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TheFetal and Neonatal Edition looks different this century. The contents will be as strong as ever, ably supervised by Janet Rennie and Peter Hope. Your letters can now be posted on our website—url: www.archdischild.com—to avoid the long delay inherent in bimonthy publication. Any suggestions or offerings for our front cover picture are welcome.
“Baby triggered ventilation” no better than conventional methods
Always committed to randomised controlled trials, neonatologists have been working hard to provide more evidence base for practice. In this issue there are two large trials of patient triggered ventilation. One is a large collaborative study in which almost 1000 preterm babies were randomly allocated to either patient triggered (PTV) or conventional ventilation for treatment of their respiratory distress syndrome (Pp 5-10). The group are to be congratulated for having persevered and achieved such a large trial size.
There was no difference in outcome: air leak remains a problem when babies are ventilated with positive pressure and there were more pneumothoraces in those under 28 weeks of gestation who were allocated to PTV. These results are not just applicable to the South of England; in Liverpool (Pp 14-18) researchers found the same outcome, with air leak still a problem. Where does this leave neonatal PTV? Will it be consigned to the store room along with the Gregory box, or will it still be used for weaning. Or have these studies got it wrong?
No added salt early on for ill preterm babies
Hartnoll and colleagues report the results of a controlled trial in which preterm babies either received routine salt supplementation from the second day of life, or later on (Pp 24-28). The delayed group were given added salt only when they had lost 6% of their body weight. Too much salt too early on meant that the babies “hung on” to their body water, mainly in the extracellular compartment. The waterlogged babies stayed in oxygen longer but grew at the same rate as the babies whose supplementation was delayed. It will be interesting to see if this study results in a widespread change in practice, or if others are already delaying the introduction of sodium. The group given sodium from day 2 received 4 mmol/kg in addition to any “hidden” sodium, and this may reflect protocols in common use already.
A little of what you fancy
The value of minimal enteral feeding, or trophic feeding is well established in neonatal practice as a means of getting the baby's gut to tolerate milk. A study reports that the overall outcome of babies given trophic feeds was better (Pp 29-33). Babies offered less than 1 ml of milk from early on went home earlier, had fewer episodes of infection, needed less oxygen, and grew faster. The benefits of these apparently homeopathic amounts of milk continue to accrue, although the authors do not speculate on why this happens.
Awake intubation and heel prick pain
Anaesthetists working with adults continue to express surprise when they realise that babies are still intubated without routine analgesia and sedation. But the fact remains that most neonatal intubations are done as emergencies. Furthermore, the available drugs have not been evaluated for safety and efficacy in babies. A New York study sheds some light on this topic in the form of a randomised controlled trial of thiopental and a placebo for semi-elective intubation (Pp 34-37). Thiopental made the procedure easier and quicker and enhanced the effects of intubation on heart rate and blood pressure. More work in this area is badly needed, particularly as many intubations are done on the labour ward where thiopental might not be an appropriate choice.
An audit conducted in the Northern Region (Pp 38-41) surveyed 239 UK neonatal units and found that only 37% reported using any sedation before intubation. There is better news on the topical anaesthesia front: a study reports that having shown no effect of EMLA cream on the heel, amethocaine gel did blunt the pain of von Frey hairs on the dorsum of the foot (Pp 42-45). A small step forward.
When hypoglycaemic, Nepalese infants are less able to release (?and use) alternative fuels, particularly when they are male and cold (Pp 52-58).