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In our efforts to prevent children limping from developmental dysplasia of the hip, we stumble towards some better understanding of ways in which we can screen for this condition without creating unacceptable early over-treatment, yet demonstrably reducing late detection and operative treatment. This month we have two papers that move the debate forward: Roovers et al report the outcome of an innovative strategy using universal routine ultrasound, but after the neonatal period; the results are mixed and this is certainly not the definitive last word on the subject. In a complementary paper, Gardner et al demonstrate that determining the need for splinting by early ultrasound does not result in excess maternal anxiety, in contrast to routine early splinting. This adds to the strength of the MRC Hip Trial result that selective treatment, determined by ultrasound examination of clinically abnormal hips, can reduce the need for abduction splinting without increasing the burden of late detection and surgery.
See pages 17 and 25
FASHIONS IN THERAPY: ETAMSYLATE AND IBUPROFEN
In neonatology, as in medicine at large, fashions and therapies come and go. Etamsylate is out, ibuprofen may soon be in. The story of etamsylate is interesting, and is nicely summarised in the perspective that accompanies the report of Schulte et al on the developmental outcome of babies in the etamsylate trial. In contrast, ibuprofen is being extensively investigated to ascertain whether, if it is genuinely as effective as indometacin, it is any less likely to harm babies. The paper by Naulaers et al gives further reassurance that ibuprofen probably does not affect the cerebral circulation in the ways that indometacin certainly does. What we still don’t know is whether ibuprofen is as effective and safe (or unsafe) as low-dose, long-course indometacin.
See pages 3, 31, and 75
You might have thought the last word on antenatal steroids had been spoken, but not at all. Foix-L’Helias et al present an intriguing observational study that suggests, but does not prove, that the effectiveness of antenatal steroids might be related to the cause of preterm birth. This is certainly biologically plausible, but it is unlikely to affect the clinical pattern of antenatal steroid use. The paper by Burguet et al suggests a similar complex interaction with maternal cigarette smoking. Neither study suggests that antenatal steroids will go out of fashion: their evidence base is far too solid.
See pages 41 and 46
Here’s a drug that manages to be both fashionable and controversial. Heikkinen et al present observational data to suggest that 15 infants need to be treated to prevent one admission with respiratory syncytial virus (RSV) bronchiolitis in Finland. Although they found lower rates of admission among ex-prems than have been reported by others, they suspect palivizumab is seldom indicated either clinically or economically. An even more direct challenge to the palivizumab fashion comes from Bala et al, who present data in a research letter from Cork in the Republic of Ireland. I had not previously come across RSV as an acronym for Reduce exposure, no Smoking, Very good hand washing, but I like it and will use this myself.
See pages 64 and 92
HYPEROXIA AND HYPOCARBIA
Both may be bad for the neonatal brain, if a baby has suffered an asphyxial insult. Although Klinger et al found this association in a retrospective cohort study, it is all too plausible, and potentially important. Since persistent pulmonary hypertension (PPHN) often complicates asphyxia, some clinicians may still be tempted to flood the baby with oxygen, and/or induce hypocarbia to raise the pH, as strategies to reduce pulmonary vascular resistance. These data sound a cautionary note, and perhaps argue for the early use of more modern (and fashionable) therapies such as nitric oxide where PPHN is a concern.
See page 49