Sahni and colleagues report that 15 neonates were given an
unspecified non-invasive analgesic prior to circumcision,[1] which may
have been EMLA cream. Test results recorded a significantly elevated heart
rate (HR) and reduced oxygen saturation, indicative of pain.[1] The HR
remained higher than baseline even after the conclusion of the surgery,
suggesting ongoing pain from the tissue damage inflicte...
Sahni and colleagues report that 15 neonates were given an
unspecified non-invasive analgesic prior to circumcision,[1] which may
have been EMLA cream. Test results recorded a significantly elevated heart
rate (HR) and reduced oxygen saturation, indicative of pain.[1] The HR
remained higher than baseline even after the conclusion of the surgery,
suggesting ongoing pain from the tissue damage inflicted. Although the
neonates were restrained in a Circumstraint™ device designed to limit
motion, "excessive motion" was recorded.[1] This suggests that the
neonates may have been severely distressed during the circumcision.
Apparently, it was necessary to subject the neonates to the iatrogenic
pain of invasive circumcision in order to generate the patient motion that
was essential to the success of the study!
EMLA non-invasive topical analgesic ointment may not protect
adequately against the intense pain of invasive circumcision because it
cannot penetrate deeply enough to be very effective.[2]
In our extensive survey of the clinical literature, my associates and
I reported evidence that invasive circumcision pain may be traumatic and
that perinatal circumcision-related trauma may be associated with an
increased risk of self-destructive behaviour in adult life.[3]
Circumcision during infancy or childhood is the recorded stressor in many
documented cases of PTSD.[3-5]
In addition, we reported alarming evidence that neonatal pain,
stress, and trauma may adversely impact on developing neurological
structures.[3] Inadequate pain control in newborns and children is a
matter of continuing concern because of reported long-term consequences
and behavioural changes.[6,7] Circumcision also removes sexual nerve
endings from the penis, which may only adversely affect sexual sensation
and response.[3]
This study was approved by an institutional review board (IRB), which
apparently turned a "blind eye" to the unethical, unnecessary infliction
of pain, trauma, and permanent sexual reduction on unconsenting minors.
Painful surgical procedures in children either should be conducted under
adequate anaesthesia or such procedures should be avoided altogether.[8]
Since currently available methods of pain control for neonatal
circumcision do not permit full analgesia,[2] non-therapeutic
circumcision, which is not essential for child health, should be avoided.
The design and execution of the invasive study by Sahni et al. falls short
of best medical practice [9] and fails modern ethical standards[10]
because of the deliberate exposure of neonates to unnecessary pain, trauma
and subsequent life-long reduced sexual sensation. This IRB has displayed
an alarming and distressing lack of vigilance and seems fixated in a pre-
human-rights 1940s ethical environment. Evidently, reforms are necessary
to implement contemporary medical ethics.
(2) Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring
block, dorsal penile nerve block, and topical anesthesia for neonatal
circumcision. JAMA 1997; 278:2158-62. http://jama.ama-assn.org/cgi/content/abstract/278/24/2157
(3) Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision:
pain, trauma and psychosexual sequelae. Journal of Health Psychology
2002;7(3):329-43. http://www.cirp.org/library/psych/boyle6
(4) Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal
circumcision on pain response during subsequent routine vaccination. The
Lancet 1997;349:599-603. http://www.cirp.org/library/pain/taddio2
(5) Ramos S, Boyle GJ. Ritual and medical circumcision among Filipino
boys: Evidence of post-traumatic stress disorder. In Denniston GC, Hodges
FM, Milos MF., Eds., Understanding circumcision: A multi-disciplinary
approach to a multi-dimensional problem. New York: Kluwer/Plenum, 2001.
(6) Sinno SHP, van Dijk M, Anand KS, et al. Do We Still Hurt Newborn
Babies? A Prospective Study of Procedural Pain and Analgesia in Neonates.
Arch Pediatr Adolesc Med 2003;157(11):1058-64. http://archpedi.ama-assn.org/cgi/content/abstract/157/11/1058
Frey and Shann have described different methods of administering oxygen
with their pros and cons[1] : There is one more option available,
although less-known and less tried, i.e., oropharyngeal administration of
oxygen.[2] Head box oxygen is wasteful, hence uneconomical. Face mask is
difficult to keep in place in children. Nasal prongs are expensive and are
not available universally. Nasopharyngeal cathe...
Frey and Shann have described different methods of administering oxygen
with their pros and cons[1] : There is one more option available,
although less-known and less tried, i.e., oropharyngeal administration of
oxygen.[2] Head box oxygen is wasteful, hence uneconomical. Face mask is
difficult to keep in place in children. Nasal prongs are expensive and are
not available universally. Nasopharyngeal catheters tend to get blocked
leading to hypoxia and deaths.[3] Nasal catheters may lead to ulcerations
and bleeding besides getting blocked.[4] Secondly, unilateral nasal
occlusion by a mere passage of a tube like, nasal or nasopharyngeal
catheter, is expected to cause airway compromise.[5,6] Oropharyngeal
oxygen administration is low flow method. Universally available feeding
tubes which are also cheap were used for this purpose. Blockage of tube
was not a problem possibly because oropharyngeal secretions are thinner
compared to nasal or nasopharyngeal secretions.
References
(1) Frey B, Shann F. Oxygen administration in infants. Arch Dis Child,
Fetal and Neonatal Edition 2003:88: F84-88.
(2) Daga SR, Verma B, Gosavi DV. Oropharyngeal delivery of oxygen to
children. Trop Doct 1999: 29: 98-99.
(3) Weber MW, Palmer A, Oparango A, Mullholland EK. Comparison of nasal
prongs and nasopharyngeal catheter for delivery of oxygen in children with
hypoxemia because of a lower respiratory tract infection. J Pediatr 1995:
127: 378-383.
(4) Muhe L, Degefu H, Worku B, Birhane O, Mullholland EK. Ann Trop Pedia
1997;17: 273-281.
(5) Martin RJ, Miller MJ, Siner B, Difiore JM, Carlo WA. Effects of
unilateral nasal occlusion on ventilation and pulmonary resistance in
infants. J Appl Physiol 1989; 66: 2522-6.
(6) Stocks J. Effects of nasogastric tube on nasal resistance during
infancy. Arch Dis Child 1980: 55: 17-2.
The authors of the recent case report[1] make an important point about the use of radio-opaque contrast to determine accurately, the position of the central line in neonates. This could perhaps be considered as ‘the gold standard’. There is however a real risk of line migration, the risk increasing with the time the line is left in. Thus, an appropriately positioned silastic line evaluated to be safe by ini...
The authors of the recent case report[1] make an important point about the use of radio-opaque contrast to determine accurately, the position of the central line in neonates. This could perhaps be considered as ‘the gold standard’. There is however a real risk of line migration, the risk increasing with the time the line is left in. Thus, an appropriately positioned silastic line evaluated to be safe by initial radiography may still migrate to an unsafe position later.[1,2]
The PACS (picture archiving and communications system) digital image archiving system3 offers image enhancement facilities. The image ‘sharpening’ tool (‘magic glass sharpen’) can be used to visualize with clarity, lines (silastic and other long lines, UAC, UVC) and tubes (ET tubes, NG tubes) inserted during neonatal intensive care. We have found this digital Xray archiving service extremely good and have found the ‘sharpened’ images particularly useful to monitor the tip position of silastic long lines.
Image 1 showing the silastic longline (with and without sharpened image)
Image 2 showing NG tube coiled in the upper oesophagus – not visible in the ‘un sharpened’ image
References
(1) N Makwana, A Lander, R Buick, and B Kumararatne
Unusual complication of a central venous line in a neonate Arch Dis Child Fetal Neonatal Ed., Sep 2003; 88: F440.
(2) P Madhavi, R Jameson, M J Robinson Unilateral pleural effusion complicating central venous catheterization. Arch Dis Child Fetal Neonatal Ed 2000;82:F248-F249(May).
(3) Nicola H Strickland PACS (picture archiving and communication systems): filmless radiology. Arch Dis Child, Jul 2000; 83: 82-86.
We congratulate Omari and Davidson[1] on producing more interesting
work on intragastric pH monitoring in preterm infants but feel that their
results do not fully support their conclusion. This could have read
"although the mid and distal stomach are quicker to re-acidify (time
pH <4 58.7% and 55.7% respectively) than the proximal stomach (time
pH<4 42.2%), these figures are still low". Perce...
We congratulate Omari and Davidson[1] on producing more interesting
work on intragastric pH monitoring in preterm infants but feel that their
results do not fully support their conclusion. This could have read
"although the mid and distal stomach are quicker to re-acidify (time
pH <4 58.7% and 55.7% respectively) than the proximal stomach (time
pH<4 42.2%), these figures are still low". Percentages may be even
lower in less mature infants or in infants fed more frequently than 4-
hourly. Variability remains a significant problem. The authors report
that their results are far less variable than in previous studies and then
go on to report highly variable results such as intragastric pH<4 for
15.3-97.7% of the time.
Their recommendation of siting the intragastric probe 9cm below the
lower oesophageal sphincter is not practical. First their is potential for
the probe to curl back on itself and secondly the infants in their study
were nursed in the right lateral position throughout the 4 hours, a
difficult technique to maintain for longer monitoring periods.
Although this study makes a valuable contribution to our knowledge of
pH monitoring it shows that the problems of extended periods of gastric
buffering and inter-subject variability remain substantial.
Reference
(1) Omari T, Davidson GP. Multipoint measurement of intragastric pH in
healthy preterm infants. Arch Dis child fetal and neonatal Ed 2003; 88: F517-520.
The authors need to be congratulated for publishing this case report
which I think must have been the lesson of the week for many budding and
trained neonatologists.
I would just like to make few comments:
1. The long line from the picture in the article appears to have been
inserted via left ante cubital fossa rather than the right as mentioned
in the text.
The authors need to be congratulated for publishing this case report
which I think must have been the lesson of the week for many budding and
trained neonatologists.
I would just like to make few comments:
1. The long line from the picture in the article appears to have been
inserted via left ante cubital fossa rather than the right as mentioned
in the text.
2. The use of contrast is obviously a must for silastic long lines as was
obvious from this case, as their visibility depends on other factors like
exposure of the film, edema of subcutaneous tissue etc, although
polyurethane long lines do not need any contrast material as they are very
radio opaque, as compared to silastic lines.
3. The authors did not mention the length of the long line inserted, which
could have given a clue to other experienced colleagues on the ward rounds
on the fate of the unaccounted length of line. In some units it is a must
for doctors to document the length of long line inserted on the baby’s
notes and cot side "line chart". We have been able to prevent a lot of
such potential complications just by that simple guideline.
It is not uncommon for many units not to use contrast media, for
silastic lines and an inexperienced operator is commonly carried away
especially in easy cases to push the line more than the measured length or
it may be a result of miscalculation of measurement or due to error in
reading the markings on the long lines as the silastic lines only have
markings every 5cm apart.
In the said case I am sure the length of the long line inserted via
left arm must have been more than 15-16cm to reach that position below the
diaphragm, and the actual length of line needed to be inserted for a
800gram baby from left ante cubital fossa to reach SVC-right atrium
junction would not be more than 11-12 cm in an average size baby. If one
could not visualise this line beyond SVC after inserting 15-16cm of length
then that should make one think harder and look for the missing portion
somewhere as the lines have the habit of wandering to unwanted places,
which unfortunately is beyond the control of the operator.
Take home message
If one cannot account for the whole length of long line inserted from
insertion site on Xray, especially in cases where contrast has not been
used, then think very hard and differ commencement of TPN till the tip is
verified conclusively.
I refer to the article by Peter M Dunn.[1] This historical account makes an incorrect statement that "There is no record of Peter the elder ever marrying" (fourth
paragraph). I would contest this statement, as a librarian and member of the Society of
Genealogists, I have found ample documentary evidence that he married and
had children.
The 'Dictionary of National Biography' states:
By his wife...
I refer to the article by Peter M Dunn.[1] This historical account makes an incorrect statement that "There is no record of Peter the elder ever marrying" (fourth
paragraph). I would contest this statement, as a librarian and member of the Society of
Genealogists, I have found ample documentary evidence that he married and
had children.
The 'Dictionary of National Biography' states:
By his wife Anne, who died before him, he had an only daughter, Hester.
(This itself is somewhat inaccurate as "had" should really be "was survived by")
There are several primary historical sources that confirm this,
including his will, proved at the Prerogative Court of Canterbury, which
mentions his daughter Hester, and several grandchildren. The family is also documented in Returns of Strangers in the
Metropolis, 1593 (transcribed in Huguenot Society Publications, Quarto
Series, 57) which mentions his wife and three children living at that
time.
Reference
(1) Dunn PM. The Chamberlen family (1560-1728) and obstetric forceps. Arch Dis Child Fetal Neonatal Ed. 1999; 81: F232-234.
We read with interest the article “Phototherapy with turquoise versus
blue light” by F Ebbesen et al.[1]
The article addresses to the
usefulness of turquoise light and its relative advantage over conventional
blue light in view of its equal efficacy in reducing serum bilirubin at a
lesser irradiance and has stated the harmful mutagenic effects associated
with blue light. However, we wou...
We read with interest the article “Phototherapy with turquoise versus
blue light” by F Ebbesen et al.[1]
The article addresses to the
usefulness of turquoise light and its relative advantage over conventional
blue light in view of its equal efficacy in reducing serum bilirubin at a
lesser irradiance and has stated the harmful mutagenic effects associated
with blue light. However, we would like to seek clarifications on the
following points, which are of research and clinical utility.
The article
did not mention whether any experimental trial was carried out with
turquoise light on the blood samples before proceeding with the human
trial, if so whether the trial had similar results. Secondly, the distance
from the phototherapy apparatus was kept at 32cm. We would like to know
that what has guided the authors to choose this specific level, the fall
in serum bilirubin would have been more effective if the distance was kept
at lower levels, as lesser distance produces more irradiance.[2]
Further
we are keen to know how turquoise light was made? What extra accessories
are required while using this light, its availability, and how will it
fare with blue light in terms of cost? We in our experimental study by
Gupta et al have innovated a simple cheap cost effective measure that
could generate significantly higher irradiance in double surface
phototherapy by the use of photoreflectant covers. (3) The maximum
irradiance generated was 76.28 microwatt/cm2/nm and the gain in
irradiance was not associated with statistically significant increase in
temperature inside the phototherapy unit. Apparently its acceptance by the
NICU staff was also better as the glare-associated problems were reduced
by use of the covers.
We solicit author’s comments for more effective
answers to such an important research domain.
References
(1) F Ebbesen, G Agati, R Pratesi. Phototherapy with turquoise versus blue
light. Arch Dis Child Fetal Neonatal Ed 2003; 88; F430-F431.
(2) Tan K L. The pattern of bilirubin response to phototherapy for neonatal
hyperbilirubinemia. Pediar Res 1982; 16:670.
(3) Gupta G et al. Unmatched evolution in phototherapy. [Unpublished work,
to be presented in Annual Convention of National Neonatal Forum of India].
We read the article by Faerk et al.[1] on the relation of bone mineral
content (BMC), ALP and serum phosphate; two commonly used markers for
monitoring of metabolic bone diseases of prematurity (MBDP). In-fact, the
author has tried to break the long-standing myth of regular monitoring of
these two parameters for early detection and possibly prevention of this
condition. However, we were disappoin...
We read the article by Faerk et al.[1] on the relation of bone mineral
content (BMC), ALP and serum phosphate; two commonly used markers for
monitoring of metabolic bone diseases of prematurity (MBDP). In-fact, the
author has tried to break the long-standing myth of regular monitoring of
these two parameters for early detection and possibly prevention of this
condition. However, we were disappointed to see that the authors failed to
explain their finding in the context of current research evidence.
There are two theories of MBDP. According to the traditional
biochemical theory, crystallization of Ca and phosphate in the previously
formed osteoid matrix heralds mineralization and appropriate concentration
of calcium and phosphate is the most crucial factor. However, it has long
been felt that even with a maximum oral intake of 200ml/kg/day and
supplementation/fortification with calcium and phosphate, it is almost
impossible to match the rate of intrauterine accretion of these 2 in the
3rd trimester (for Ca it is about3.5 mmol/Kg/day and for P it is about 2.7
mmol/Kg/day). It is therefore often presumed that reduced bone formation
is the primary cause of MBDP.
However some evidence suggest that increased bone resorption is the main
factor.[2,3] Two separate groups have already demonstrated that urinary
excretion of bone resorption markers like hydroxyproline, type 1 collagen
telopeptide, calcium and phosphorus concentration is 3 to 4 times higher
in preterm in comparison to term babies.
There is however a growing evidence that increased bone resorption is
a result of lesser degree of mechanical load on preterm bone following
birth. In comparison, term infant gets the effect of intrauterine
kicking, bouncing etc as mechanical stimulus for bone formation over last
few crucial weeks. Therefore, apart from fortification,it may be important
to introduce some form of physical exercise in order to prevent MBDP.
This can be good topic for future trial .
We believe that, the serum phosphate as measured in the laboratory,
is a combination of phosphate coming out of bone due to bone resorption
and the dietary phosphate. Therefore, a high serum phosphate may indicate
increased bone resorption leading to reduced BMC. On the other hand, a low
phosphate may be a marker of less bone resorption and thereby a normal
BMC. Therfore it is premature to conclude( according to Author’s other
article) [4] that supplementation of phosphate has no effect on BMC.
Previous studies have shown that preterm infants have a rapid phase of
mineral accretion between 40 and 60 weeks’ postconceptional age.[5]
We still do not know the actual chemical assimilation pathway of dietary
phosphorus. In fact We suggest that one of the ways to solve the problem
is to do a tracer study where a specific isotope of phosphate molecule can
be used as dietary source and subsequently chasing its course by
radioisotope study. (I am bit skeptical about getting an ethics committee
permission).
We also beg to differ with the author’s statement "Alkaline phosphates in the vesicle membrane transports phosphate into the vesicle.
Calcium diffuses passively through the membrane". ALP act upon inorganic
and organic phosphates from different sources and break it down to
inorganic phosphorus (Pi). Pi is then transported inside the matrix
vesicle by Na-Pi symport system. Calcium enters through the specific
calcium channels (annexins).[6]
Reference
(1) J Faerk, B Peitersen, S Petersen, and K F Michaelsen.
Bone mineralisation in premature infants cannot be predicted from serum alkaline phosphatase or serum phosphate. Arch Dis Child Fetal Neonatal Ed. 2002; 87: F133-F136.
(2) Beyers N, Alheit B , Taljaard JF et al. High turnover osteopinea in
preterm infants.Bone 1994;15:5-13.
(3) Mora S, Weber G et al. Bone modeling alteration in preterm
infants. Arch Ped Adolesc Medicine 1994;148: 1215-1217.
(4) Faerk J, Petersen S, Peitersen B, et al. Phosphorus intake is of
major importance for growth velocity in premature infants. Pediatr Res
1999;45:915.
(5) Horseman A, Ryan SW, Congdon PJ et al. Bone mineral content and
body size 56 to 100 weeks postconception in preterm and full term infants.
Arch Dis Child 1989; 64 : 1579-1586.
(6) Montesuit C,Caverzasio J,Banjour JP. Characterization of Pi
transport system in cartilage matrix vesicle. Potential role in
calcification process. Journal boil chemistry 1991, 266 : 17791-17797.
The review article on neonatal thrombocytopenia highlighted practical
aspects in the management of a common yet often overlooked problem in
neonatal practice. Three important factors were correctly highlighted by
the authors – that thrombocytopenia exists in more than a fifth of the
babies in any neonatal intensive care unit (and in a severe form in a
sizeable minority), that it often is multifactorial...
The review article on neonatal thrombocytopenia highlighted practical
aspects in the management of a common yet often overlooked problem in
neonatal practice. Three important factors were correctly highlighted by
the authors – that thrombocytopenia exists in more than a fifth of the
babies in any neonatal intensive care unit (and in a severe form in a
sizeable minority), that it often is multifactorial in origin and
guidelines for platelet transfusion are now more conservative. I would,
however, like to bring out some difficulties that are faced in managing
this problem, especially in developing countries.
1. The first manifestation of thrombocytopenia may well be a baby
bleeding from nose, mouth and venepuncture sites and massive pulmonary
hemorrhage is a common component of this. Once pulmonary hemorrhage has
taken place, the outcome is usually poor. We, therefore, assess adequacy
of platelets in common high-risk situations such as prematurity, sepsis,
placental insufficiency and necrotizing enterocolitis.
2. Adequacy of platelets as seen in a well-prepared peripheral blood smear
seen by an experienced pathologist is felt to be the best indicator of
platelet counts. It also helps in diagnosis of specific platelet anomalies
(e.g. May-Hegglin and Wiskott Aldrich anomalies); and provides corroborative
evidence of sepsis while utilizing very little blood. A need possibly
exists to incorporate this investigation into NICU protocols and to carry
it out on a daily basis till platelets are consistently adequate.
3. In many centers, well-equipped blood banks are not available, and
platelets as a component are always difficult to procure. If random donor
platelets are not available, time taken to bleed donors and prepare
platelet concentrates may be too long and sick neonates may not survive
this period. Use of fresh whole blood in this situation, while far from
ideal, is the only option available in these situations.
4. Tests for HPA are not routinely available even in many tertiary care
centers of our country. Indeed, the diagnosis as well as management of
NAITP is difficult in this situation.
5. Use of rhTpo as well as rhIL-11 is not likely to be the standard of
care in most centers. One wonders whether systemic EACA can help tide
over crises where blood or its components are not available for the
bleeding neonate.
References
(1) I Roberts, NA Murray. Neonatal thrombocytopenia: causes and management.
Arch Dis Child Fetal Neonatal Ed 2003; 88: F359-364.
We read with interest the findings of Maayan-Metzger et al. relating
fever in healthy newborns during the first days of life.[1]
It is difficult
to identify febrile neonates at low risk for serious bacterial infection.[2]
Although, no consensus exists on the optimal approach to diagnosis and
treatment, current guidelines recommend to admit all febrile infants less
than 28 days of age to the...
We read with interest the findings of Maayan-Metzger et al. relating
fever in healthy newborns during the first days of life.[1]
It is difficult
to identify febrile neonates at low risk for serious bacterial infection.[2]
Although, no consensus exists on the optimal approach to diagnosis and
treatment, current guidelines recommend to admit all febrile infants less
than 28 days of age to the hospital and give intravenous antibiotics for
48 to 72 hours. But as mentioned in this report dehydration is the primary
cause of fever especially during the first days of life.
We retrospectively reviewed the medical charts of patients admitted to our
neonatal intensive care unit between 1 May 1999 and 30 September 2003 with
the complaint of fever.
The inclusion criteria were; gestational age 37
weeks, 1-7 days of postnatal age excluding the first day of life, axillary
or rectal temperature 37.8 oC on admission, normal physical examination
with well appearance and without any sign focal infection, no history of
illness or previous antibiotics.
Overall 46 febrile neonates were included
in the study. Most (90-95%) of the babies were exclusively breast fed.
Laboratory data of the babies’ included complete blood count, c-reactive
protein, serum urea and sodium levels, urinalysis, blood, urine and
cerebrospinal fluid cultures.
The mean (SD) age on admission was 3.4 (1.9) days. The mean (SD) duration
of fever was 2.8 (2.4) hours. Twenty seven infants (58.7%) had lost 8% to
24.3% of their birth weights. In 34 of the babies white blood cell counts
were between 5000 and 15,000/mm3. Serum sodium levels were obtained in 35
patients. The mean (SD) serum sodium level was 147 (6.7) mmol/l, and in 14
(40%) of them the levels were equal to or higher than 150 mmol/l. There
was a positive correlation between weight loss and high serum sodium
levels (p=0.002). The mean (SD) serum urea nýtrogen level was 19.3 (11.1)
mmol/l. In 22 (47.8) babies serum bilirubin levels were equal to or
greater than 220 mmol/l.
Cultures were positive in seven babies. Coagulase negative staphylococci
was recovered from five blood cultures and considered to be contaminated
both clinically and a negative repeated culture. In one infant blood
culture was positive for staphylococcus aureus and enterococcus grew from
the culture of the urine in the other.
The majority (82.6%) of admissions were between June and early October,
which are the warmest months of the year in this area.
In this low risk group of infants only two patients had serious bacterial
infection. Compatible with the findings by Maayer-Metzger et al, the
results of our study supported dehydration being the main cause of fever
during the first week of life. Because of the detection of majority of
cases during summer and early autumn environmental temperature could have
an additive effect in this population.
References
(1) Maayan-Metzger A, Mazkereth R, Kuint J. Fever in healthy asymptomatic
newborns during the first days of life. Arch Dis Child Fetal Neonatal Ed
2003;88:F312-F314.
(2) Baker MD, Bell LM. Unpredictability of serious bacterial illness in
febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med
1999;153:508-511.
Dear Editor
Sahni and colleagues report that 15 neonates were given an unspecified non-invasive analgesic prior to circumcision,[1] which may have been EMLA cream. Test results recorded a significantly elevated heart rate (HR) and reduced oxygen saturation, indicative of pain.[1] The HR remained higher than baseline even after the conclusion of the surgery, suggesting ongoing pain from the tissue damage inflicte...
Dear Editor
Frey and Shann have described different methods of administering oxygen with their pros and cons[1] : There is one more option available, although less-known and less tried, i.e., oropharyngeal administration of oxygen.[2] Head box oxygen is wasteful, hence uneconomical. Face mask is difficult to keep in place in children. Nasal prongs are expensive and are not available universally. Nasopharyngeal cathe...
Dear Editor
The authors of the recent case report[1] make an important point about the use of radio-opaque contrast to determine accurately, the position of the central line in neonates. This could perhaps be considered as ‘the gold standard’. There is however a real risk of line migration, the risk increasing with the time the line is left in. Thus, an appropriately positioned silastic line evaluated to be safe by ini...
Dear Editor
We congratulate Omari and Davidson[1] on producing more interesting work on intragastric pH monitoring in preterm infants but feel that their results do not fully support their conclusion. This could have read "although the mid and distal stomach are quicker to re-acidify (time pH <4 58.7% and 55.7% respectively) than the proximal stomach (time pH<4 42.2%), these figures are still low". Perce...
Dear Editor
The authors need to be congratulated for publishing this case report which I think must have been the lesson of the week for many budding and trained neonatologists.
I would just like to make few comments:
1. The long line from the picture in the article appears to have been inserted via left ante cubital fossa rather than the right as mentioned in the text.
...
Dear Editor
I refer to the article by Peter M Dunn.[1] This historical account makes an incorrect statement that "There is no record of Peter the elder ever marrying" (fourth paragraph). I would contest this statement, as a librarian and member of the Society of Genealogists, I have found ample documentary evidence that he married and had children.
The 'Dictionary of National Biography' states: By his wife...
Dear Editor
We read with interest the article “Phototherapy with turquoise versus blue light” by F Ebbesen et al.[1]
The article addresses to the usefulness of turquoise light and its relative advantage over conventional blue light in view of its equal efficacy in reducing serum bilirubin at a lesser irradiance and has stated the harmful mutagenic effects associated with blue light. However, we wou...
Dear Editor
We read the article by Faerk et al.[1] on the relation of bone mineral content (BMC), ALP and serum phosphate; two commonly used markers for monitoring of metabolic bone diseases of prematurity (MBDP). In-fact, the author has tried to break the long-standing myth of regular monitoring of these two parameters for early detection and possibly prevention of this condition. However, we were disappoin...
Dear Editor
The review article on neonatal thrombocytopenia highlighted practical aspects in the management of a common yet often overlooked problem in neonatal practice. Three important factors were correctly highlighted by the authors – that thrombocytopenia exists in more than a fifth of the babies in any neonatal intensive care unit (and in a severe form in a sizeable minority), that it often is multifactorial...
Dear Editor
We read with interest the findings of Maayan-Metzger et al. relating fever in healthy newborns during the first days of life.[1]
It is difficult to identify febrile neonates at low risk for serious bacterial infection.[2] Although, no consensus exists on the optimal approach to diagnosis and treatment, current guidelines recommend to admit all febrile infants less than 28 days of age to the...
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