We thank Dr Amore for her instructive comments on our article. [1] Dr
Amore correctly points out that our study population was limited to high-
risk VLBW infants. However, the point of our article seems to have been
missed.[2] Our large population-based study showed that VLBW triplets,
when compared with singletons and twins, have increased risk for RDS and
mortality, even after detailed correction...
We thank Dr Amore for her instructive comments on our article. [1] Dr
Amore correctly points out that our study population was limited to high-
risk VLBW infants. However, the point of our article seems to have been
missed.[2] Our large population-based study showed that VLBW triplets,
when compared with singletons and twins, have increased risk for RDS and
mortality, even after detailed correction for many confounding variables.
We agree that not all triplets are VLBW. Large population-based
studies [3] showed that about 1/3 are VLBW, a figure similar to that found
in the relatively small series of D’Amore et al.[1] Thus, clearly, no
meaningful comparisons can be made between a relatively small hospital-
based study collected over two decades and the findings of our population-
based study collected within the last few years.
Finally, the mean gestational age of D’Amore’s sample was 31.5 weeks
and the mortality rate 10%. This is similar to the findings of Doyle’s
population-based study in England and Wales showing a seven-fold increased
mortality in twins and >20-fold increase in triplets.[4] This is
important information for prospective parents of multiples.
References
(1) D'Amore A, Kelsall W, Ahluwalia J. Outcome of triplet pregnancies [electronic response to Shinwell ES et al. Excess risk of mortality in very low birthweight triplets: a national, population based study] archdischild.com 2003 http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;88/1/F36#200
(2) Shinwell ES, Blickstein I, Lusky A, Reichman B. Excess risk of mortality in very low birthweight triplets: a national, population based study. Arch Dis Child Fetal Neonatal Ed 2003;88:F36-F40.
(3) Alexander GR, Kogen M, Martin J, Papiernik E. What are the fetal growth patterns of singletons, twins and triplets in the United States? Clin Obst
Gynecol 1998;41(1):115-25.
(4) Doyle P. The outcome of multiple pregnancy. Hum Reprod 1996:11:110-117.
We wish to amend and supplement the information supplied by Bayley
[1] regarding the technique of insertion of central venous catheters in
newborn infants. The report implied that the prescribed method for long
line insertion in neonates at the Royal Children’s Hospital, Melbourne is
that using a 19 FG butterfly needle. This is incorrect; no particular
technique is stipulated as the preferred method, a...
We wish to amend and supplement the information supplied by Bayley
[1] regarding the technique of insertion of central venous catheters in
newborn infants. The report implied that the prescribed method for long
line insertion in neonates at the Royal Children’s Hospital, Melbourne is
that using a 19 FG butterfly needle. This is incorrect; no particular
technique is stipulated as the preferred method, and data from our unit
affirm that several methods are currently in use.
Over an 18 month period (July 2001-January 2003), we prospectively
collected data on 107 episodes of silastic long line insertion (Epicutaneo
-Cava-Katheter, Vygon GmbH, Aachen, Germany). 73 of the episodes (68%)
were undertaken by senior neonatal trainees (Fellows), and 34 (32%) by
paediatric registrars. For each episode, we documented the method or
methods used for insertion of the line, the number of insertion attempts
(i.e. number of separate venepunctures), and the outcome. A 19 FG
butterfly needle was used for 73 attempts, and was successful on 39
occasions (53% success rate). Methods other than the 19 FG butterfly
technique (including that described by Bayley) were used for 74 attempts,
of which 41 (55%) were successful. Overall the silastic long line was
successfully inserted in 79 episodes (74%), but required on average 1.7
separate venepunctures. Paediatric registrars successfully inserted the
long line in only 16 out of 34 episodes (47%). These data highlight the
difficulty presented by long line insertion in neonates, and the need for
better methods to be developed.
The modified Seldinger technique described by Bayley has been used in
our unit to insert silastic lines into the femoral vein for 7 years. We
have not found it as useful for more peripheral veins, as the 20 FG IV
cannula does not fit snugly over the guide wire, and its tip often catches
in the skin or subcutaneous tissue, even if an incision is made at the
puncture site. This difficulty may be potentially be overcome using a
“piggy-back” technique where a 20 FG precut cannula sleeve is loaded onto
a 24 FG cannula,[2] but the risk of cannula fragment embolisation will
need to be overcome before this method can be widely recommended.
Although direct cannulation of the target vein using a 19 FG
butterfly needle is difficult in small babies, some Neonatologists and
senior Neonatal trainees are very successful in inserting long lines using
this method. The butterfly needle is also used in some centres for long
line insertion into the femoral vein, even in neonates less than 1000
grams.[3] Given the inherent risks associated with blind insertion of a
19 FG needle into the femoral triangle, we would not favour this method in
very low birth weight infants.
References
(1) Bayley G. Technique for insertion of percutaneous central venous
catheters in the newborn period. Arch Dis Child Fetal Neonatal Ed
2003;88:256-7.
(2) Fischer JE, Fanconi S. Percutaneous central venous catheterisation in
premature infants: a method for facilitating insertion of silastic
catheters via peripheral veins. Pediatrics 1998;101:477-9.
(3) Serrao PR, Jean-Louis J, Godoy J, Prado A. Inferior vena cava
catheterisation in the neonate by the percutaneous femoral vein method. J
Perinatol 1996;16:129-32.
Hodge and Puntis[1] suggest that "up to 80 % of coagulase negative
staphylococcus infection... in young children can be eradicated with
antibiotics". The study referenced, Raad et al.[2] was carried out in
adults (mean age 43 yr) with underlying malignancy, most of whom had non-tunnelled subclavian lines. It may not be appropriate to apply Raad et
al.’s results to children with long term...
Hodge and Puntis[1] suggest that "up to 80 % of coagulase negative
staphylococcus infection... in young children can be eradicated with
antibiotics". The study referenced, Raad et al.[2] was carried out in
adults (mean age 43 yr) with underlying malignancy, most of whom had non-tunnelled subclavian lines. It may not be appropriate to apply Raad et
al.’s results to children with long term parental nutrition, in view of the
differences in age, illness, and catheter type.
The authors endorse the treatment of infected central venous
catheters in situ without an adequate appraisal of the risks. In the
neonatal population retention of catheters has a lower success rate than
suggested them with only 50 % of catheters being
successfully treated.[3] Importantly, treating catheters rather than
immediate removal significantly prolonged the bacteremia. The risk of
bacterial end organ damage increases with each day that there are positive
cultures.[4]
R Nicholl
Neonatal Consultant
Northwick Park Hospital
K Nistala
Neonatal SPR
Northwick Park Hospital
References
(1) D Hodge, JWL Puntis. Diagnosis, prevention and the management of
catheter related bloodstream infection during long term parental
nutrition. Arch Dis Child Fetal Neonatal Ed 2002;87:F21-F24.
(2) Radd I, Davis S, Khan A, Tarrand J, Elting L, Bodey G.
Impact of central venous catheter removal on the recurrence of catheter-
related coagulase negative staphylococcal bacteremia. Infect Control Hosp
Epidemiol 1992;13:215-21.
(3) Karlowicz MG, Furigay PJ, Croitoru DP, Buescher ES. Central venous catheter removal versus in situ treatment in neonates with coagulase-negative staphylococcal bacteremia. Pediatr Infect Dis J 2002
Jan;21(1):22-7.
(4) Benjamin DK Jr, Miller W, Garges H, Benjamin DK, McKinney RE Jr, Cotton
M, Fisher RG, Alexander KA. Bacteremia, central catheters, and neonates:
when to pull the line. Pediatrics 2001 Jun;107(6):1272-6.
We read Dr Bayley's letter with interest, as we use a similar but probably safer
technique to insert 27 guage lines (medex, vygon ). I was surprised at the
author`s technique where the hub of the 24 guage canula was cut and then
the long line passed through the plastic sleeve of the canula. We think
this can be very dangerous as sometimes the thin plastic sleeve in front
of the hub can be easily dislodge...
We read Dr Bayley's letter with interest, as we use a similar but probably safer
technique to insert 27 guage lines (medex, vygon ). I was surprised at the
author`s technique where the hub of the 24 guage canula was cut and then
the long line passed through the plastic sleeve of the canula. We think
this can be very dangerous as sometimes the thin plastic sleeve in front
of the hub can be easily dislodged in to the vein in a baby who is
vigorous during the procedure which may require surgical removal. We
always insert our above long lines through a 24 guage canula and leave the
hub which is easily fixed to the end of the long line unit and secured in
place with a tegaderm. We do not really see any advantage of cutting the
hub of the 24 guage canula. With our above technique, we do not have any
increased risk of infection as compared to other longlines(23 and 24 guage
vygon)that we use.
We thank Drs Nistala and Nichol for their comments on our leading
article concerned with management of catheter related blood stream
infection in chldren receiving long term parenteral nutrition. The points
they make with regard to neonates may well have some validity, but our
paper relates to children on parenteral nutrition for many months, and
sometimes years. The balance of risk and benefits when tre...
We thank Drs Nistala and Nichol for their comments on our leading
article concerned with management of catheter related blood stream
infection in chldren receiving long term parenteral nutrition. The points
they make with regard to neonates may well have some validity, but our
paper relates to children on parenteral nutrition for many months, and
sometimes years. The balance of risk and benefits when treating infected
central venous catheters in situ is clearly quite different in this group
in whom loss of venous access may well jeopardise survival. We emphasise
the point that experience in adults has established that eradication of
catheter sepsis is possible, because it has been common clinical practice
in some centres to remove catheters on suspicion of sepsis rather than
even attempt treatment with antibiotics. This has relevance to children on
long term parenteral nutrition, notwithstanding that findings of studies
in one population should not be mechanically applied to another. Our own
experience with treating catheter related infection in children well
beyond the newborn period was cited.[1,2]
We suspect that Nistal and Nichol have been mislead by an arguably
perverse editorial decision to place our review in the Fetal and Neonatal
Edition of Archives. We can only agree that it is not appropriate to apply
our observations based on a review of the adult and paediatric literature
to short term PN via percutaneous catheters in the newborn. Perhaps some
intimation of our area of focus might have been gained from the fact that
we did not include a single paper on the subject of their letter (i.e.
central lines in the neonate) among the 55 references cited in our review?
References
(1) Page S, Abel G, Stringer MD, et al. Management of septicaemic
infants during long term parenteral nutrition. Int J Cln Pract 2000;54:147
-50
(2) Hoy CM, Kite P, Abel G, et al. The role of quantitative blood
culture surveillance in the diagnosis and management of central venous
catheter sepsis. Clin Nutr 2000;19(suppl 1):38.
We have inserted over 150 lines using the Townsville technique [1] (for
babies as small as 500 gram birth weight) and had no problems with the 24 G
cannula segment slipping into the vein. The disadvantage of leaving the
hub is the possibility of a blood pool in it during the procedure. Another
important reason is that it is easier and neater to secure the central
line with Tegaderm without the potenti...
We have inserted over 150 lines using the Townsville technique [1] (for
babies as small as 500 gram birth weight) and had no problems with the 24 G
cannula segment slipping into the vein. The disadvantage of leaving the
hub is the possibility of a blood pool in it during the procedure. Another
important reason is that it is easier and neater to secure the central
line with Tegaderm without the potential of the hub pressing on and
abrasing the baby's skin.
As with any procedures in NICU insertion of percutaneous lines
requires the baby to be kept still (a much shorter period using our
method) with a small dose of sedative if need be, being careful and a
normal blood glucose on the part of the operator. It is important to
remember that the Premicath 27 G is only 200 mm long and may therefore be
unsuitable for bigger babies.
Reference
(1) Gandini D, Koh THHG. A novel, simple way to insert percutaneous
central venous catheters in newborn babies. J Perinatology 2003;23:162-163.
The investigation of the effect of maternal tobacco smoking on
arousal in healthy infants[1] concluded that maternal tobacco smoking
increases arousal thresholds (i.e. impairing arousal) in infants of 2-3
months of age, in quiet sleep, in the supine position. It is suggested
that this may provide an explanation for the association between smoking
and sudden infant death syndrome (SIDS).
The investigation of the effect of maternal tobacco smoking on
arousal in healthy infants[1] concluded that maternal tobacco smoking
increases arousal thresholds (i.e. impairing arousal) in infants of 2-3
months of age, in quiet sleep, in the supine position. It is suggested
that this may provide an explanation for the association between smoking
and sudden infant death syndrome (SIDS).
This conclusion is not supported by the data since the study also
found that maternal tobacco smoking reduces arousal thresholds in 2-3
month old infants, in active sleep, in the prone position, the very position
in which victims of SIDS are still most commonly found.[2,3] Could
passive smoking then be protective of death from SIDS?
Smoking is undoubtedly associated with SIDS. However, these
contradictory findings do not support the hypothesis that an alteration of
infants’ arousal thresholds by passive smoking is explanatory.
Is it not time that SIDS research concentrated less on smoking and
more on alternative mechanisms?
References
(1) Horne RSC, Ferens D, Watts A-M, Vitkovic J, Lacey B, Andrew A,
Cranage SM, Chau B, Greaves R, Adamson TM. Effects of maternal tobacco
smoking, sleeping posistion and sleep state on arousal in healthy term
infants. Arch Dis Child Fetal Neonatal Ed 2002;87: F100-F105
(2) Fleming PJ, Blair PS, Bacon C et al. Environment of infants during
sleep and the risk of sudden infant death syndrome: results of 1993-1995
case-control study for confidential inquiry into stillbirths and deaths in
infancy. BMJ 1996;313:191-5.
(3) Skadberg BT, Marild I, Markestad T. Abandoning prone sleeping: Effect
on the risk of sudden infant death syndrome. J Pediatr 1998;132(2):340-3.
I read with interest Tenbrock and colleagues account of hyponatraemia
following cerebrospinal fluid drainage for hydrocephalus in preterm
infants.[1] The fact that they were draining the fluid via a reservoir device
probably enabled large amounts of fluid to be drained daily. Even using
direct ventricular needle tap or spinal taps to drain cerebrospinal fluid
in preterm infants can lead to hyponatraemia a...
I read with interest Tenbrock and colleagues account of hyponatraemia
following cerebrospinal fluid drainage for hydrocephalus in preterm
infants.[1] The fact that they were draining the fluid via a reservoir device
probably enabled large amounts of fluid to be drained daily. Even using
direct ventricular needle tap or spinal taps to drain cerebrospinal fluid
in preterm infants can lead to hyponatraemia as was described 20 years ago
in this journal. This problem calls into question the value of the practice
of fluid drainage in these infants in all but the severest cases, as
controlled trials of fluid drainage have not shown long term benefits.
References
(1) K Tenbrock, A Kribs, B Roth, and B Speder.
Hyponatraemia as a consequence of serial liquor punctures in preterm infants with a ventricular access device after posthaemorrhagic hydrocephalus. Arch Dis Child Fetal Neonatal Ed 2003;88:F351.
(2) P MacMahon, Cooke RWI. Hyponatraemia caused by repeated cerebrospinal
fluid drainage in post-haemorrhagic hydrocephalus. Arch Dis Child 1983; 58:365-386.
In response to the letter from Tom Blyth and Sheila McKenzie[1] we wish
to clarify the following points. Our study is the first to examine the
effects of both sleeping position and maternal smoking, both factors which
are associated with an increased risk for Sudden Infant Death Syndrome
(SIDS), on arousal from sleep. We had hypothesised that the effects of
these two risk factors might be additive. O...
In response to the letter from Tom Blyth and Sheila McKenzie[1] we wish
to clarify the following points. Our study is the first to examine the
effects of both sleeping position and maternal smoking, both factors which
are associated with an increased risk for Sudden Infant Death Syndrome
(SIDS), on arousal from sleep. We had hypothesised that the effects of
these two risk factors might be additive. Our findings however, showed
that sleeping position had no effect on arousal threshold in the smoking
group, but arousal was impaired in the non-smoking group when they slept
prone. The arousal responses to both stimulus induced and spontaneous
arousal were however impaired in the smoking group in the supine position.
The significant findings that Drs Blyth and McKenzie highlight as being
supportive of the idea that passive smoking is protective of SIDS may be
explained by this finding that prone sleeping elevated arousal thresholds
only in the non-smoking group.
We strongly disagree with the suggestion that passive smoking might
be protective of SIDS when infants sleep prone. Our finding of depressed
arousal responses in infants of smoking mothers is also supported by those
of other workers (Lewis and Bosque[2] 1995 and Franco et al.[3]). As yet the
mechanism(s) which cause some infants to die suddenly and unexpectedly are
unknown, it is thus of great importance that research should focus on how
the known risk factors for SIDS might act. At present, a failure to arouse
from sleep in the face of a life-threatening event is a leading hypothesis
for SIDS. In support of this, prone sleeping, maternal smoking, recent
infection, head covering, overheating and prematurity, all risk factors
for SIDS, have all been demonstrated to decrease arousability in otherwise
healthy infants. Conversely, the use of pacifiers, which decrease the risk
of SIDS[4] has been shown to increase arousability.[3]
References
(1) Blyth T, McKenzie S. SIDS, smoking and arousal thresholds: conclusions not supported by data [electronic response to Horne RSC et al., Effects of maternal tobacco smoking, sleeping position, and sleep state on arousal in healthy term infants] archdischild.com 2002.http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;87/2/F100#143
(2) Lewis KL, Bosque EM. Deficient hypoxia awakening response in infants of smoking mothers: possible relationship to sudden infant death syndrome. J Pediatr 1995;127:691–9.
(3) Franco P, Pardou A, Hassid S, et al. Auditory arousal thresholds are higher when infants sleep in the prone position. J Pediatr 1998;132:240–3.
(4) L'Hoir MP. Proceedings 7th SIDS International Conference. Florence, 2002.
We are grateful to our colleagues for their interest and responses to our paper.[1] In response to Dr Ovaly’s comments we agree that late anaemia can be a problem in these babies who receive intravenous immunoglobulin (IVIG), as also demonstrated in our systematic review. Even when infants have received exchange transfusions (XTs) top-up red cell transfusions may be required. In a recent local audit of XTs, 3...
We are grateful to our colleagues for their interest and responses to our paper.[1] In response to Dr Ovaly’s comments we agree that late anaemia can be a problem in these babies who receive intravenous immunoglobulin (IVIG), as also demonstrated in our systematic review. Even when infants have received exchange transfusions (XTs) top-up red cell transfusions may be required. In a recent local audit of XTs, 35% of babies received top-up red cell transfusions after one or more exchange transfusions. During a five year period from 1998 -2002, twenty-seven babies with Rhesus, Kell of ABO incompatibility had 28 XTs. Gestation ranged from 28 to 40 completed weeks. Of 26 infants for whom follow-up data was available, 9 (35%) had received top-up red cell transfusions.
We read with interest Dr Ovaly and colleagues paper describing a double blind randomised controlled trial of subcutaneous recombinant human erythropoietin (rHEPO) and its use in this situation.[2]
We await with interest the outcome of a Cochrane meta-analysis of this therapy in newborn infants (currently at the protocol stage).
We reviewed our computer database for a three year period from December 1999 to December 2002 to postulate what impact IVIG might have on our population of babies with haemolytic disease of the newborn. 205 babies had a positive direct Coombes test (DCT) result. Of these infants 12 received XTs. There is a degree of under ascertainment with this database as there were four additional babies who required an XT during this time period. However, we make the assumption that the proportions of those missed requiring XTs is similar to the proportions of DCT positive babies who were missed from the database. Eighty-five babies had moderate or strongly positive DCT. Of these eleven received an XT; thus the XT rate in this group was 13%. After IVIG the RR of requiring an XT is 0.28,[1] 1 thus with IVIG the XT rate would be reduced to 3.6%, decreasing the number of XTs to 3 thus preventing 8. Therefore if IVIG were administered to all babies with moderate or strongly positive DCT, in our population the NNT would be 10.6 to prevent one XT. The degree of positivity of the DCT is an objective validated assessment of the strength of antigen/antibody reaction, determined by the degree of agglutination in the laboratory.[3]
During the three year period of this database there was only one infant who had only a weakly positive DCT and required an XT.
We were interested to read Dr. Cleary and colleagues case reports. We recognise that IVIG is not specific for a particular type of haemolysis and that it is a pooled blood product. We therefore agree that all the usual procedures regarding documentation of batch number etc. are followed as for any other blood product. IVIG has been used previously even in preterm and low birthweight infants [4] and is currently being used in the INIS Trial.[5] As with any drug or blood product we will need to remain vigilant for the occurrence of any adverse events.
References
(1) Gottstein R, Cooke RWI. Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed 2003;88:F6-10.
(2) Ovali F, Samanci N, Daðoðlu T. Management of late anemia in rhesus hemolytic disease: Use of recombinant human erythropoietin (A pilot study). Pediatr Res 1996:39:831-834.
(3) Dunsford I, Bowley CC (1967) Techniques in Blood Grouping, 2nd edn, Vol. II. Edinburgh: Oliver and Boyd, Pp 270, 287.
(4) Ohlsson A, Lacy JB. Intravenous immunoglobulin for preventing infection in preterm and / or low birthweight infants. (Cochrane Review). The Cochrane Library Oxford: Update Software, 2000:issue 3.
Dear Editor
We thank Dr Amore for her instructive comments on our article. [1] Dr Amore correctly points out that our study population was limited to high- risk VLBW infants. However, the point of our article seems to have been missed.[2] Our large population-based study showed that VLBW triplets, when compared with singletons and twins, have increased risk for RDS and mortality, even after detailed correction...
Dear Editor
We wish to amend and supplement the information supplied by Bayley [1] regarding the technique of insertion of central venous catheters in newborn infants. The report implied that the prescribed method for long line insertion in neonates at the Royal Children’s Hospital, Melbourne is that using a 19 FG butterfly needle. This is incorrect; no particular technique is stipulated as the preferred method, a...
Dear Editor
Hodge and Puntis[1] suggest that "up to 80 % of coagulase negative staphylococcus infection... in young children can be eradicated with antibiotics". The study referenced, Raad et al.[2] was carried out in adults (mean age 43 yr) with underlying malignancy, most of whom had non-tunnelled subclavian lines. It may not be appropriate to apply Raad et al.’s results to children with long term...
Dear Editor
We read Dr Bayley's letter with interest, as we use a similar but probably safer technique to insert 27 guage lines (medex, vygon ). I was surprised at the author`s technique where the hub of the 24 guage canula was cut and then the long line passed through the plastic sleeve of the canula. We think this can be very dangerous as sometimes the thin plastic sleeve in front of the hub can be easily dislodge...
Dear Editor
We thank Drs Nistala and Nichol for their comments on our leading article concerned with management of catheter related blood stream infection in chldren receiving long term parenteral nutrition. The points they make with regard to neonates may well have some validity, but our paper relates to children on parenteral nutrition for many months, and sometimes years. The balance of risk and benefits when tre...
Dear Editor
We have inserted over 150 lines using the Townsville technique [1] (for babies as small as 500 gram birth weight) and had no problems with the 24 G cannula segment slipping into the vein. The disadvantage of leaving the hub is the possibility of a blood pool in it during the procedure. Another important reason is that it is easier and neater to secure the central line with Tegaderm without the potenti...
Dear Editor
The investigation of the effect of maternal tobacco smoking on arousal in healthy infants[1] concluded that maternal tobacco smoking increases arousal thresholds (i.e. impairing arousal) in infants of 2-3 months of age, in quiet sleep, in the supine position. It is suggested that this may provide an explanation for the association between smoking and sudden infant death syndrome (SIDS).
This con...
Dear Editor
I read with interest Tenbrock and colleagues account of hyponatraemia following cerebrospinal fluid drainage for hydrocephalus in preterm infants.[1] The fact that they were draining the fluid via a reservoir device probably enabled large amounts of fluid to be drained daily. Even using direct ventricular needle tap or spinal taps to drain cerebrospinal fluid in preterm infants can lead to hyponatraemia a...
Dear Editor
In response to the letter from Tom Blyth and Sheila McKenzie[1] we wish to clarify the following points. Our study is the first to examine the effects of both sleeping position and maternal smoking, both factors which are associated with an increased risk for Sudden Infant Death Syndrome (SIDS), on arousal from sleep. We had hypothesised that the effects of these two risk factors might be additive. O...
Dear Editor
We are grateful to our colleagues for their interest and responses to our paper.[1] In response to Dr Ovaly’s comments we agree that late anaemia can be a problem in these babies who receive intravenous immunoglobulin (IVIG), as also demonstrated in our systematic review. Even when infants have received exchange transfusions (XTs) top-up red cell transfusions may be required. In a recent local audit of XTs, 3...
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