eLetters

700 e-Letters

  • Response to Lack of data/evidence to back recommendations for significant change of practice

    Dear Editors,

    Archives of Disease in Childhood

    We thank Dr. Khashu for his comments on our article Metabolic bone disease of prematurity: causes, recognition, prevention, treatment and long-term consequences.

    Below we provide responses to his comments.

    1. The review is suggesting significant change to current UK practice but does not review any data to suggest that current practice is causing secondary hyperparathyroidism ( apart from an anecdotal case discussed). While the recommendations may have merit based on physiology , it seems suboptimal to recommend a significant change of practice without any data to clearly show that current practice is causing a problem.

    Response: Our suggested approach on management of Metabolic Bone Disease of Prematurity (MBDP) is underpinned by pathophysiology of this disorder. The case discussed is not an anecdotal case but represents many such cases referred to our service. In all age groups calcipaenic state (Calcium deficiency) causes increase in PTH secretion while phosphopaenic states (inadequate Phosphate absorption from diet or primary urinary phosphate leak) do not. Therefore our approach is to measure PTH to guide mineral supplementation and more specifically to maintain appropriate oral Calcium (Ca) to Phosphate (PO4) ratio for adequate mineralisation of bones. It is our observation that PTH is not routinely measured in MBDP but, there are publications where PTH has been measured...

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  • The need for adequate methodology to study bronchopulmonary dysplasia using lung ultrasound

    In response to: "Early lung ultrasound affords little to the prediction of bronchopulmonary dysplasia".

    We read with great interest the article by Dr Woods et al (1) that adds evidence to recent, large multicenter studies on lung ultrasound (LUS) as a predictive tool for bronchopulmonary dysplasia (BPD) (2-4). These studies, performed on a total of more than 600 infants, stem from a validated scoring system whose signs represent a progressive decrease in lung aeration in standardized ultrasound views (5). Notably, this approach is also well established in adult critical care (6).
    The grading system adopted by Dr Woods and coworkers, has not been validated and its highest scores do not correspond to less air in the lung and therefore to a more severe pulmonary disease. Also, rather than the conventional sum of scores, Dr Woods et al. calculate a two-decimals mean score that may undermine the technique discrimination. None of these choices have ever been made for any other LUS scores, neither in neonates nor in older patients, despite ultrasound semiology and statistics needed to evaluate the predictive power are always the same (6). These factors may undermine the LUS prediction power for BPD.
    Moreover, the authors needed a full ROC procedure to perform a formal diagnostic accuracy analysis, but even then, its strength would have been questionable with only 7 out 96 infants suffering from moderate-to-severe BPD (7) as target condition. This smal...

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  • Re: Neonatal videolaryngoscopy as a teaching aid

    Dear Editor,
    As an emerging medical education researcher with an interest in video, and as a practising anaesthetist, I read O’Shea et al’s article on neonatal videolaryngoscopy[1] with great interest. I applaud and encourage the authors for their interest in medical education, which I believe underpins medicine’s ability to do the best for our patients. However, I wish to draw attention to two points that I believe should be addressed for future papers covering this topic.
    1. The authors in this paper use the words “conventional laryngoscope blades” to describe direct laryngoscopy without video feed. This assumes that what is conventional for the authors is conventional for the audience. In this paper I had assumed that “conventional” to a neonatologist would be a Miller (straight) blade, and that the video laryngoscope blade was a Macintosh blade because it was curved. However, after reviewing Kirolos and O’Shea[2], I recognised that both types of blade used in the study were possibly Miller blade variants, although I cannot know for certain. I feel it would be better in future papers that the term “conventional largynoscope blade” be avoided and the specific type of blades be specified.
    2. Grounded theory is cited as the methodology used for the free text response analysis. I wish to point out that there are several variants of grounded theory with different methodologies following the divergence between the two original authors, Glasser and Strauss[3]...

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  • A reply to: “Parenteral nutrition for preterm infants: Correcting for arachidonic and docosahexaenoic acid may not suffice” by Bernard et al.

    A reply to:

    “Parenteral nutrition for preterm infants: Correcting for arachidonic and
    docosahexaenoic acid may not suffice” by Bernard et al. regarding the publication:
    Frazer LC, Martin CR. Parenteral lipid emulsions in the preterm infant: current issues
    and controversies. Arch Dis Child Fetal Neonatal Ed. 2021 Jan 29: fetalneonatal-
    2020-319108. doi: 10.1136/archdischild-2020-319108. Epub ahead of print. PMID:
    33514630.

    Lauren C. Frazer1,2, Camilia R. Martin2,3,4

    1Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
    2Department of Pediatrics, Harvard Medical School, Boston, MA, USA
    3Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, MA, USA 4Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
    Correspondence: cmartin1@bidmc.harvard.edu

    Word Count: 216

    Keywords: arachidonic acid, docosahexaenoic acid, lipid emulsions, preterm infant

    Dear Editor,

    We would like to thank Bernhard and colleagues for their thoughtful letter “Parenteral nutrition for preterm infants: Correcting for arachidonic and docosahexaenoic acid may not suffice” written in response to our review. The authors of the letter raised important issues regarding the lack of data surrounding the optimal balance of arachidonic (ARA) and docosahexaenoic acid (DHA) that should be administered...

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  • Letter/Comments to Editor on paper “Necrotizing enterocolitis in newborns receiving Diazoxide” published in ADC Fetal Neonatal Ed 2020; 0: F1-F5.

    Dear Editor,
    We read with interest the paper from our colleagues in Toronto on the possible association between the use of diazoxide treatment for hypoglycemia and the onset of necrotizing enterocolitis (NEC). We wish to share our single-center experience on diazoxide and we beg to differ with the authors. Our NICU is a tertiary care center from Midwest Canada that has the least incidence of NEC across all the centers in Canada as per Canadian Neonatal Network (CNN) database. For nearly 2 decades, we have been using diazoxide in our unit, in the treatment of persistent neonatal hypoglycemia among intra-uterine growth retardation, small-for-gestational age, infant of a diabetic mother, and transient hyperinsulinemic hypoglycemia neonates.
    Our neonates are comparable to Toronto population, with prematurity, and other risk factors. We have used both moderate doses (5-10mg/kg/day) and higher doses (maximum up to 15mg/kg/day) in 3 divided doses in our practice. Over the last 10 years (between the years 2010-2020), 164 neonates have received diazoxide treatment in our NICU and none of them have had NEC as a complication of treatment during or after the therapy. Common side-effects of diazoxide in infants and children include nausea, vomiting, loss of appetite, headache, dizziness, stomach pain or upset, diarrhea, changes in sense of taste, hypertrichosis (especially in women and children), anxiety, weakness, pruritus or skin rash. We agree as the authors mentioned on...

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  • Blood pressure trials in preterm infants

    We read with interest results from the Hypotension in Preterm Infants (HIP) trial by Dempsey et al.1 Unfortunately this multicentre randomised controlled trial (RCT) could not provide robust conclusions. Enrolment was limited to 58 of the planned 830 infants, 7% of those screened, attributed to strict inclusion criteria and recruitment challenges. This along with high inotropic usage in the restrictive group limits study power and generalisation.
    Some clarification would be useful. The CONSORT diagram should label the two study arms, where imbalance in numbers not receiving the allocated intervention (6/29 vs 1/29) may warrant further analysis. The proportion with invasive lines seems low, exact reasons for exclusion/non-inclusion could be detailed, and maximum age at enrolment given.
    In our published RCT 2, three blood pressure (BP) intervention protocols were compared (BP below gestational age as in HIP, more active, or less active). This single centre pilot study randomised 60 infants <29 weeks, 45% of those screened and 100% of target recruitment, with invasive BP acquired every 10 seconds for a week. The HIP trial suggests their hypotension rate of 25% is low but without BP acquisition details, comparison is difficult. Their figure showing BP following dopamine or placebo requires data variability measures.
    In our study, we found higher BP was associated with lower EEG discontinuity.3 The HIP study4 did not stipulate commonly used end-organ p...

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  • Is MRSOPA algorithm a cause for concern?

    The reported findings that some MRSOPA corrective steps actually made matters worse (1) should be a wake-up call to those teaching neonatal resuscitation (NRP), especially as many components of the algorithm are not evidence based and have never been validated.
    I wish to briefly report on two adverse outcomes which occurred on Vancouver Island at separate sites and at separate times, both following the introduction of the MRSOPA algorithm. Both infants were delivered at term by C Section under maternal general anesthetic. One was a preplanned elective C Section, the other for failure to progress with no concerns with the fetal heart tracing. There was no meconium present in the amniotic fluid. Both infants were depressed at birth but with palpable heartbeat. For both infants, there was difficulty in establishing effective ventilation. When intubation was eventually achieved, there was no colour change with CO2 detector, resulting in removal and resumption of bag-mask ventilation. The Neopuff (Fisher & Paykel) T piece was used in both cases and pressures were initially set at 20/5cm H20, as per NRP guidelines. However pressure increases occurred late. One baby had completely normal arterial cord gases. The other had an arterial cord pH 7.17.
    Following a prolonged but eventually successful resuscitation, both infants were cooled for 72hours. One infant required transport to a level 3 site and subsequently did well. The other child did poorly. That child now...

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  • Letter/Comments to Editor on paper “Necrotizing enterocolitis in newborns receiving Diazoxide” published in ADC Fetal Neonatal Ed 2020; 0: F1-F5.

    Dear Editor,
    We read with interest the paper from our colleagues in Toronto on the possible association between the use of diazoxide treatment for hypoglycemia and the onset of necrotizing enterocolitis (NEC). We wish to share our single-center experience on diazoxide and we beg to differ with the authors. Our NICU is a tertiary care center from Midwest Canada that has the least incidence of NEC across all the centers in Canada as per Canadian Neonatal Network (CNN) database. For nearly 2 decades, we have been using diazoxide in our unit, in the treatment of persistent neonatal hypoglycemia among intra-uterine growth retardation, small-for-gestational age, infant of a diabetic mother, and transient hyperinsulinemic hypoglycemia neonates.
    Our neonates are comparable to Toronto population, with prematurity, and other risk factors. We have used both moderate doses (5-10mg/kg/day) and higher doses (maximum up to 15mg/kg/day) in 3 divided doses in our practice. Over the last 10 years (between the years 2010-2020), 164 neonates have received diazoxide treatment in our NICU and none of them have had NEC as a complication of treatment during or after the therapy. Common side-effects of diazoxide in infants and children include nausea, vomiting, loss of appetite, headache, dizziness, stomach pain or upset, diarrhea, changes in sense of taste, hypertrichosis (especially in women and children), anxiety, weakness, pruritus or skin rash. We agree as the authors mentioned on...

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  • Constant or variable flow nCPAP devices.

    Dear Sir or Madam!
    Nasal CPAP is one of the most important therapies in neonatology. Accordingly, the manufacturers of such devices are very interested in gaining market share. Not all of their "sales arguments" correspond to clinical or physical reality. This is why studies comparing different devices are so extremely important.
    The authors claim to have compared three CPAP systems that are referred to as "variable-flow" devices. This refers to CPAP systems that generate their CPAP through one or more jets, corresponding to jet ventilation as it is known in laryngeal surgery. But does the Miniflow CPAP belong in this category? The Miniflow has one inspiratory and one expiratory tube and does not have a jet. Pressure is generated through the expiratory valve of a ventilator. Such CPAP devices are actually called "constant-flow" devices.
    Basically, the division into variable-flow and constant-flow devices is considered very confusing and, above all, physically questionable. However, the terms are very persistent. In any case, however, the statement of the study could be supplemented. It shows not only that there is no difference between variable flow devices, but equally no difference between variable and constant flow devices.
    Yours sincerely,
    Martin Wald

  • Increase of stillbirth and decrease of late preterm infants during the COVID-19 pandemic lockdown

    Ravaldi et al. in their letter raise two points of dispute. The first is linked to epidemiological data and the other to the fact that, according to them, a reduction in gynecological checks during pregnancy did not occur in the lockdown of spring 2020. I appreciate their engagement with the article but I disagree.

    On the first point (epidemiological data), the difference between the data presented by Ravaldi and those indicated by us is linked to the fact that they mistakenly refer to older years. Ravaldi’s 2019 stillbirth is taken from the Italian Statistical Yearbook 2019, which refers to the entire 2016. Our data, obtained from the CEDAP (hospital discharge database, which records perinatal information on all newborns), are instead those of Mar-May 2019 and Mar-May 2020 (3 months of lockdown).
    Furthermore, Ravaldi’s stillbirth data starting from 22 weeks were taken from the ISTAT Reproductive Health document published in 2018, which refers to 2015 data. The authors therefore cannot contest the difference in the results because they are using different data sources. A further analysis (to be published) on larger samples on all births in Lazio confirmed a significant difference between stillbirths in the period March-May 2020 compared to the same months in the years 2017-2019 (3.23 vs 1.83 per thousand, p value = 0.014) . The increase in stillbirths in the first half of 2020 was observed in numerous developed and developing countries as well as in Italy (1-...

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