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HEALTHY BABIES IN CAR SEATS…
Two reviews this month examine issues of the transport of babies: ex-prems in car seats and any sick baby being transported by fixed wing aircraft. The first is the more contentious, since much of the belief about the potential for harm has been derived from physiological measurements rather than empirical observation of infants directly harmed by being transported in car seats, as is clearly demonstrated by the citations in Pilley and McGuire’s review. However, as more fragile babies are discharged earlier into home care programmes, not just with nasal oxygen but increasingly with tube feeding, it is important to try to predict possible hazards before they come to light because babies have suffered harm. This means it is very important to develop adequately validated tests, and it is here that the problems arise.
See page 452
…AND SICK BABIES IN AIRCRAFT
Conversely, safe air transport requires adherence to the certification procedures of several regulatory authorities, and has more to do with creating safe systems than with individual physiological responses. Although these issues have been addressed and overcome in many other countries, in the UK at present only Scotland has developed a fixed wing air transport service for neonates. Elsewhere in the UK the potential benefits of fixed wing transfers are probably most relevant for babies needing extracorporeal membrane oxygenation, since none of the four UK centres are handy for the south west peninsula and south Wales. Any neonatal service in England or Wales that is contemplating fixed wing air transport will be able to learn valuable lessons from the Scottish experience.
See page 456
TO OSCILLATE OR VACILLATE?
Thome et al have updated the recent Cochrane reviews of high frequency oscillatory ventilation with a further three trials. They conclude that optimising conventional ventilation seems to be as effective as using oscillation for the primary treatment of preterm babies with hyaline membrane disease. Whether all readers, on examining the plots, will agree with this conclusion or vacillate between viewpoints, may become apparent on our rapid response web pages. It may be that modern treatment with antenatal steroids and early surfactant means that the added value of oscillation is genuinely much smaller than it would have been when the respiratory mortality of preterm babies was much higher. Importantly, the authors do not address the issues either of term babies in respiratory failure, the use of oscillation for rescue treatment, or oscillation in special situations such as pulmonary haemorrhage.
See page 466
KEEP WARM – STAY CLOSE
Healthy term babies, during their first postnatal days, are often stretched to their physiological limits in trying to maintain their temperature, unless they are in close thermal contact with their mothers. So concludes a very interesting paper by Fransson et al that is relevant to maternity units all over the world. The World Health Organization has long recognised the importance of neonatal hypothermia as an issue in international child health, and in the developed world it is still a common avoidable hazard of the early neonatal period. Yet the remedy is so simple.
See page 500
DRUGS, OLD AND NEW
Antenatal steroids are old hat, but we are still learning about their effects beyond the lungs and the brain. Dimitriou et al examine the effects on water and salt balance, concluding that effects on the maturation of the skin, and perhaps also renal perfusion, play a part in improved water and salt homeostasis. Sildenafil, itself a relatively new drug, continues to find new uses. So Chaudhari et al report a baby in whom sildenafil appeared to play an important part in the management of pulmonary hypertension. There will need to be some randomised controlled trials of this drug in babies, the sooner the better.
See pages 509 and 527