May I suggest an alternative term for the egregious "upper extremity"
used in the title of Labore and Befell's article. I believe that the body
part to which they are referring is also known as an "arm"?
The overall tone of this systematic review is to reassure the reader
that waterbirths are safe; this is not justified by the results which rely
almost exclusively on extremely poor quality retrospective cohort studies.
Different study designs have significant differences in their
susceptibility to bias and the authors have largely ignored this issue.
Larger, non-randomised studies, more prone to bias, carry more weight ; n...
The overall tone of this systematic review is to reassure the reader
that waterbirths are safe; this is not justified by the results which rely
almost exclusively on extremely poor quality retrospective cohort studies.
Different study designs have significant differences in their
susceptibility to bias and the authors have largely ignored this issue.
Larger, non-randomised studies, more prone to bias, carry more weight ; no
meta-analysis should have been done with these data.
In contrast to the use of immersion in the first stage of labour,
waterbirth confers no benefit to the mother or baby and puts the baby at
unacceptable risk; current trials are too small to rule this out. Adverse
events for the baby are rare but devastating. A hypoxic-ischaemic fetus
will aspirate water when gasping while immersed.
The authors have deemed that a large, prospective, cohort study is an
acceptable approach to determining the benefit/harm ratio for waterbirth.
Such non-randomised studies are prone to significant bias. The control
group would be fundamentally different to the waterbirth group, and such
differences would undermine the major principle that both groups should be
as similar as possible with respect all other factors that may be related
to treatment and outcomes except for the intervention. With non-random
assignment in a cohort study, equally eligible women with different risks
for adverse outcomes will be assigned the intervention group (consciously
or unconsciously) based on how the women themselves or their caregivers
perceive the risk of adverse outcome -large numbers of women enrolled in
this way will seriously imbalance the treatment groups with regard to
factors affecting outcomes.
An appropriately sized, good quality RCT with longterm follow-up
remains the only reliable way to assess both the efficacy and the safety
of waterbirths.
We are grateful for the interest in our paper and the opportunity to
refute the suggestion that it is falsely reassuring. Our paper provides a
fair and accurate representation of the best available data; it concludes
that "this systematic review and meta-analysis did not identify definitive
evidence that waterbirth causes harm to neonates ... However, there is
currently insufficient evidence to conclude that there are no...
We are grateful for the interest in our paper and the opportunity to
refute the suggestion that it is falsely reassuring. Our paper provides a
fair and accurate representation of the best available data; it concludes
that "this systematic review and meta-analysis did not identify definitive
evidence that waterbirth causes harm to neonates ... However, there is
currently insufficient evidence to conclude that there are no additional
risks or benefits for neonates".
It does indeed state that "existing evidence is not strong enough to
examine the relative risk of rare and potentially devastating adverse
events" as well as citing the risk of aspiration in a compromised baby who
was born gasping (paragraph 8).
It is incorrect to suggest that the susceptibility to bias of
different study designs was ignored and that results are reliant on poor
quality retrospective studies. The entire meta-analysis was repeated, for
every outcome, using data only from randomised controlled trials. These
results were entirely consistent with the primary analysis and are
available to view in supplementary file D.
There are a number of ways to examine safety and capture rare,
serious adverse events. The merits and drawbacks of each approach must be
carefully considered before any future study. We recognise the limitations
of prospective cohort studies and agree that a large, adequately powered
RCT would be ideal to determine the safety of waterbirth. However, there
are significant ethical and practical issues with randomising enough
women. In one UK pilot, of 40 women randomised to water birth, only 10
delivered in water.[1] The National Institute for Health Research recently
called for an observational study to address this question and stated the
design 'should not involve randomisation given the rarity of adverse
events'.[2]
[1] Woodward J, Kelly SM. A pilot study for a randomised controlled
trial of waterbirth versus land birth. BJOG: an international journal of
obstetrics & gynaecology. 2004 Jun 1;111(6):537-45.
[2] National Institute for Health Research (NIHR). HTA commissioned
funding opportunities, call 15_157 'Delivering babies in or out of water'.
http://www.nets.nihr.ac.uk/funding/hta-commissioned
I read the article by Watson et al and the accompanying Editorial.
While it is an interesting concept to link nurse patient ratios with
mortality this does not take into account the individual nurses and their
experiences. I would challenge the authors to demonstrate how
retrospective data measures acuity and nursing experience. The authors
presented the 1:1 ratio as measured by the percentage of ICU days where
there wa...
I read the article by Watson et al and the accompanying Editorial.
While it is an interesting concept to link nurse patient ratios with
mortality this does not take into account the individual nurses and their
experiences. I would challenge the authors to demonstrate how
retrospective data measures acuity and nursing experience. The authors
presented the 1:1 ratio as measured by the percentage of ICU days where
there was one nurse per patient. Realistically each patient has a
different level of acuity and this will determine the nurse to patient
ratio. However even with a one to one ratio each nurse also has a
different level of experience. With the critical shortage of nurses in
acute care areas in both the UK and Australia the practice is to recruit
less experienced nurses and many NICUs take first year nurse graduates.
How these nurses are supported and supervised to provide a level of safe
practice would be a more meaningful measure to link with mortality or
indeed morbidity in this vulnerable patient population.. If there is
inadequate supervision from senior nurses or clinical nurse educators then
the novice nurses learn from each other, indeed an unsafe practice.
Perhaps a more useful measure would be for researchers to assist
clinicians in auditing practices so we know what is actually being
practiced and then look at morbidity and mortality as an outcome. As an
experienced neonatal nurse I would challenge researchers that mortality is
not a reliable measure of nursing work - we need to develop a set of
outcome measures that are meaningful measures of nursing work in the NICU.
By clinicians and researchers working together we can then strive to
ensure the NICU is a safe environment and we would have measures to
improve practice and outcomes for the infants and their families.
Hellman, Knigthon et Al and Carter in the accompanying editorial
raise many issues dealing with the end of life care of sick newborn
babies. Although consensus within multidisciplinary teams in each centre
is recorded as being achieved relatively easily, the wide variation
between centres in how each deals with the issue of withholding life
saving treatments, particularly where there are 'quality of life issues'
und...
Hellman, Knigthon et Al and Carter in the accompanying editorial
raise many issues dealing with the end of life care of sick newborn
babies. Although consensus within multidisciplinary teams in each centre
is recorded as being achieved relatively easily, the wide variation
between centres in how each deals with the issue of withholding life
saving treatments, particularly where there are 'quality of life issues'
underscores a wider lack of consensus amongst practicing neonatologists.
This raises a number of issues. The most challenging of which is why,
when there is such variation between units is there such agreement within
them? This could be because like-minded people work together, or more
likely people who work together become like minded. More disturbingly, it
raises the possibility that the consensus may not be as great as perceived
with particularly junior members of the decision making team- perhaps even
the parents- feeling unable to voice dissent.
A further issue is the weight given to medical opinion in making
ethical and moral judgements. In common with most doctors, I received
little or no formal training in ethics. I can use technical language to
make my forthright opinions sound ethical, but in an era increasingly
asking for evidence I have little to back these up. Historically the
medical profession has not always cloaked itself in glory when trying to
play society's moral arbiter. We can often lapse into a language of
certainty and authority which makes it difficult for others to challenge
our positions.
I have another difficult personal issue, which being late to the
table I have only just realised. In common with most doctors of my
generation I was not encouraged to think about why I do what I do. I see
that there are many different types of doctors, many of us in hospital
seem to be 'fixing' doctors in that we see ourselves as people that make
problems better. If we could cope with uncertainty and some degree of
failure we may be in different specialties. Patients that will not or
cannot be fixed can challenge me as a doctor and make me feel in some way
'undermined.' In these situations I worry that decisions that I make or
recommend may be as much for my benefit as they are for my patients or
their family. As a 'fixer' it is easier to discard rather than live with
broken things. These are incredibly complex feelings to acknowledge but
they certainly do exist.
The obvious solution, as is available in much of North America and
other countries in the world would be to establish Ethics panels who could
judge these matters. These could be hospital based, regional or supra
regional and would include members with proper training in Ethics and
legal knowledge. Undoubtedly their deliberations would be heavily informed
by medical evidence and input, in much the same way that medical input
informs but does not make, safeguarding decisions which are ultimately in
the gifts of the courts and their agents. This would provide safeguards
for patients, families and the medical teams who look after them.
We read with interest the paper by Cuttini et al (1). Although policy
regarding parental visiting is a relatively easier issue to evaluate,
parental participation in decision making, particularly in decisions with
strong ethical overtones, is a much more complex issue. It is difficult to
evaluate with accuracy with accuracy and by its nature much more
controversial. The paper does not stress that data col...
We read with interest the paper by Cuttini et al (1). Although policy
regarding parental visiting is a relatively easier issue to evaluate,
parental participation in decision making, particularly in decisions with
strong ethical overtones, is a much more complex issue. It is difficult to
evaluate with accuracy with accuracy and by its nature much more
controversial. The paper does not stress that data collected from each
participating unit through a structured questionnaire completed by the
unit co- ordinator, represent policies, that is the intention and stance
of each unit towards the particular issue for evaluation. Data collected
through questionnaires and interviews involving both unit staff and
parents would have provided a better understanding of the actual practice
of each participating unit.
No unit from Greece took part in the study by Cuttini et al (1) but
Greece is briefly mentioned in the discussion, using results from a
previous study (2) where in a sample of 38 units from 11 European
countries it was shown that the 9 units imposing visiting restrictions
were in France, Greece, Italy and Portugal.
We would like to provide further information regarding visiting
policies in Greek NICUs. There are 15, two of which are private; twelve
attached to maternity hospitals and the remaining three are in children's
hospitals and accept distant referrals. In all but one (Aglaia Kyriakou
Children's Hospital) visiting restrictions are imposed. These allow
parents only and the usual practice is ½ -1 hour visiting time in the
morning and afternoon (excepting lactating mothers). The most common
reasons given for imposing restrictions are an increased danger of
infection and a disruptive effect on the unit.
We conducted a survey through a questionnaire and an interview of
parents whose baby has been cared for in another NICU imposing visiting
restrictions before transfer to our NICU and / or parents who had a
previous baby in another NICU imposing restrictions. The overwhelming
majority (98.6%) said they preferred the liberal policy we have adopted
with respect to visiting. One mother of preterm baby with bronchopulmonary
dysplasia said that 'if I had delivered at term I would be with my baby,
if I had not delivered prematurely I would also be with my baby (in my
womb), now that I have delivered prematurely why can't I be with my baby?
We conclude that in Greece there is a demand for unrestricted
parental visiting but most Greek NICUs do not meet this demand for reasons
which are not based on medical or sociological evidence.
It is worth noting that, in Greece, infants beyond the neonatal
period have been admitted to children's wards with their mothers for many
years.
Dr H D Dellagrammaticas MD, FRCPCH
Dr Nicoletta Iacovidou MD
NICU, 2nd Department of Paediatrics
University of Athens
Aglaia Kyriakou Children's Hospital
115 27 Athens, Greece
References
1. Cuttini M, Rebagliato M, Bortoli P, et al. Parental visiting, communication and participation
in ethical decisions: a comparison of neonatal unit policies in Europe.
Arch Dis Child Fetal Neonatal Ed 1999;81:F84 - F91
2. Reid M, Andersen E, EC Study Group of Parental Involvement in Neonatal
Care (Adam H, Cuttini M et al). Variations in family visiting policies in
neonatal intensive care units in eleven EC countries. Pediatr Perinat
Epidemiol 1994;8:41 - 52
The rapid response from Dellagrammaticus and Iacovidou (17 May) provides
interesting information and further support to the conclusion of our
study (1): namely, that NICUs from Southern European countries (Italy, Spain
and, according to Dellagrammaticus, also Greece) adopt parental visiting
policies more restrictive than in Northern countries.
We agree that exploring the role of parents in deci...
The rapid response from Dellagrammaticus and Iacovidou (17 May) provides
interesting information and further support to the conclusion of our
study (1): namely, that NICUs from Southern European countries (Italy, Spain
and, according to Dellagrammaticus, also Greece) adopt parental visiting
policies more restrictive than in Northern countries.
We agree that exploring the role of parents in decision-making is
much more complex, and that data collected through a structured
questionnaire completed by the unit coordinator represent only that unit's
policy, "that is the intention and stance of each unit" towards the issue
at hand. In fact, this was precisely the aim of our study: to describe and
compare NICUs' policies in the various countries.
In a separate part of the EURONIC project we interviewed also
individual staff members (both doctors and nurses), asking for their views
and practices regarding parental involvement in decision-making: overall,
results match quite closely with findings from the NICUs policy study.
It would be certainly very interesting to obtain the parents'
views on the issue; however, results from interviews with parents carried
out by Unit's staff during a baby's hospital stay should be interpreted with
caution, given the understandable tendency of interviewed parents to
comply with perceived wishes and ideas of the staff caring for their baby.
References
(1) Cuttini et al. Parental visiting, communication and participation in
ethical decisions: a comparison of neonatal unit policies in Europe. Arch
Dis Child Fetal Neonatal Ed 1999;81:F84-91
We would like to highlight the varying practices in the
management of cardiac murmurs in well newborn infants. Two years after the
publication of Wren's important paper on this subject[1] urging an early
definitive structural diagnosis to be made on such infants we conducted a
telephone survey of local hospitals to assess whether practices had
changed.
We would like to highlight the varying practices in the
management of cardiac murmurs in well newborn infants. Two years after the
publication of Wren's important paper on this subject[1] urging an early
definitive structural diagnosis to be made on such infants we conducted a
telephone survey of local hospitals to assess whether practices had
changed.
Until recently it was common practice to investigate a well neonate
with a 12-lead electrocardiogram (ECG), a chest radiograph (CXR), 4-limb
blood pressure and oxygen saturation. If these investigations were normal,
infants were discharged home, to be reviewed later. Wren's paper reminds
us that there is a structural defect in 54% of newborns with a persisting
murmur. Some of these structural defects (particularly outflow tract
obstructions) may be fatal if not treated early. Wren recommended
therefore that an early definitive diagnosis should be made within the
first month of life in this group.[1,2]
We obtained data from 14 district general and 6 teaching hospitals.
Whilst one third (5/14) of district general hospitals complied with
recommendations two thirds (9/14) did not, primarily because echocardiography was not available on-site. In the latter group,
management consisted of investigations (excluding echocardiography) prior
to discharge and follow-up at 4-6 weeks in a general paediatric or
neonatal follow-up clinic. Two hospitals did not routinely follow neonates
with apparently "benign" heart murmurs. One hospital did not investigate
well infants with a murmur prior to discharge. Teaching hospitals complied
with Wren's recommendations with two thirds (4/6) obtaining an
echocardiogram before discharge and the remainder obtaining one within 2
weeks.
In light of this survey we feel it is important that all perinatal
units are enabled to adopt the evidence-based recommendations by the
provision of adequate paediatric echocardiographic resources.
References
(1) Wren C, Richmond S, Donaldson L. Presentation of congenital heart
disease in infancy; implications for routine examination. Arch Dis Child
1999;80:F49-F53
(2) Richmond S and Wren C. Early diagnosis of congenital heart disease.
Semin Neonatol 2001;6:27-35
The personal experience by Katumba-Lunyenya echoes the views and
experiences of many contemporary neonatologists who recognize the
importance of routine echocardiography as an integral part of neonatal
intensive care [1]. Oftentimes the importance of routine echocardiography in
the management of the sick preterm or term infant is underestimated. The
echocardiographic needs of a large neonatal intensive c...
The personal experience by Katumba-Lunyenya echoes the views and
experiences of many contemporary neonatologists who recognize the
importance of routine echocardiography as an integral part of neonatal
intensive care [1]. Oftentimes the importance of routine echocardiography in
the management of the sick preterm or term infant is underestimated. The
echocardiographic needs of a large neonatal intensive care unit could
potentially cripple any cardiology service. Some neonatologists continue
to "work in the dark" when confronted with common problems such as
hypotension, pulmonary hypertension and the silent ductus arteriosus. The
impact of a hemodynamically significant patent ductus arteriosus (PDA) on
blood pressure and consequently cerebral and systemic perfusion is well-
recognized [2,3]. In very low birth weight infants the characteristic signs
of a clinically significant PDA on which may neonatologists rely, such as
bounding pulses and wide pulse pressure, are unreliable as the immature
heart is not able to compensate for the large left to right shunt by
maintaining systolic blood pressure [3]. Without serial echocardiography in
the early perinatal period therapeutic intervention is often delayed until
the appearance of a murmur by which time the effects of systemic
hypoperfusion include necrotizing enterocolitis [4], ischaemic cerebral
white matter disease and intraventricular hemorrhage have occurred [5]. A
targeted approach to the management of the ductus arteriosus based on the
early identification of suitable echocardiographic markers may minimise
complications. This article also highlights the importance of regular
echocardiography in the management of the "blue baby" which commonly leads
to misdiagnosis and inappropriate therapeutic intervention when
conventional methods are used. The benefits are twofold; by
differentiating duct dependant cyanotic heart disease from persistent
pulmonary hypertension of the newborn and when the latter is diagnosed by
monitoring pulmonary pressure and left ventricular function and gauging
the response to therapeutic interventions such as inotropes and Nitric
Oxide. Routine screening for the ductus arteriosus, monitoring pulmonary
pressure and ventricular function, tracking central venous and arterial
line position and diagnosing pericardial effusions before the onset of
catastrophic haemodynamic collapse in high-risk neonates would impose a
great burden on paediatric cardiology resources leading one to conclude
that they would be best performed by a neonatologist with a dedicated
interest in perinatal cardiology and skilled in echocardiographic methods.
One must tread with caution however and recognise our limitations
particularly with respect to the management of complex structural heart
lesions. Katumba-Lunyenyaa tabulates a comprehensive list of cardiac
lesions diagnosed at his institution which deserves credit however it must
be stressed that all neonates with potential structural cardiac problems
need urgent referral to a paediatric cardiologist for appropriate
investigation and counselling. It is vitally important that the role and
expertise of the paediatric cardiologist remains paramount to the
management of these patients.
Pediatric cardiologists in the past have raised great concerns that
in the wrong hands this "tool" may be potentially dangerous and without
appropriate training and supervision this may indeed be the case. I can
share a personal experience of a 3-day-old term infant of a diabetic
mother who presented on day 3 of life with respiratory distress and
cardiomegaly on chest x-ray. I performed an echocardiogram, which revealed
a large PDA, perimembranous ventricular septal defect (VSD) and postductal
coarctation of the descending aorta. The child was referred to the
regional pediatric cardiology center that diagnosed a PDA with a
perimembranous VSD and recommended treatment with diuretics and an ACE
inhibitor. The clinical course deteriorated over the ensuing 3-4 days and
when the patient needed to be intubated for cardiorespiratory support the
child was referred back to the tertiary cardiac center. A decision was
made to perform ductal ligation however following the procedure the child
became profoundly hypotensive and when further exploratory surgery was
performed a coarctation of the aorta was diagnosed. Postoperatively the
patient developed multiorgan failure and eventually died. I share this
case with your readers not to criticize the management by the tertiary
cardiac center but to highlight the valuable contribution a neonatologist
competent in echocardiography has to the management of sick newborns. My
personal associations with echocardiography began as a senior house
officer at Royal Maternity hospital, Belfast in 1995 and over the last
seven years my skills have improved under the supervision of several
neonatologists, pediatric cardiologists and echocardiography technicians
who have helped me achieve my level of competency. Like Dr Katumba-
Lunyenya it took me time to successfully reach the point where I could
obtain clear reproducible images and confidently recognize normal cardiac
anatomy. However since negotiating that steep part of the learning curve
I have accumulated a portfolio of diverse cardiac abnormalities by
regularly (oftentimes 10-20 scans per week) performing detailed heart
scans on suitable patients. It has often been said in the centers I have
worked that "I am attached by an umbilical cord to the echo-machine". My
enthusiasm and desire to stress the importance of regular echocardiography
and develop the role of the neonatologist as a competent echocardiographer
has led me to cross the Atlantic to further my knowledge and skills. I am
currently working as a research fellow in collaboration with the
paediatric cardiologists at the Hospital for Sick Children, Toronto,
Canada and using novel echocardiographic methods such as acoustic
quantification, three-dimenisonal echocardiography and Tissue Doppler
imaging to assess ventricular function in neonates.
I firmly believe that the role of the modern neonatologist, armed
with his/her comprehensive knowledge of the individualistic clinical
problems of each patient and the additional benefits of experience in
neonatal echocardiography, potentially compliments the role of the
pediatric cardiologist in a neonatal intensive care setting. My views and
experiences are stereotypical of a new generation of neonatologists who
recognize the importance of routine neonatal echocardiography and also the
lack of appropriate consideration for cardiac related problems in the
newborn period. Unfortunately the heart is oftentimes the "forgotten
organ" with current research interests concentrating on brain, lungs and
bowel disease. The time has come to reconsider the training needs of
physicians interested in neonatal medicine to address these fundamentally
important issues. All specialist registrars should be given the
opportunity to spend a predetermined period of time in a formal training
programme under the supervision of experienced pediatric cardiologists and
neonatologists with expertise in perinatal cardiology and
echocardiography. The programme should include focused teaching of
cardiovascular physiology and the transitional circulation, fetal
medicine, assessment of ventricular function and pulmonary hemodynamics,
identification of common structural heart defects as well as supervised
"hands-on" echocardiography. The longterm benefits to both patient care
and the evolving link between neonatology and pediatric cardiology will be
great.
References (1) Katumba-Lunyenya. Neonatal/infant echocardiography by the non-
cardiologist: a personal practice, past, present and future
(2) Ratner I, Perelmunter B, Toews W, Whitfield J. Association of low
systolic and diastolic blood pressure with significant patent ductus
arteriosus. Pediatrics 1985; 13:497-500
(3) Evans N, Moorcraft J. Effect of patency of the ductus arteriosus on
blood pressure in very preterm infants. Arch Dis Child 1992; 67:1169-1173.
(4) Ryder RW, Shelton JD, Guinan ME. Necrotising enterocolitis: A
prospective multicenter investigation. Am J Epidemiol 1980; 112:113-23
(5) Lipman B, Server GA, Brazy JE. Abnormal cerebral hemodynamics in
preterm infants with patent ductus arteriosus. J Pediatr 1982; 112:113-23
May I suggest an alternative term for the egregious "upper extremity" used in the title of Labore and Befell's article. I believe that the body part to which they are referring is also known as an "arm"?
Conflict of Interest:
None declared
The overall tone of this systematic review is to reassure the reader that waterbirths are safe; this is not justified by the results which rely almost exclusively on extremely poor quality retrospective cohort studies. Different study designs have significant differences in their susceptibility to bias and the authors have largely ignored this issue. Larger, non-randomised studies, more prone to bias, carry more weight ; n...
We are grateful for the interest in our paper and the opportunity to refute the suggestion that it is falsely reassuring. Our paper provides a fair and accurate representation of the best available data; it concludes that "this systematic review and meta-analysis did not identify definitive evidence that waterbirth causes harm to neonates ... However, there is currently insufficient evidence to conclude that there are no...
I read the article by Watson et al and the accompanying Editorial. While it is an interesting concept to link nurse patient ratios with mortality this does not take into account the individual nurses and their experiences. I would challenge the authors to demonstrate how retrospective data measures acuity and nursing experience. The authors presented the 1:1 ratio as measured by the percentage of ICU days where there wa...
The 'Dr Isaac 'Harry' Gosset Collection' a repository of UK General Paediatric and Premature Baby Care 1947-1965 is now on line.
http://www.northamptongeneral.nhs.uk/AboutUs/Ourhistory/Dr-Gosset/The -Dr-Isaac-Harry-Gosset-Collection.aspx
Conflict of Interest:
I am the author of the paper I am replying to
Hellman, Knigthon et Al and Carter in the accompanying editorial raise many issues dealing with the end of life care of sick newborn babies. Although consensus within multidisciplinary teams in each centre is recorded as being achieved relatively easily, the wide variation between centres in how each deals with the issue of withholding life saving treatments, particularly where there are 'quality of life issues' und...
Editor,
We read with interest the paper by Cuttini et al (1). Although policy regarding parental visiting is a relatively easier issue to evaluate, parental participation in decision making, particularly in decisions with strong ethical overtones, is a much more complex issue. It is difficult to evaluate with accuracy with accuracy and by its nature much more controversial. The paper does not stress that data col...
Dear Editor,
The rapid response from Dellagrammaticus and Iacovidou (17 May) provides interesting information and further support to the conclusion of our study (1): namely, that NICUs from Southern European countries (Italy, Spain and, according to Dellagrammaticus, also Greece) adopt parental visiting policies more restrictive than in Northern countries.
We agree that exploring the role of parents in deci...
Dear Editor
We would like to highlight the varying practices in the management of cardiac murmurs in well newborn infants. Two years after the publication of Wren's important paper on this subject[1] urging an early definitive structural diagnosis to be made on such infants we conducted a telephone survey of local hospitals to assess whether practices had changed.
Until recently it was common practice to...
Dear Editor
The personal experience by Katumba-Lunyenya echoes the views and experiences of many contemporary neonatologists who recognize the importance of routine echocardiography as an integral part of neonatal intensive care [1]. Oftentimes the importance of routine echocardiography in the management of the sick preterm or term infant is underestimated. The echocardiographic needs of a large neonatal intensive c...
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