2]
In addition, I consider their report raises an important clinical
issue, in that I regard their selection of list of references as
subjective and arbitrary. In particular, the work of our group in revealing
some major features of sodium homeostasis in premature has been ignored;
for example wasting, sodium depletion and hyponatraemia, [3,4,5] and the
first introduction of NaC1 supplementation in a dose of 3-5 mM/kg/day to
prevent sodium deprivation, to improve somatic stability and to avoid
untoward clinical consequences.[6]
Endre Sulyok MD
Professor & Chairman
County Children's Hospital, Institute of Health Promotion and Family Care
Faculty of Health Sciences, University of Pecs
H-7624 Pecs, POB 76, Hungary
References
(1) Al-Dahhan, Jannoun L, Haycock GB. Effect of salt supplementation of newborn premature infants on neurodevelopmental outcome at 10-13 years of
age. Arch Dis Child Fetal Neonatal Ed 2002;86:F120-F123.
(2) Ertl T, Hadzsiev K, Vincze O, Pytel J, Szabó T, Sulyok E. Hyponatraemia and sensorineural hearing loss in preterm infants.
Biol Neonate 2001;79:109-12.
(3)Sulyok E.
The relationship between electrolyte and acid-base balance in the premature infant during early postnatal life.
Biol Neonate 1971;17:227-37.
(4) Sulyok E, Heim T, Soltész G, Jászai V.
The influence of maturity on renal control of acidosis in newborn infants.
Biol Neonate 1972;21:418-35.
(5) Sulyok E.
Sodium homeostasis in preterm infants.
Lancet, 1975;I:930 (letter).
(6) Sulyok E, Németh M, Tényi I, Csaba IF, Varga L, Varga F.
Relationship between the postnatal development of the renin-angiotensin-aldosterone system and
electrolyte and acid-base status of the NaCl supplemented premature infants.
In: The Kidney during Development Morphology and Function. Edited by Spitzer A.
Masson Publishing, New York 1982;273-281.*
*This paper was presented in 1980 in the First International Workshop on Developmental Renal
Physiology organized by A. Spitzer in New York
Dear Editor
The paper by Wardle et al brings the interesting concept of use of peripheral fractional oxygen extraction to guide the blood transfusion in preterm infants in clinical practice[1]. The clinical dilemma of deciding when to and when not to transfuse preterm neonates is always a major topic of debate amongst professionals involved in caring preterm neonates. There is a great deal of variation among...
Dear Editor
We read with interest the paper by Dimitriou et al.,[1] in which it was confirmed again that head up tilting to 45 degrees results in better oxygenation in stable preterm neonates. However compared to our study,[2] in which the same effect was observed, there is a (probably) significant difference. Their infants were studied in the horizontal prone, in the horizontal supine and in the 45 degre...
Dear Editor
we would like to thank Drs Millman and Satodia for their considerate comments on our paper.[1] The randomised controlled trial reported in the Archives is part of a larger evaluation study of the implications and cost effectiveness of extending the role of midwives to include the routine (24 hour) examination of the newborn. The evaluation study includes, apart from the RCT, a longer term follow-up (...
Dear Editor
In a recent issue of the journal, Ng et al. described the endoscopic view of an congenital epiglottic cyst. We report the recently discovered antenatal vallecular cyst (VC). [1] The incidence of VC is low.[2] We discovered this case of congenital VC at 25 weeks of gestation, diagnosed on routine ultrasound survey for polyhydramnios. An axial scan of the oropharyngeal region showed a cystic mas...
Dear Editor
We read with interest the findings of Wolke et al.[1] regarding maternal satisfaction with routine examination of the newborn. Whilst appreciating their conclusions and those reached by others (Lee TWR et al.[2] and Walker D[3])we wish to provide further comment. Perhaps an equally valuable study would be one which explores the attitudes of senior house officers to performing this examinat...
Dear Editor
Armstrong and Simpson’s letter in May’s edition of Archives of Disease in Childhood highlights the difficulties encountered by junior medical staff when examining the neonatal palate.[1] Their concern is echoed by a presentation at the recent Royal College of Paediatrics and Child Health spring meeting. Habel et al. presented the results of their audit revealing that 31 % of isolated cleft pal...
Dear Editor
We read the article by Reece et al [1] and closely followed the responses to it. We even went ahead to carry out a study looking at identification of the tip of the long lines using inversion of image technique on PACS (picture archiving and communication system).
Background: Positioning of long lines into the heart has serious consequences including death due to cardiac tamponade.[2] The...
To The Editor:
I am familiar with the work of Dr Shehadeh et al. There may indeed be a place for insulin in infant formula. However, before such a step is taken, I believe that it is imperative that appropriate prospective studies be done, including safety monitoring. Although our human pilot study and animal studies suggest there may be a benefical effect of oral insulin, much more work needs to be done...
Dear Editor
I read with great interest the article by Shulman.[1] Indeed, orally administered insulin may have a positive effect on gut maturation and mucosal enzyme expression in preterm infants. We have recently demonstrated that human milk is rich in insulin (mean = 60.2 micro U/ml), and that insulin is barely detected in infant formulas.[2] Moreover, we have hypothesized that insulin content of human milk may ha...
I read with interest the report by Al-Dahhan and colleagues on the beneficial effect of NaC1 supplementation of preterm infants during the neonatal period on their later neurodevelopmental outcome. They found better memory, learning, language and educational performances at the age of 10-13 years in prematures who were given 4-5 mMol/day NaC2 when compared to those not receiving NaC1 supplement.[1] In th...
Pages