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HEEL STICKS: RETHINKING A LONGSTANDING PRACTICE
One of the many painful indignities that babies have to put up with in the intensive care environment is heel sticks for blood sampling. We have all been brought up to obey the principle that there are “safe” and “unsafe” parts of the heel, with the “unsafe” midline being so because the distance from the skin surface to the calcaneus was thought to be too small. How refreshing that Arena et al have revisited this dogma, bringing to bear some modern ultrasound technology to make direct in vivo measurements, and finding that the dogma is simply wrong. This paper deserves to become widely known and cited, and to influence practice among all who use the heel as a source of blood for analysis, including neonatal nurses and midwives.
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GLUCOSE CONCENTRATIONS: RETHINKING THEIR MEASUREMENT
Can we move on from heel sticks in the measurement of blood glucose concentrations? These measurements are important, but for many babies they can be a major source of distress and discomfort. Beardsall et al report on the development of a technology that might prove important both in research and in routine clinical practice, and could supplant heel sticks for some babies. The continuous glucose monitor sensor is placed subcutaneously, so it measures tissue glucose rather than blood glucose: arguably, this is the more relevant value, but much work will have to be done to understand what it means and how it relates to blood glucose in health and disease. Nevertheless, the continuous sensor may come to represent a real advance in the detection and management of disordered blood glucose homeostasis in neonates.
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QUESTIONING THE WAY WE USE GENTAMICIN…
One would have thought that gentamicin had been around sufficiently long that we had sorted out how best to use it, but it has only been in the last 10 years that the possibility of using it more sparingly, but just as effectively, has been properly explored. In neonatal care this is of particular importance, not least because the promotion of expensive third generation cephalosporins has often focused on the “dangers” of aminoglycosides and the need to measure concentrations to avoid toxicity. The meta-analysis that Nestaas et al have done shows that a more parsimonious approach is just as effective and possibly safer than shorter dosing intervals. Indeed many babies for whom antibiotics are started as a precaution, only to be discontinued when blood cultures are negative, would only ever need a single dose of gentamicin, and no measurement of levels. Simple, effective, less work, safer, and very inexpensive.
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… AND ERYTHROMYCIN
How nice it would be to see resolution of the controversy about the role of erythromycin as a prokinetic agent. Alas, unlike Nestaas et al, Patole and colleagues could not find enough consistency between trials to perform a valid meta-analysis. This is a shame, given that encouraging feed tolerance might be valuable in some babies and cisapride is no longer available (and probably ineffective as well). Meta-analysis of small trials may not be the best way forward here: surely it would be much better for someone to plan a really big and definitive trial to answer the question once and for all.
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THE DILATED RENAL PELVIS: HOW BIG BEFORE WE SHOULD WORRY?
To answer this we have a short but important paper (still on the theme of doing things differently). Plant et al report the outcome of babies with antero-posterior renal pelvis dilatation up to 15 mm, presenting reassuring data that suggest there is no higher rate of either urine infection or renal scarring than in the background population. So it is hard to justify enthusiastic postnatal investigation for reflux where fetuses have moderate dilatation. More good news for babies.
See page 339
Having served for two years as the Deputy Editor with responsibility for the Fetal and Neonatal edition, I step down this July and return to my previous role as an associate editor. I would like to take this opportunity to thank Ben Stenson and Ann Stark, the current associate editors for F&N, for their support; Howard Bauchner, our Editor-in-Chief, for keeping an eye on me with great discretion, and the Archives technical staff who manage us amateurs with such professionalism and good humour. Ben takes over as Deputy Editor, and I wish him every success in the role.