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Recent eLetters

Displaying 1-9 letters out of 561 published

  1. Physiolgical transition ?

    Dear Sir,

    We congratulate the authors on this study of neonatal transitional circulation performed so quickly after birth. The authors state that the ductal flow ratio reported in their study reflects pulmonary and haemodynamic transition and can be used to monitor neonatal transition in healthy infants. The implication is that their study describes a physiological transition in healthy term infants, but we question that this is the case.

    Delivery by elective caesarean section is not a physiological birth but it does permit the neonate an atraumatic birth. We are particularly concerned that the transition may have been disrupted by the timing of cord clamping which was between 30 and 60 seconds. While this is considered delayed cord clamping by some, most guidelines recommend a minimum of 60 seconds have elapsed before the circulation is interrupted by cord clamping. The WHO advises 3 minutes.(1) Not all of the babies in the series had established respiration before clamping and cord clamping before the onset of respiration has a marked effect on cardiac output.(2) It is therefore questionable that the mean and range of results published represents a normal transition in healthy infants.

    The normal fetal circulation is well described with the two ventricles pumping in parallel, the right ventricular output being significantly more than the left and the flow across two shunts, right to left in the ductus arteriousus and right to left across the foramen ovale. The normal neonatal circulation is also well described with equal outputs by both ventricles and closed shunts. A closer look at the results suggest some anomalous flow not readily compatible with the end result of the neonatal circulation. For example at ten minutes the mean right ventricular output is 343 mls/kg/min and mean left ventricular output is 212 mls/kg/min and the DA flow is 8mls/kg/min left to right. (ratio R to L =0.9). Where does the right ventricle get the 343 output as only 212 - 8 are reaching the systemic circulation and returning to the right atrium. Also if the pulmonary blood flow is 343+8 = 351, the excess of 141 must be spilling left to right across the foramen ovale. Reverse flow in the foramen ovale is described but has not been quantified. We question that these flows are evidence that this heart is now close to transitioning to a parallel ventricular pattern with equal outputs. Reverse flow across the foramen ovale of 141 is contributing to over 40% of the right ventricular output. This blood has just been through the pulmonary circulation and is oxygenated but is now returning to the right ventricle to be pumped through the pulmonary circulaton once more. Such flow is completely inefficient. Can the authors explain this anomaly in physiogical terms or could this finding in fact be a demonstration that the early clamping at under 60 seconds sometimes before the onset of respiration has indeed disrupted the transitional circulation ?

    Reference 1. World Health Organization (WHO), US Agency for International Development (US AID), Maternal and Child Health Integrated Program (MCHIP). (2013). Delayed cord clamping of the umbilical cord to reduce infant anaemia. Updated 2013. Available from: http://www.mchip.net/node/1562 (Accessed June 12, 2014). 2. Bhatt S, Alison BJ,Wallace EM, Crossley KJ, Gill AW, Kluckow M, et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 2013 591(Pt 8): 2113-26.

    Conflict of Interest:

    I am a co-inventer of the LifeStart trolley

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  2. Cardiac assessment using echocardiography in the sick neonate - An unmet need for a training syllabus for aspiring neonatologists

    In the UK speciality training through the grid scheme has been in existence for about a decade with a well-defined syllabus of knowledge and skills deemed necessary for the qualified neonatologist. Although much emphasis is laid on various aspects of neonatal care and the acquisition of procedural skills including cranial ultrasound, cardiac assessment using echocardiography is still considered to be an optional skill (1).

    There are many reasons why this position should now be challenged. Not least the greatly enhanced armentarium of the neonatologist when considering therapy, coupled to the relative ease of access to the equipment necessary to undertake such an evaluation.

    Hence our question 'Should cardiac assessment using echocardiography be considered an essential skill for the neonatologist?'

    The recent article by Kluckow (2) highlights the value of clinician performed cardiac ultrasound in neonatal practice. The ability to undertake a timely competent functional cardiac assessment - even of limited parameters - might help optimise therapy, reduce morbidity and potentially mortality. Yet this ability is not yet deemed essential in the training of those looking after the most vulnerable babies.

    A syllabus in functional cardiac assessment for the neonatologist needs to be developed as a matter of priority, with access to structured training in order that all those aspiring to be neonatologists learn the potential of these techniques and are able to acquire the skills during their time as a trainee. It might be argued that it would be advantageous for those already working in the field but who lack these abilities to do likewise.

    References

    1. http://www.rcpch.ac.uk/training-examinations-professional- development/postgraduate-training/sub-specialty-training/neonatal

    2. Kluckow M. Use of ultrasound in the haemodynamic assessment of the sick neonate. Arch Dis Child Fetal Neonatal Ed. 2014 Apr 15. doi: 10.1136/archdischild-2013-30492

    Conflict of Interest:

    None declared

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  3. Decision-making during preterm birth in Italy

    Dear Dr. Gallagher,

    We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a document on the bioethical questions regarding the resuscitation of extremely preterm infants 1. Briefly, the document states the following recommendations: 1. The resuscitation of extremely preterm infants must be made without considering the gestational age, using criteria similar to that adopted for children and adults; 2. The sole high probability of severe disabilities does not justify a decision not to resuscitate an infant in the delivery room; 3. Neonatologists can discontinue the assistance (starting palliative care) when it appears futile and inappropriate; 4.Parental opinion is central, but when it is in contrast with that of Neonatologists, this late must prevail. The Italian Society on Neonatology, the most important Italian association of Neonatologists, substantially agree this document. Thus, in the majority of Italian Hospitals extremely preterm infants are resuscitated in the delivery room on the basis of their viability and not merely evaluating their gestational age.

    Prof. Carlo Dani, Division of Neonatology, Careggi University Hospital of Florence, Italy. Prof. Costantino Romagnoli, Division of Neonatology, Sacred Heart Catholic University of Rome, Italy. President of Italian Society of Neonatology Prof. Giovanni Corsello, Department of Sciences for Health Promotion and Mother and Child Care, University of Palermo President of Italian Society of Pediatrics.

    Conflict of Interest:

    None declared

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  4. Response to the two letters regarding tongue-tie, from Dr Essex and Mr Mercer

    Dr Essex and Mr Mercer highlight many of the reasons why we undertook the Bristol Tongue Tie trial. Ankloglossia is a spectrum condition, which overlaps with 'normal' variation in anatomy, and milder forms do not result in feeding impairment. There is very limited evidence of the need for frenotomy in mild-moderate degrees of tongue tie. However, it is also true that at the severe end of the spectrum infants can be limited in their ability to breastfeed efficiently because they are not able to latch effectively.

    We agree that it is easy to blame a visible tongue tie for breast feeding difficulties which may be due to other factors, and entirely support the view that good breastfeeding support is essential in helping mothers with feeding difficulties.

    The inequity in the use of frenotomy worldwide and within the UK is exactly why well conducted trials are needed, to clarify which babies should be offered frenotomy and when. The widespread use of social media, and campaigning by some pressure groups, has resulted in an increase in demand for the procedure. Good quality evidence from randomised trials is needed to inform evidence- based clinical practice and the rational commissioning of services.

    Conflict of Interest:

    None declared

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  5. Banked donor human milk: more research is needed

    We thank Dr. Verd and colleagues for their comments [1] on our review of the use of human milk for preterm infants. Our aim was certainly not to discourage the use of donor human milk, but rather to look objectively at the evidence base that currently exists for its use.

    The authors of the letter refer to a 1984 study by Narayanan et al [2] which appeared to show a reduction in the risk of infection in infants fed pasteurised human milk. This study, which looked at 226 low birth weight infants, randomised them to receive unpasteurised human milk or pasteurised human milk, with or without formula. Many of the anti- infective factors in human milk are preserved after pasteurisation, and we therefore do not dispute the potential of donor breast milk (DEBM) to protect against infection. However, deductions from this paper about the benefits of pasteurised DEBM have to be made with caution because (a) no distinction was made in the analysis between mothers' own milk (MEBM) and DEBM, (b) there is no description of anti-infective precautions in reconstituting and feeding formula in a study carried out in a very different setting to a modern NICU, and (c) there is no suggestion of masking of analysis to study group. The second study referred to, the R?nnestad study [3], is a national survey of late onset sepsis which relates to babies who were predominantly fed unpasteurised human milk, and thus does not have direct relevance to our practice -we are aware of only one country in Europe (Norway) in which unpasteurised donor milk is routinely used. A Cochrane review which we cited in our article [4] looked at whether donor human milk might be better than formula in terms of rates of invasive infection. They found only one study that they judged to be of sufficient quality to include in their analysis, the final study quoted by Verd and colleagues, that by Schanler et al [5]. This study found no statistically significant difference in the incidence of one or more episodes of invasive infection when donor milk, rather than formula, was used to feed preterm infants. Babies were randomised to receive DEBM or PTF to make up any shortfall of MEBM in preterm infants. Although there was a (barely statistically significant) lower rate of chronic lung disease in infants fed DEBM as opposed to PTF, the authors rightly state that this is one of several outcomes assessed which the study was not designed to look at, and requires more research.

    We welcome an open discussion of the evidence base for the use of DEBM. Currently, the use of DEBM varies from not at all to extensive use in preterm infants in place of formula milk. If we over-interpret the current data, there is the very real risk that we may discourage the funding of research studies which have the potential to measure the cost- effectiveness of DEBM more fully and thus the potential to benefit the care of a larger number of infants by allowing the development of evidence -based guidelines.

    References 1. Verd S, Porta R and Ginovart G. Human milk feeding. Arch Dis Child Fetal Neonatal Ed, 2014. 99(2): F172-3.

    2. Narayanan I, Prakash K, Murthy NS, et al. Randomised controlled trial of effect of raw and holder pasteurised human milk and of formula supplements on incidence of neonatal infection. Lancet 1984;2:1111-13.

    3. Ronnestad A, Abrahamsen TG, Medb? S, et al., Late-Onset Septicemia in a Norwegian National Cohort of Extremely Premature Infants Receiving Very Early Full Human Milk Feeding. Pediatrics, 2005. 115(3): p. e269- e276.

    4. Quigley MA, Henderson G, Anthony MY, et al. Formula milk versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev 2007;(4):CD002971.

    5. Schanler RJ, Lau C, Hurst NM, et al. Randomized trial of donor human milk versus preterm formula as substitutes for mothers' own milk in the feeding of extremely premature infants. Pediatrics 2005;116:400-6.

    Conflict of Interest:

    None declared

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  6. The child has rights!

    Sirs

    The tongue remains with in the boundaries of the mandible during suckling and so it is difficult to see the anatomical or the physiological basis for how a frenulectomy works in reducing breast and nipple discomfort during feeding. This randomised trial does not seem to assess the potential, positive psychological impact of the mother being told their child has had a frenulectomy. That is the question that must be answered before a procedure performed on the most sensitive organ in the body, with out anaesthesia is undertaken routinely.

    Tongue tie is not proven to impact upon speech and if a release is performed in a child with a small chin, with or without a cleft palate, it can cause airway obstruction. A significant tongue tie causes social embarrassment in later life but it has no other proven physical impact on the child and so more concrete evidence of benefit for the procedure being performed upon a neonate, with out anaesthesia, must be provided before the practice is offered routinely. Every surgical procedure has complications and surely there must be greater proof of benefit than relieving nipple pain in the mother? When else is a procedure inflicted on any patient, let alone a child, for the benefit of reducing discomfort in a third party? With out this additional proof, practitioners may well be performing unnecessary procedures on a defenceless infant.

    With out a "sham" group, the psychological impact on the mother cannot be excluded.

    Nigel Mercer

    MB ChB ChM FRCS FRCPCH

    Conflict of Interest:

    None declared

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  7. Most tongue tie is the medicalisation of childhood

    Lawson's editorial and Emond and colleagues' article exposes potentially bad medicine: lack of knowledge of normal and variations of normal; lack of knowledge of the natural history of a condition; a desire to do something - Ulysses syndrome (1); medicalising the child by giving the condition a name; and then ascribing any improvement to the intervention, forgetting that association does not mean causation.

    This writer did many years of community child health clinics seeing babies with a variety of problems that never went near a hospital: a W- shaped tongue [M-shaped from the baby's perspective] is a normal finding. To describe it as tongue tie and to intervene are medicalising normality in the majority of cases. As Illingworth says in The Normal Child (2) [which should be required reading for all health professionals involved with children] "The tongue is always short at birth but as the infant grows the tongue becomes longer and thinner. Many mothers [and health professionals - my insertion] ascribe their children's feeding difficulties and lateness in speaking to tongue tie".

    Unfortunately blaming tongue tie becomes self-perpetuating. The fact that parents want subsequent children to have a frenotomy after their first child has had one and doctors acquiesce to this or lactation experts believe it is the cause of breastfeeding difficulties does not represent proof nor does it justify performing the operation. Countries with initial and sustained high breastfeeding rates such as New Zealand, where this writer worked for several years, do not have high rates of frenotomy to ensure that breastfeeding is successful. Rather it is good breastfeeding support.

    Recently a tongue-tie service was set up in my local area. I can predict the outcome. In 12 months' time those who promoted and run the service will announce how many tongue tie operations they done, how parents are pleased and feel the baby is feeding better and how "successful" the service is. The specious conclusion will be that tongue tie was a significant problem for these babies which frenotomy cured. I consider this is 21st Century charlatanism.

    Signed

    Dr Charles Essex Consultant Neurodevelopmental Paediatrician Suite 115 41 Oxford Street Leamington Spa CV32 4RB

    References

    1. Essex C. Ulysses syndrome. BMJ 2005; 330: 1268.

    2. Illingworth RS. The Normal Child. Churchill Livingstone, Edinburgh 1983.

    Conflict of Interest:

    None declared

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  8. Re: Strengthening the evidence base on frenulotomy

    Dear Editors:

    We read Val Finigan's letter with interest, and agree with her experience that most mothers do report an improvement in the comfort and efficacy of breastfeeding after their baby has had a frenotomy. The difficulty is in showing objective improvement in breastfeeding after division of less severe degrees of tongue tie.

    In the Bristol Tongue Tie Trial, the median age of the babies at recruitment was 5 days, and the median age at follow-up for the primary outcome was 11 days. We are now planning a larger trial of frenotomy, involving all degrees of tongue tie, with a primary outcome 2 weeks after recruitment, using a more detailed tool to assess breastfeeding. For more information on the proposed trial design, please contact alan.emond@bristol.ac.uk

    Yours sincerely,

    Alan Emond

    Jenny Ingram

    Centre for Child and Adolescent Health, University of Bristol

    Conflict of Interest:

    None declared

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  9. Concerns regarding statistical presentation and interpretation

    I am writing to express my concern regarding the discordance between the results and conclusions of this paper. The paper compares a point of care glucose measurement with a laboratory "gold standard". The results are presented in a number of forms (and with no consistency regarding units of measurement). The error-grid analysis is unhelpful as high levels will be high and low levels will be low for both methods and the scale of the graph is too large to see what the real differences are. The "accurate estimate zone" includes potential values 4mmol/l above and below zero in the lower glucose range. Whilst the authors are to be applauded for inserting a Bland Altman plot, this plot demonstrates "limits of agreement" which are around 0.5mmol/l above and below the line of zero. 6 points lie outside the limits of agreement with the extremes being 0.7mmol/l above and below zero. Therefore the plot demonstrates that in an unpredictable manner the glucometer may be over reading or under reading by a value as great as 0.7mmol/l. This is not of clinical significance in the normoglycaemic or hyperglycaemic range, but acquires clinical significance when blood glucose levels are low. For example if a glucometer reading is 2.0mmol/, the accurate level (at the extreme) could be 1.3-2.7mmol/l which will result in over diagnosis and treatment or under diagnosis and treatment. The authors state in the results section that the plot shows "good correlation", but the plot does not represent correlation, and the agreement between the values is not good. The conclusion that there is good "correlation" between the glucometer and the laboratory measurement draws on the wrong statistical method. Correlation does not provide accuracy data. Under "what this study adds" it is stated that the glucometer provides accurate results and is suitable for measuring glucose levels in premature infants. I suggest that the results as plotted on Bland Altman plot are directly counter to this conclusion.

    Conflict of Interest:

    None declared

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