711 e-Letters

  • The "kinder, gentler" approach revisited


    We read the letter from Noureldein and colleagues with interest. As former members of the NICE guideline committee on neonatal jaundice and individuals who have advised on many medico-legal claims involving kernicterus, we retain our interest in the topic. Thirty years after discussions about a “kinder, gentler” approach (1), the choice of threshold values for phototherapy remains contentious. The Birmingham group question whether the decision to treat babies born at 37 weeks gestation differently from those born at 38-42 weeks was justified. It took many years to appreciate that there was a significant difference regarding the risk of transient tachypnoea of the newborn between babies born at 37 weeks compared with more mature babies (2). Similar information about the risk of kernicterus is never likely to be forthcoming.

    The rationale for treating 37 week gestation babies differently from those born at >38 weeks was based in part on the observation that the less mature group were over-represented in the US kernicterus registry of 1992-2004 (3). Denominator numbers are not available but there were 24 cases at 37 weeks, and a total of 71 at >37 weeks. The new AAP guideline notes that the risk of neurotoxicity from hyperbilirubinaemia is higher at <38 weeks, and with an albumin <3 g/dL (4). The evidence examined for the NICE 2010 guideline consistently showed that a gestational age <38 weeks was associated with an increased risk of hyperbi...

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  • High CLD in nCPAP group despite high use of ANS

    The data in the study [1] support the clinician in practicing heated humidified high-flow nasal cannula (nHF) as a viable alternative method for weaning preterm infants with a median gestational age of 28 weeks. The benefits of nHF include ease of application, earlier introductions of suck feeds, and parents’ satisfaction. While looking at the data, the nasal continuous positive airway pressure (nCPAP) group had more chronic lung disease (CLD) (OR of 0.42, favoring nHF). The question is: why nCPAP group have a significantly higher CLD despite receiving higher antenatal steroids (ANS)? The data is contradictory. ANS should be protective against the development of CLD. The nCPAP group received higher antenatal corticosteroids 48/61 (78%) compared to the nHF group 34/59 (57%). The difference in ANS use was statistically significant (as per online stats (https://www.socscistatistics.com/tests/chisquare2/default2.aspx), the chi-square statistic is 6.1481. The p-value is .013155).

    The second question is regarding the use of nHF at 8 L/min as rescue instead of bubble CPAP of 6 cm. What was the rationale?

    What is CHiPS stand for?

    Reference: 1. Clements J, Christensen PM, Meyer M. A randomised trial comparing weaning from CPAP alone with weaning using heated humidified high flow nasal cannula in very preterm infants: the CHiPS study [published online ahead of print, 2022 Jul 18]. Arc...

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  • Head Growth looking beyond the NICU

    In this study Selvanathan et al [1] showed small birth head circumference (HC) to be associated with poorer neurodevelopment outcome, independent of postnatal illness and white matter injury. They concluded that normalisation of HC during NICU care appears to moderate this risk.

    It was interesting to note that normal/small group had the highest chorioamnionitis (40%), lowest ROP (0) and highest NEC (30%) rates. They also received the highest Energy (kcal/kg/day), median 80. What could be the reason for the HC to regress from normal to small?

    We need to investigate other factors that affect the head growth. The individual factors such as parental bonding and availability, environmental exposure to noise, light and other stimuli may have some role in slowing the head growth.

    Interestingly, in the same issue of ADC, Ni et al [2] have shown poor HC growth in EPICure2 that was unchanged from EPICure, which is alarming.

    1. Selvanathan T, Guo T, Kwan E, et al. Head circumference, total cerebral volume and neurodevelopment in preterm neonates. Arch Dis Child Fetal Neonatal Ed. 2022;107(2):181-187. doi:10.1136/archdischild-2020-321397

    2. Ni Y, Lancaster R, Suonpera E, et al. Growth in extremely preterm children born in England in 1995 and 2006: the EPICure studies. Arch Dis Child Fetal Neonatal Ed. 2022;107(2):193-200. doi:10.1136/archdischild-2020-321107

  • Response to "How to Recognise encephalopathy earlier?"

    We have read with interest the response by Dr. Shabih Manzar on our article. The Thompson score is a clinical score consisting of nine items that are associated with neurologic dysfunction to assess the severity of neonatal encephalopathy (NE) in infants with perinatal asphyxia.[1] There are indeed important limitations that need to be considered; the assessment of infants by use of the Thompson score requires interpretation from the examiner, and the degree of NE may change over time.[2] It should be noted that these limitations are also applicable to other clinical grading tools, such as the modified Sarnat score, which is being widely applied to select infants for therapeutic hypothermia.[2,3] We would like to emphasize that the majority of the infants described in this study was born in a level-II-hospital. Amplitude-integrated electroencephalography (aEEG), another tool to select infants for therapeutic hypothermia, allows continuous monitoring, expert revision and the detection of subclinical seizures, but also requires well-trained staff for correct interpretation and is often not available in these hospitals. By design, the Thompson score did not require extensive training of the observer, which is why it is suitable to be used in smaller hospitals.[1] In a previous study, our study group demonstrated that the Thompson score and aEEG had a similar predictive value for an adverse outcome.[4] We however completely agree with Dr. Manzar that it is of concern that the...

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  • How to Recognise encephalopathy earlier?

    The article by Parmentier et al [1] highlights the role of Amplitude-integrated electroencephalography (aEEG) and early biomarkers in selecting infants for therapeutic hypothermia (TH). They also suggested the role of the Thompson score (TS) in asphyxiated infants. The problem with TS is that it is subjective. It consists of nine clinical signs: tone, level of consciousness, fits, posture, moro reflex, grasp, suck, respiration, and fontanelle, which could change over time [2]. Also, in the data presented by Parmentier et al [1], twenty-one (53%) infants did not have TS performed.

    It was surprising to note that four cases that had moderate neonatal encephalopathy (NE) were not treated with TH despite having seizures within the first 6 hours. The reason for not treatment was rapid recovery. What was the definition of rapid recovery? According to the published flow diagram for NE, the onset of seizure within 6 hours warrants TH [3].

    The definition of perinatal asphyxia used by Parmentier et al [1] was from a study in 2003 [4]. It was defined as an arterial cord blood pH <7.1, Apgar Score <7 at 5 min, or need for neonatal resuscitation. While the analysis was done with pH of < 7 and > 7 [(Table 1) 1]. A pH of 7.1 and Apgar of 7 at 5 min is higher than the definition/criteria used in the TH trial [5].


    1. Parmentier CEJ, Steggerda SJ, Weeke LC, Rijken M, De Vries LS, Groenendaal F. Outcome of non-cooled asphyxiated infants w...

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  • Low dose Diazoxide for Hyper-insulinemic hypoglycemia- Do we agree?

    We read with great interest this article published by Chandran et al. However, we have some critical
    reservations on implementation of low dose diazoxide. The target blood glucose thresholds used for
    management have been taken from Pediatric endocrine society guidelines of 2015, which are based
    on adult neuroglycopenic effects. However, AAP guidelines recommend a lower treatment target of
    <2.2 mmol/l (40 mg/dl) for asymptomatic,<2.5 mmol/l (45 mg/dl) for symptomatic neonates
    during first 48 hours and <3.3 mmol/l (60mg/dl) thereafter (1, 2) . Moreover, in a recent multi-centric
    trial published by Kempen et al; it was concluded that low treatment threshold of <2 mmol/l (36
    mg/dl) was non inferior in terms of neurodevelopmental outcomes at 18 months of age in healthy
    asymptomatic neonates (3) . Hence it is still debatable whether all the neonates being managed for
    hypoglycemia warranted an intravenous glucose infusion therapy and diazoxide.
    Authors have used a combination of starting dose of diazoxide along with hydrochlorothiazide for
    management of SGA neonates; which are known to have a synergistic effect on increasing blood
    glucose levels, hence actual dose of diazoxide required if used alone could have been potentially
    higher in these neonates.
    In the study design the authors have mentioned that this was an observational cohort study,
    however neither the absence of compar...

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  • Therapeutic Hypothermia in Mild Hypoxic Ischemic Encephalopathy

    I agree with Yieh et al [1] that there is an overuse of therapeutic hypothermia (TH) in mild HIE resulting in increased resource utilization. The two main reasons we see this practice are the fear of litigation and scare that infant would later have neurological problems. DuPont et al [2] reported abnormal short-term neurologic outcomes in 20% of newborns with perinatal acidemia and mild HIE not treated with TH. However, in the same study they had 14% of infants that did not receive TH despite the neurological examination consistent with moderate and severe HIE.
    Mehta et al [3] have earlier described overutilization of TH in mild HIE, recommending a robust review of the eligibility criteria definitions, especially the 10-min Apgar score. The subjectivity of TH criteria put the practitioner in a decision dilemma. For example, out of five components of Apgar score, only heart rate assessment is objective. A color score of 1 or 2 can change the Apgar from 5 to 6. Similarly, a slight variation in observer examination in obtaining Sarnat score could change it from mild to moderate. Therefore, using a combination of factors in deciding about TH would be a better approach [4].
    One of the most important criterion for TH is presence of perinatal academia. Recently, Blecharczyk et al [5] have shown the benefits of standardized screening pathway for evaluating abnormal cord gases in neonates at risk for HIE. Following a structured pathway resulted in minimizing unnecess...

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  • Umbilical Venous Line Extravasation

    Kamupira et al [1] presented a case of umbilical venous line extravasation that was confirmed by contrast study. To justify the contrast use they stated, “There is evidence routine contrast use in checking tip positions improves long line positioning (reference 3 on the paper) and British Association of Perinatal Medicine (BAPM) has included this in it's central access guidance (reference 4 on the paper)”. The caveats with this statement are that first umbilical lines are not synonymous to long lines and second that in BAPM executive summary statement there is no mention of contrast use, “The findings of the Working Group recommend that:
    • Any clinical deterioration of a baby in whom a central venous catheter is present should raise the question of catheter-related complications, particularly infection, extravasation and tamponade.
    • All central catheter tips should be positioned outside the cardiac silhouette.
    • An umbilical venous catheter (UVC) tip should ideally be sited at T8-T9 (assuming this lies outside the cardiac silhouette). A UVC tip sited at or below T10 carries a significantly higher risk of extravasation. It may be necessary to use these catheters in the short term, but they should be replaced at the earliest opportunity”.
    In fact, the use of contrast has been associated with hypothyroidism in neonates [2]. UVC misplacements happen either due to the wrong placement or due to the migration of UVC from a safe to wrong position. Th...

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  • Re: Triggered ventilation in neonates
    JH Baumer
    Dear Editor

    The interest displayed in the trigger ventilation trial by Burmester and Petros is welcome.(1) Their letter raises questions about the interpretation of the performance of the Dr�ger babylog 8000, which was used in a minority of infants in the study.

    The trigger sensor device is different, and I agree with their implied statement that as each trigger ventilator performs differently results obtained...

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  • prem birth/taking seroxat
    sarah elvin

    i was taking seroxat(20mg) per day in 2001.i became pregnant and decided that i should stop taking seroxat,as doctors were unable to provide any data to say that it was safe to take during pregnancy.

    several weeks later,after terrible withdrawl(which my doctor refused to put down to withdrawl,just sickness in pregnancy)my daughter was born prematurely at 28 weeks gestation.she was 2lb 4oz and very poorly.we had...

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