Displaying 1-10 letters out of 618 published
Congenital intraoral Fordyce spots misdiagnosis
Dear editor, We read with interest the report by Arun Babu and colleagues1 and have concern with the diagnosis of "congenital intraoral Fordyce spots" that was rendered in this case. Fordyce spots/granules in the oral cavity are considered ectopic holocrine glands, and they differ considerably from those shown in the mentioned article. Fordyce spots usually appear as asymptomatic, multiple yellowish raised papules with well-defined borders as we demonstrate in Figure 1. In our experience Fordyce granules are permanent, variable in size depending on the state of cytoplasmic engorgement, and considered as a normal variant of the oral cavity. We believe that the lesions in the case report appear as multiple areas of "ductal ectasia" with mucous retention, which should resolve with appropriate hydration. On close observation you can notice a central ductal opening in each lesion, which is inconsistent with the clinical presentation of Fordyce granules. Clinicians involved with the case reported should also be aware of the possibility of cystic fibrosis due to the presence of mucous plugs. Another less likely possibility would be lymphectasia. Finally, the two references2,3 cited do not support the diagnosis made by the original authors.
References. 1. Arun Babu T, Vijayadevagaran V, Carounanidy U. Congenital intraoral Fordyce spots. Arch Dis Child Fetal Neonatal Ed. 2016 May;101(3):F252. 2. Flinck A. Oral findings in a group of newborn Swedish children. Int J Paediatr Dent. 1994 Jun;4(2):67-73. 3. Cutaneous disorders of the newborn. In: Paller AS, Mancini AJ, eds. Hurwitz's clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence. 4th ed. Philadelphia, PA: Elsevier Saunders, 2011:10-36.
Thamer M. Musbah, B.D.S. Assistant Professor Division of Oral Diagnosis, Oral Medicine and Oral Radiology University of Kentucky College of Dentistry
Craig S. Miller D.M.D., M.S. Professor of Oral Medicine Chief, Division of Oral Diagnosis, Oral Medicine and Oral Radiology University of Kentucky College of Dentistry
Douglas D. Damm, D.D.S. Professor of Oral Pathology Chief, Division of Oral and Maxillofacial Pathology University of Kentucky College of Dentistry
Conflict of Interest:
Re: Neonatal antibiotics; a response to White and co-authors
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence were likely underestimated due to underreporting, particularly the low incidence of neonate antibiotic exposure for suspected sepsis... which [was] substantially lower than estimates described in the literature at academic institutions". However, despite likely overall underreporting, antibiotic treatment for sepsis would be reported non-differentially between epidural and non-epidural groups. Therefore, we believe the comparisons between groups and associations identified to be valid and an important step in describing the issue of neonatal sepsis evaluation. The issue the writer raises highlights the need to improve administrative data collection tools, such as the birth certificate database, in order to provide more precise estimates, but does not impact the validity of the conclusions of this study.
Conflict of Interest:
Current UK practice: Infant Car Seat Challenges
This paper highlights some limitations in the use of infant car-seat challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior to hospital discharge. Current practice is non-standardised and unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks gestation or birth-weight <2500g should have a period of observation in a car-seat prior to hospital discharge. This is based on reports of preterm infants experiencing cardiorespiratory compromise in car-seats. There is no national UK guidance.
We evaluated current practice in England and Wales by conducting a postal survey of the 179 level I-III Neonatal Units between December 2013 - January 2014.
The response rate was 62.6% (n=112). Our results showed that 27.7% of respondents regularly tested infants in car-seats pre-discharge; compared to 10% of 200 UK units contacted in 2005 and 30% of 30 units in 2006.
In our survey, 51.6% of units had no gestational age or weight criteria for performing the ICSC. 25.8% had no formal failure criteria. Parameters tested and duration of monitoring varied widely.
Arya reported the static ICSC does not reflect the angle or motion of a moving vehicle. Infants, in a more upright seat (40 degrees) with vibration experienced in a car, showed significantly increased heart rate, respiratory rate and decreased oxygen saturations. Of note, 83.8% of units in our survey placed the car-seat on the floor (~30 degrees) rather than more upright in a seat.
The 2006 Cochrane review of ICSCs found no eligible randomised controlled trials and concluded that further studies were required to determine if ICSCs accurately predict risk of clinically significant adverse events. Schutzman compared an ICSC and polysomnogram (PSG). The ICSC negative predictive value was 0.45 when compared with PSG. They concluded that although less time consuming, the ICSC is not a reliable substitute. However, current ICSCs are time consuming. In a previous study we performed 181 ICSCs over 18 months. Each ICSC observation period was 120 minutes, which totaled 362 hours (30.2 working days) of nursing time. Thus, implementing a national policy that advocates ICSC would impact on nursing staff and may have a significant financial impact on neonatal units.
This is an important problem. Car-seats are vital and 71% effective in reducing infant fatality in road traffic accidents. However, car- seats are frequently observed to be used inappropriately; Callahan reported infants spending a mean of 5.7+/- 3.5 hours per day in a car-seat or similar sitting device. Bamber identified 14 car-seat associated deaths; 70% occurred whilst the seat was being used inappropriately or outside the car. In a recent review, Davis discusses observations of infants in the semi-upright position and the continued unanswered questions regarding ICSCs.
Our survey highlights that significant nursing time is being spent on performing ICSCs in UK units in disparate ways. At present there is not enough evidence regarding testing or how to interpret results. Therefore, education of parents about appropriate use of car-seats must remain paramount whilst further research establishes the appropriate use of ICSCs in UK hospitals.
1. Arya R, Williams G, Kilonback A et al. Is the infant car sear challenge useful? A pilot study in a simulated moving vehicle. Arch. Dis. Child. Fetal Neonatal Ed. 2016.doi:10.1136/archdischild-2016-310730.
2. Bull M, Agran P, Laraque D et al. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge. Pediatrics. 1999;104:986-987.
3. N Joffe, J Hall (2006) Limiting the risks of apnoea and bradycardia in low birth weight infants using car seats.. Journal of Neonatal Nursing 12, 91-96.
4. Bhojani S., Desai P., Skeoch C. Car seat challenge - the current practice. Infant 2008; 4(6): 211-13.
5. Pilley E, McGuire W. Pre-discharge "car seat challenge" for preventing morbidity and mortality in [preterm infants. The Cochrane Library 2008 Issue 3.
6. Schutzman DL, Salvador A, Janeeczko M et al. A comparison of the infant car seat challenge and the polysomnogram at the time of hospital discharge. Arch Dis Child Fetal Neonatal Ed 2013; 98: F411-F415.
7. Towler R, Eastwood R, Ballentyne B, Arya R. The car seat challenge - 18 months experience in a district general hospital. Arch Dis Child Fetal Neonatal Ed 2013; 98: F411-F415
8. Callahan CW, Sisler C. Use of seating devices in infants too young to sit. Arch Pediatr Adolesc Med. 1997 Mar;151(3):233-5.
9. Bamber AR, Pryce J, Ashworth MT et al. Sudden unexpected infant deaths associated with car seats. Forensic Sci Med Pathol. 2014 Jun;10(2):187-92.
10. Davis NL Screening for cardiopulmonary events in neonates: a review of the infant car seat challenge. Journal of Perinatology (2015) 35, 235-240.
Conflict of Interest:
Response to the article by Zanardo et al
We read with interest the article by Zanardo et al (1). The authors found a lower pre-ductal SpO2, a higher hearth rate (HR) and hematocrit in term infants born by cesarean delivery (CD) compared to those born by vaginal delivery (VD), similarly to the findings by Dawson et al (2) but not confirmed by others (3). The authors did not mentioned if a different management of cord clamping was performed between vaginal and cesarean delivered newborns, as the higher hematocrit at birth found in the VD group suggests. In fact, hematocrit at birth, in term newborns, seems not to be significantly influenced by the mode of delivery (4). In this study, a delay in cord clamping (DCC) in VD newborns comapred to CD could have determined a better neonatal adaptation in the formers and explain the differences in HR, SpO2 and neonatal hematocrit described by the Authors. In animal models, cord clamping before the onset of spontaneous breathing resulted in lower right and left ventricular output, slower reduction in pulmonary vascular resistance, a longer period of right-to-left shunt through the ductus arteriosus and higher HR in the minutes after delivery. Smit et al (5) demonstrated that healthy VD newborns with DCC have higher SpO2 and lower HR in the first minutes of life compared to current reference ranges (2). We believe that the influence of delayed cord clamping, a standard practice when resuscitation in not required, should be further investigated in term and preterm newborns delivered by elective cesarean section.
1. Zanardo V, Cengio V, Parotto M, et al. Elective caesarean delivery adversely affects preductal oxygen saturation during birth transition. Arch Dis Child Fetal Neonatal Ed. 2016 Jul;101(4):F339-43. 2. Dawson JA, Kamlin CO, Vento M, et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 2010; 125: e1340-7. 3. Ying-Chun Lu, Chih-Chien Wanga, Chuen-Ming Leed, et al. Reevaluating Reference Ranges of Oxygen Saturation for Healthy Full-term Neonates Using Pulse Oximetry. Pediatr Neonatol 2014; 55:459-65. 4. Glasser L, Sutton N, Schmeling M, et al. A comprehensive study of umbilical cord blood cell developmental changes and reference ranges by gestation, gender and mode of delivery. J Perinatol 2015; 35: 469-475 5. Smit m, Dawson JA, Ganzeboom A, et al.Pulse oximetry in newborns with delayed cord clamping and immediate skin-to-skin contact. Arch Dis Child Fet Neonat Ed 2014; 99:F309-F314.
Conflict of Interest:
How a Belgian daily paper informed its readers about the contents of the review on waterbirth
Le Soir, one of Belgium's leading French language newspapers (1), headlined the front page of its 23 May 2016 edition with "Birth in water: a dangerous new fashion." Page 6 was devoted to the review by Taylor et al; the subtitle said "New study underlines the dangers of drowning and pulmonary infection for babies; no benefit from this fashionable birthing technique". I was asked that afternoon, in my capacity of adviser to the Belgian French-speaking maternal and child welfare agency "ONE" (2) to provide an answer to a parliamentary question on ONE's response to women about the reported risks of waterbirths. My answer to the parliamentary question was that "no, there is no new evidence that waterbirths present an increased risk to babies." However important questions remain about how a serious newspaper arrived at such a distortion of the content of the review by Taylor et al. I offer three possible causes:
- Translation issues: the paper in ADC-FN said that "no definitive evidence" was found. This scientific statement was translated as "the study underlines the dangers of [...]" - The British RCOG and RCM have clearly established standard procedures for waterbirths whereas in the US ACOG recommends that waterbirths are limited to experimental cases. It may be that Belgian obstetricians are more familiar with US guidelines. - It is possible that the wording of the Reuters press release, quoting an email from one of the authors "[...] my advice is to wait until there is more convincing evidence of safety before having the actual delivery in water," contributed to the biased representation of the paper in Le Soir (3). Waterbirths are not in fact a new fashion or fad in Belgium. There is a pioneering hospital in Ostend which has been doing it for over 30 years (4).
Answering the parliamentary question accurately and with a fast turn- around was made possible thanks to the efficiency of JISCMAIL (the academic midwifery list) and I would like to thank them here for their help.
(1) Le Soir (Belgian daily newspaper http://journal.lesoir.be/ accessed 15/6/16 (2) Office de la Naissance et de l'Enfance http://www.one.be/ accessed 15/6/16 (3) Reuters press release http://www.reuters.com/article/us-health- pregnancy-water-birth-idUSKCN0XW1QT accessed 15/6/16 (4) Sint Jan hospital in Ostend http://www.azsintjan.be/materniteit- hs/bevallen/bevalling/onderwaterbevalling.aspx accessed 15/6/16
Conflict of Interest:
Re: Handheld Doppler use for measuring newborn HR has been described in the literature
We thank Dr Hutchon for his interest in our article and acknowledge his contribution to developing this technique of measuring heart rate rapidly and efficiently in newborns. We were particularly interested to hear of his experience with a Doppler that displays an averaged heart rate. We can see that having a displayed rather than counted Doppler heart rate would be highly practical in the delivery room providing that it is accurate, able to detect heart rates of <60bpm and has a suitably short averaging time. During our study we found that counting the audible Doppler sound was considerably more accurate than using the displayed heart rate provided by our Doppler machine Hadeco Smartdop 45(Hadeco--2-7- 11 Arima, Miyamae-ku, Kawasaki, 216-0003, Japan) (1) and cannot find other published data to the contrary. We also agree that there are clearly practical and ergonomic advantages to having a hands free transducer as has been described by Dr Hutchon, particularly if this can be used with a Doppler that is used for fetal heart rate monitoring and therefore already present in the delivery room.
We think that the focal depth of the probe is likely to have an impact on the accuracy of the device given the variation in size of the neonatal population and found that our 8MHz probe was more accurate in smaller babies <1.5kg (1). We found that while it has been shown that the using a 2MHz probe is effective in detecting the heart rate in newborns over 35 weeks gestation in the delivery room (2), we wonder if the focal depth of 10cm of a 2MHz probe might make it difficult to obtain accurate measurements in smaller preterm newborns and feel that this should be a direction of further research.
1. Dyson A, Jeffrey M, Kluckow M, Measurement of Newborn Heart Rate Using Handheld Doppler ultrasound, Arch Dis Child Fetal Neonatal Ed doi:10.1136/archdischild-2016-310669
2. Goenka S, Khan M, Koppel RI, Heiman HS. Precordial Doppler Ultrasound Achieves Earlier and More Accurate Newborn Heart Rates in the Delivery Room. Pediatric Academic Societies and Asian Society for Pediatric Research 2014; 590p.
Conflict of Interest:
Re:End of Life Decisions - Do we make them wisely?
Reply to End of Life Decisions - Do we make them wisely?: End of life decisions: How do we improve process? We thank Dr Cohn for his response to our paper and for voicing the issues it raised for him. Certainly one of the objectives of the study was to explore whether there were differences in approach to similar medical disorders in NICUs across Canada. We hoped that our finding of differences in what appear to be medically similar disorders would cause physicians and teams to reflect on how they come to EOL decisions and why variability exists. We agree that the working environment of an NICU may be a major factor in such decisions and defined the term 'ethical culture' of an NICU as the prevailing ethical consciousness and sensitivity to moral issues in an NICU. This, we believe is understood by the health care professionals as the readiness to engage in ethical discourse, the respect given to diverse views and values, the past experience of the unit and the awareness of the group as to the normative boundaries of deviation in ethical decision making. Although we, together with Dr Cohn, can only speculate that this 'culture' does have a strong influence on individual and team behavior, we were not able to probe this further via the design of our study. Only with very detailed, multidisciplinary (including parental perspectives) description of individual decisions one may be able to uncover how decisions are derived and to what degree they are a manifestation of "this is the way we do things here". As to the concern that consensus may have been achieved in the face of junior members of the team or even parents feeling unable to voice dissent, we specifically asked each responsible neonatologist to comment on the ease of the consensus-building process. We trustingly accepted their description on a spectrum of difficulty. As to the concern of how each individual deals with medical uncertainty, we hope to explore this aspect in a deeper analysis of the study findings. What we cannot agree with is Dr Cohn's "solution" that "ethics panels" judge these matters. It is not clear what is envisaged but a spectrum of bioethics committees and consultation services do exist in North America and elsewhere. Such committees may be decision making or more likely (certainly in Canada) more procedurally oriented in helping teams elucidate values, preferences, and the rightful voices to be heard to ensure fair process and help teams determine the ethical defensibility or vulnerability of different options. There may be other committees in which panels judge decisions but in Ontario this would only come into operation when intractable differences exist between parents and the team as to the best interest of the newborn infant. Here the Consent and Capacity Board can be called into action when the parents' role as substitute decision makers is questioned or the parents seek an alternate pathway to resolution of difference with the team. We firmly believe the safeguards Dr Cohn seeks remain in the integrity of neonatal physicians, parents and teams deriving decisions by open sharing of values, clarification of issues, moral reasoning and negotiation towards consensus (with bioethics consultation when necessary).
Authors: Jonathan Hellmann,1 Prakesh S Shah2 1 Department of Bioethics and Division of Neonatology, Hospital for Sick Children, Toronto 2 Department of pediatrics, Mount Sinai Hospital, Toronto.
Conflict of Interest:
Handheld Doppler use for measuring newborn HR has been described in the literature
We read this article with considerable interest as it confirms that Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate within seconds of birth, much earlier than is possible with oximetry and much more reliably than with auscultation. As the authors state "Handheld Doppler use for measuring newborn HR has been described in the literature" (by Goenka et al and by Hutchon) "but needs further investigation before being used clinically.". Dyson et al chose to use a Hadeco Smartdop 45 (Hadeco--2-7-11 Arima, Miyamae-ku, Kawasaki, 216-0003, Japan), which is a bidirectional handheld Doppler usually used for measuring arterial and venous blood flow in the extremities although it can also detect a fetal HR. In 2014 we demonstrated the use of a readily available and low cost dedicated fetal doppler machine and found the 2mHz probe readily detected the neonatal heart rate when placed on the chest(1). We reported on the Contec Sonoline C2 Pocket Fetal Doppler which also provides a digital display of heart rate and records the signal for subsequent computer download, and documentation and review.
We have also shown that if the transducer is separated from the hand held probe of the machine and connected with light flexible wiring, the lightweight transducer can sit on the neonate's chest held in place simply by the surface tension of the ultrasound gel. This allows hands-free use and avoids the risk of excessive pressure by a handheld probe on the neonate's chest. The position of the transducer on the chest is not critical and can easily be adjusted. By aligning with the skin the transducer automatically scans at 90 degrees.
Precordial Doppler Ultrasound (PDU) can be readily adapted to provide a measurement of the neonatal heart rate at caesarean section without compromising the sterile surgical field. The Doppler machine is connected to a bluetooth transmitter and placed inside a sterile polythene bag ensuring that transducer is coated in ultrasound gel and in contact with the wall of the bag. The transducer can then be handled by a member of the scrubbed team and applied to the neonatal chest through a further application of ultrasound gel. The signal is received by a matching bluetooth receiver outside the sterile field. This can be used to provide an audible signal to the neonatologist and team and recorded for documentation and audit.
For the preterm neonate at risk of hypothermia it is important to avoid exposure of the skin and PDU can be carried out through the recommended polythene wrap without the exposure of the neonatal skin required by ECG or oximetry.
Although we reported on the Contec Sonoline C2 Pocket Fetal Doppler, other machines without a recording facility have been shown to be as effective. After a few minutes when oximetry is functional the PDU becomes redundant.
Goenka S, Khan M, Koppel RI, Heiman HS. Precordial Doppler Ultrasound Achieves Earlier and More Accurate Newborn Heart Rates in the Delivery Room. Pediatric Academic Societies and Asian Society for Pediatric Research 2014; 590p.
Hutchon DJR. Technological Developments in Neonatal Care at Birth. J Nurs Care 2014; 3: 218.
Conflict of Interest:
Re: Water births: adverse events for the baby are rare but devastating
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. 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'.
 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.
 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
Conflict of Interest:
Re: Current debate about the limit of viability: the neglected majority
Neonatal mortality in poor countries
We appreciate Dr. Berger's astute observation that most of the babies in the world do not have access to neonatal intensive care. His statistics underestimate the extent of the problem. Around the world, 7 million infants die each year. Most die of diseases that are preventable or treatable. Their deaths are due to lack of access to the most basic medical care. This is not unique to premature babies. Most health outcomes are better in wealthier countries. This is a serious problem of distributice justice.
We would suggest, however, that resource allocation decisions in both poor countries and rich consistently favor adults and older children over neonates. The systematic devaluation of neonates, prevalent in high- income countries, also exists in emerging economies. For example, the Disease Control Priorities Project, an ongoing effort to produce evidence- based analysis and resource materials to inform health policymaking in developing countries, suggests that the death of a 20 year old is worse than the death of a neonate: "An individual life acquires value only as it acquired self-awareness [...] an individual life acquired value as it develop bonds with others." An Institute of Medicine (1985) review of vaccine development priorities judged that the prevention of a death at age 20 should be valued at about two times the value of preventing an infant death. Some studies suggest that the lives of older people are worth three or four times the value of the life of a baby.
Our comment focused on the data from a study of NICU decisions in France. We suspect that we would find a parallel phenomenon at a different point on the cost/age curve in lower income countries. It seems unlikely to us that the solution to infant mortality in poorer countries is to let more babies die in richer countries. Instead, the solution is to insist that, throughout the world, babies' lives should be valued as highly as those of adults and older children.
1. Jamison DT, Shahid-Salles SA, Jamison J, Lawn JE Zupan J. Incorporating deaths near the time of birth into estimates of the global burden of disease. In Jamison DT, et al (Editors) Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): World Bank; 2006.
2. Institute of Medicine. Committee on Issuees PfNVD. Division of Health Promotion and Disease Prevention. New Vaccine Development: Establishing Priorities. The National Academies Press, Washington, DC. 1985.
3. Johannesson M, Johansson PO. Is the valuation of a QALY gained independent of age? Some empirical evidence. J Health Econ. 1997 Oct;16(5):589-99
Conflict of Interest:
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