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In the report "Heart rate characteristics index monitoring for
bloodstream infection in an NICU: a 3-year experience", Coggins and
colleagues make several observations that are important for properly using
the HRC (HeRO) monitor in the NICU:
1) Continuous monitoring is more effective than intermittent. Coggins
analyzed scores recorded in the medical record every 12 hours, or 8% of
the hourly scores; high scores may have...
In the report "Heart rate characteristics index monitoring for
bloodstream infection in an NICU: a 3-year experience", Coggins and
colleagues make several observations that are important for properly using
the HRC (HeRO) monitor in the NICU:
1) Continuous monitoring is more effective than intermittent. Coggins
analyzed scores recorded in the medical record every 12 hours, or 8% of
the hourly scores; high scores may have been missed.
2) Many high HRC index scores are not associated with bloodstream
infection. We have found that an acute rise in the score can also be
associated with urinary tract infection, necrotizing enterocolitis,
clinical sepsis, acute respiratory deterioration, surgery[1], brain
injury[2][3], and administration of atropine. In some cases, a rise in the
score is not associated with any apparent illness or event.
3) Some infants with septicemia do not have an acute rise in the HRC index
prior to diagnosis. In the Coggins report, only 37% of the 46
intermittently-sampled cases of septicemia were associated with HRC index
>2. In our analysis from the continuously-sampled RCT, 79% of the 974
cases of septicemia in 700 VLBW infants, were associated with a score
>2 in the day before diagnosis[4].
4) The HRC index monitor should never replace clinical judgement. A
septic-appearing baby should get antibiotics regardless of the score, and
a baby with a high score but low clinical index of suspicion for infection
could be closely watched without antibiotics[5]. A scenario in which a
baby might benefit is the VLBW infant whose baseline HRC index is <1
for several days, followed by a rise to >2, prompting clinicians to
look more closely, send laboratory tests, and detect and treat infection
before the baby has obvious clinical deterioration.
Karen Fairchild MD,
David Kaufman MD,
John Kattwinkel MD
University of Virginia School of Medicine
1) Sullivan BA, Grice SM, Lake DE, et al. Infection and other
clinical correlates of abnormal heart rate characteristics in preterm
infants. J Pediatr 2014;164:775-80.
2) Vergales BD, Zanelli SA, Matsumoto JA, et al. Depressed heart
rate variability is associated with abnormal EEG, MRI, and death in
neonates with hypoxic ischemic encephalopathy. Am J Perinatol 2014;31:855-
62.
3) Fairchild KD, Sinkin R a, Davalian F, et al. Abnormal heart rate
characteristics are associated with abnormal neuroimaging and outcomes in
extremely low birth weight infants. J Perinatol 2014;34:375-9.
4) Fairchild KD, Schelonka RL, Kaufman D a, et al. Septicemia
mortality reduction in neonates in a heart rate characteristics monitoring
trial. Pediatr Res 2013;74:570-5.
5) Griffin MP, Lake DE, O'Shea TM, et al. Heart rate characteristics
and clinical signs in neonatal sepsis. Pediatr Res 2007;61:222-7.
We very much welcome Martin Ward Platt's review of the MBRRACE-UK
perinatal surveillance report and would like to respond to a number of
points that he has highlighted.
The article focussed on the first perinatal surveillance report (1) from
the MBRRACE-UK team and noted that it was produced from a new system of
data collection after a three year gap in national perinatal surveillance.
As well as changing the approach to...
We very much welcome Martin Ward Platt's review of the MBRRACE-UK
perinatal surveillance report and would like to respond to a number of
points that he has highlighted.
The article focussed on the first perinatal surveillance report (1) from
the MBRRACE-UK team and noted that it was produced from a new system of
data collection after a three year gap in national perinatal surveillance.
As well as changing the approach to data collection, MBRRACE-UK have
introduced a number of changes to the nature of the data collected. In
order to facilitate international comparisons WHO guidance was followed in
terms of the inclusion criteria: i.e. all neonatal deaths resulting from a
registered live births from 20 weeks gestation and all late fetal losses
of 22 and 23 weeks gestation are now included. In addition the inclusion
of these babies should facilitate the investigation of the wide variation
in practices between units concerning whether such babies are registered
as a live birth or not registered (2) which has a large impact on neonatal
mortality rates.
An overview of the new statistical method used to stabilise and adjust the
mortality rates between populations was included in appendix 3 of the
published report as well as in a short podcast which is downloadable from
the MBRRACE-UK website: https://www.npeu.ox.ac.uk/mbrrace-
uk/presentations. A broad summary of the methodology was presented at the
report launch meeting as it was felt that the majority of the constituent
audience would not be interested in the full detail of the statistical
methods employed. However, although these methods are new to the UK they
have been used in the US and are discussed in the references cited in the
report (3,4).
We agree that neonatal death is not a homogeneous group and over the next
few years we will be developing different methods of exploring the various
groups of deaths and this will be facilitated by the use of data for two
or three years combined rather than a single year.
The review queried the choice of the International Cause of Death and
Associated Conditions (CODAC) classification system (5) by MBRRACE-UK.
CODAC was chosen following consultation with an expert group primarily
because it was felt it would provide a far better insight into the
mechanisms involved with the various types of perinatal loss. In the past
simple hierarchical systems have been used which failed to provide any
insight into the cause of death for over half of all stillbirths. However,
we acknowledge that this system is complex and we have established a
working group to identify key problems and help produce the answers to
frequently asked questions for users.
The review highlighted the importance of moving to reports of
outcomes based on individual Trusts and Health Boards. Dr Ward Platt would
have been unaware at the time of writing that such reports were always
intended to be produced but were delayed for this first report simply
because of the time and resources needed to establish an appropriate
approach in the first instance. All Trusts and Health Boards should now
have received a report of their 2013 cases (based on the place of birth
for all deaths) and in subsequent years this information will be produced
at the same time as the geographical analysis (by commissioning or public
health organisation).
We would like to reassure readers that the methods used by MBRRACE-UK
for perinatal confidential enquiries have been built on the learning from
the Confidential Enquiry into Stillbirths and Deaths in Infancy and its
successor bodies. Those who have been involved in the topic expert groups
and panels for the enquiries carried out since 2012 will almost certainly
have recognised that the enquiries have many features in common with those
run by predecessor organisations.
In this response we hope that we have addressed the concerns
presented in the editorial and clarified how we have developed the MBRRACE
-UK programme of work building on previous experience but using new
methodologies where appropriate.
References
1. https://www.npeu.ox.ac.uk/downloads/files/mbrrace-
uk/reports/MBRRACE-UK%20Perinatal%20Surveillance%20Report%202013.pdf
2. Smith L, Draper ES, Manktelow BN, Pritchard C, Field DJ. Comparing
regional infant death rates: the influence of preterm births <24 weeks
of gestation. Archives of Disease in Childhood Fetal & Neonatal
Edition. 2013;98(2):F103-7.
3. The COPSS-CMS White Paper Committee, Ash AS, Fienberg SE, Louis TA,
Normand S-LT, Stukel TA, et al. Statistical issues in assessing hospital
performance: Committee of Presidents of Statistical Societies; 2012 [cited
2015 8 Apr]. Available from: http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-
Instruments/HospitalQualityInits/Downloads/Statistical-Issues-in-Assessing
-Hospital-Performance.pdf
4. Mohammed MA, Manktelow BN, Hofer TP. Comparison of four methods for
deriving hospital standardised mortality ratios from a single hierarchical
logistic regression model. Statistical Methods in Medical Research.
2012:published online 6 November 2012.
5. Froen JF, Pinar H, Flenady V, Bahrin S, Charles A, Chauke L, et al.
Causes of death and associated conditions (Codac) - a utilitarian approach
to the classification of perinatal deaths. BMC Pregnancy and Childbirth.
2009;9(1):22.
We read with interest the article by Eryigit-Madzwamuse et al (1) on
the personality of young adults who were born preterm. We would like to
draw the attention of the journal's readers to our recent work in the same
field (2) with some important similarities and some interesting
differences.
We also studied approximately 200 cases and 200 controls and also
assessed the 'big five' personality traits (neuroticism...
We read with interest the article by Eryigit-Madzwamuse et al (1) on
the personality of young adults who were born preterm. We would like to
draw the attention of the journal's readers to our recent work in the same
field (2) with some important similarities and some interesting
differences.
We also studied approximately 200 cases and 200 controls and also
assessed the 'big five' personality traits (neuroticism, extraversion,
agreeableness, openness, and conscientiousness). Our cases were more
preterm at birth (28 vs. 30 weeks), and in spite of this, the estimates of
effect sizes expressed as population standard deviation (Cohen's d) were
smaller for neuroticism (0.28 vs. 0.54) and for extraversion (0.30 vs.
0.45) while the effect size was similar for agreeableness (0.25 vs. 0.24).
These differences may have led to a very different focus of the
discussion section in the two articles. Eryigit-Madzwamuse et al used
factor analysis (including a scale on autistic features) to build a
concept of a 'socially withdrawn personality' and propose bullying in
school as a link between the early neurodevelopmental impairments to the
abnormalities of adult personality. We, on the other side, concluded that
the effect sizes were smaller than the typical effect on IQ as a general
measure of brain injury in very preterm infants. Also, the increased
agreeableness could be the result of upbringing by adults appreciating the
small miracle of survival. The increased agreeableness could help explain
that the deficits in education, income, and family-building are
surprisingly small (3).
Were the differences in effect size due to differences in Bavarian
and Danish culture as regards upbringing of children? Or was the
difference in focus rather a question of seeing the glass as half empty or
half full? Did it come from the fact that the authors were mainly
psychologists or neonatologists, respectively?
Yours, sincerely
Gorm Greisen
Department of Neonatology, Rigshospitalet, Copenhagen Denmark
Bo M?lholm Hansen
Department of Paediatrics, Herlev Hospital, Copenhagen, Denmark
References
1. Eryigit-Madzwamuse S, Strauss V, Baumann N, Bartmann, Wolke D.
Personality in adults who were born very preterm. Arch Dis Child Fetal
Neonatal Ed 2015;100:F524-529.
2. Hertz CL, Mathiasen R, Hansen BM, Mortensen EL, Greisen G. Personality
in Adults Who Were Born Very Preterm. PLoS ONE 2013; 8(6): e66881.
doi:10.1371/journal.pone.0066881
3. Mathiasen R, Nybo-Andersen AM, Hansen BM, Greisen G. Social integration
at the age of 30 years of individuals born before 33 weeks of gestation.
Acta Paediatrica, 2007;120:96: 85.
I read with interest the editorial by D Wilkinson and B Stenson
commenting on a series of papers which suggest that current outcomes of
neonates with APGAR scores of zero at 10 minutes are not universally poor.
Given that stopping at 10 minutes in all cases will then lead to a number
of unnecessary death they rightly ask what stopping time is appropriate.
I wonder if this is the right question. A baby who has fa...
I read with interest the editorial by D Wilkinson and B Stenson
commenting on a series of papers which suggest that current outcomes of
neonates with APGAR scores of zero at 10 minutes are not universally poor.
Given that stopping at 10 minutes in all cases will then lead to a number
of unnecessary death they rightly ask what stopping time is appropriate.
I wonder if this is the right question. A baby who has failed to
respond to expert and prompt resuscitation by 10 or 12 minutes is likely
to have a different prognosis to a baby who has had delayed or sub optimal
resuscitation with possibly intubation first occurring at 10 minutes or
more. We know from clinical experience that babies who requiring
resuscitation due to hypovolaemia rather than prolonged fetal hypoxia
often do better than their APGARs would suggest. Time from birth alone
would seem to be too simplistic to predict the inevitability of death or
severe disability in a very disparate group of infants.
We need a paradigm shift possibly towards response to treatment as a
predictor. Research is needed to identify a predictor that is both
specific and easily clinically applicable in the first 20 minutes of life.
The question is not "what is the right time" but "what is the right
predictor".
A culture-negative neonatal sepsis is more than herpes virus
infection
Ying Dong a, Christian P. Speer b
a Department of Paediatrics, Children's Hospital of Fudan University,
Shanghai, China
b University Children's Hospital, University of Wurzburg, Wurzburg,
Germany
We highly appreciate the authors' contribution to the full picture of
pathogens causing systemic late-onset neonatal infection. The letter by
Dr. Batra and Dr. Smith highlights the morbidity and mortality of neonatal
herpes infection, and in a broader sense, calls to our attention the
differential diagnosis and treatment of culture-negative neonatal sepsis.
It should be noted, however, that bacteria still remain to be the primary
causative agents of neonatal sepsis, and negative culture results do not
necessarily rule out the possibility of bacterial infections given the
inherent limitation of culture technology and nonculturability of many
potential pathogenic bacteria.1 With rapid development in molecular- based
methods such as polymerase chain reaction (PCR) and denaturing gradient
gel electrophoresis, previous culture-negative cases deemed to have other
pathogenic origins may actually turn out to be bacterial infections.
Should the possibility of bacterial and fungal sepsis be reliably
excluded, a viral etiology has to be considered. Apart from herpes virus,
enteroviruses as well as parechoviruses are also demonstrated to be
frequent viral causes of neonatal infections, with herpes virus identified
in 17.5 per 100,000 live births and the latter two affecting up to 12% of
neonates followed until one month of life. 2, 3, 4 The prevalence and the
spectrum of viruses as well as the predominant virus in late-onset
neonatal infections have yet to be revealed due to a lack of population-
based epidemiological data. Virus infections have a spectrum of clinical
manifestations ranging from nonspecific mild symptoms to sepsis-like
illness which can result in rapid deterioration. 2, 3, 4 Enteroviruses,
parechoviruses as well as herpes viruses were shown to be able to cause
devastating infections among neonates, with risk factors and mortality
rate yet to be adequately elucidated. Current data show that the mortality
rate could be as high as 42% for enterovirus and 47% for herpes virus. 2,
4 Concerns about the adverse outcomes of severe viral infections prompt
some clinicians to consider incorporating an antiviral agent into the
empirical treatment of neonatal sepsis. However, this process may be
confounded by the harm of using antiviral agents against sepsis proven
otherwise and the difficulty in applying specified molecular techniques to
confirm viral infections especially in resource-limited regions.
We agree with Dr. Batra and Dr. Smith that the differentiation of
systemic viral infections from bacterial late onset sepsis at presentation
seem to be extremely difficult. Neonatologists and pediatricians should be
highly vigilant and include viral infections in the differential diagnosis
of late onset sepsis. No doubt, whenever herpes infection is suspected, a
prompt treatment with acyclovir has to be initiated. However, we are
hesitant to recommend intravenous acyclovir directed against herpes
viruses as a routine strategy to be included in protocols on late onset
sepsis. Besides the above mentioned open questions, future research should
focus on rapid and reliable diagnostic procedures and markers of early
diagnosis of neonatal infections which will allow a differentiation
between bacterial, fungal and viral organisms.
The authors have no potential conflict of interests.
References
1. Kellenberger E. Exploring the unknown. The silent revolution of
microbiology. EMBO Rep 2001; 2:5-7.
2. Tebruegge M, Curtis N. Enterovirus infections in neonates. Semin
Fetal Neonatal Med 2009;14:222-7.
3. Cilla A, Megias G, Suarez J, et al. Human parechovius and
enterovirus in neonates: Distinct infections with overlapping features.
Early Hum Dev 2015;91:475-8.
4. Batra D, Davies P, Manktelow BN, Smith C. The incidence and
presentation of neonatal herpes in a single UK tertiary centre, 2006-2013.
Arch Dis Child 2014; 99:916-21.
Prognostication using whole genome and whole exome (WG/WE) sequencing
depends on the use of a tool which - currently - has the potential to add
to rather than decrease uncertainty. A problem in using information from
genomic testing as a prognostic tool is the self-fulfilling nature of
these 'diagnoses'. Many of these will initially be hypotheses, which
become untestable unless the same genotypes are seen in family member...
Prognostication using whole genome and whole exome (WG/WE) sequencing
depends on the use of a tool which - currently - has the potential to add
to rather than decrease uncertainty. A problem in using information from
genomic testing as a prognostic tool is the self-fulfilling nature of
these 'diagnoses'. Many of these will initially be hypotheses, which
become untestable unless the same genotypes are seen in family members or
the variant is reported in the literature. Even where the consequences of
a particular variant are known, a decision to discontinue active care of
an infant is then considered to be an appropriate decision enabled by
genomic methods, yet we will never know what would have happened if the
baby had been supported further - perhaps the variant(s) were not (very)
pathogenic?
The form which non-directive counselling and informed consent would
take in this context remains poorly evidenced. There is a need for
situated empirical research into what constitutes 'informed' consent when
the potential outcomes are so wide ranging. Binary classifications of the
social, legal and ethical challenges into 'pro' versus 'con' lists fail to
recognise that many of the advantages of these technologies are highly
situated, situational and both beneficial and problematic - for example,
increased diagnostic yield is an advantage, but having a diagnosis when
the phenotype is highly variable and not yet apparent means counselling
will be limited in its ability to provide information.
Case 2 raises interesting challenges in that there are Gene x
Environment interactions between copy number variants and adverse fetal,
neonatal and childhood experiences, in terms of increased risk of
psychiatric conditions in later life [1]. The failure to acknowledge the
role of epigenetic factors fails to recognise the complexity of what the
interpretation of prognostic information would/will be. Whilst the
consequences of these complex epigenetic factors are difficult to take
into account, not acknowledging them oversimplifies the situation,
overstating the potential contribution of genomic information in this
context.
Without wanting to invoke genetic exceptionalism, it is difficult to
see how other 'prognostic' investigations, such as MRI, can be compared
with WGS/ES, given the potential for results which impact parents, both in
terms of reproductive decision-making and current and future health. The
extent of the role of genomics requires critical analysis and careful
stewardship, as clinical, ethical, legal and social challenges emerge.
[1] Harold GT et al. Biological and rearing mother influences on
child ADHD symptoms: revisiting the developmental interface between nature
and nurture. Journal of Child Psychology and Psychiatry 2013
Oct;54(10):1038-46. doi: 10.1111/jcpp.12100
Unfortunately the authors have failed to understand the utility of
CRP at 18-24 hours. This has a high negative predictie value but low
positive predictive value. This means that while a low CRP is reassuring
but a high value has to be evaluated in the clinical context. A high CRP
should not be equal to a lumbar puncture. I should point that NICE
guidelines do not recommend using CRP in isolation and clinical acumen
sho...
Unfortunately the authors have failed to understand the utility of
CRP at 18-24 hours. This has a high negative predictie value but low
positive predictive value. This means that while a low CRP is reassuring
but a high value has to be evaluated in the clinical context. A high CRP
should not be equal to a lumbar puncture. I should point that NICE
guidelines do not recommend using CRP in isolation and clinical acumen
should always prevail. This is a very small study over a short period of
time and no information has been provided on the risk factors for
infection in each of the groups.
I call upon the reviewers to be critical of such publications as this
letter may put people off using NICE guidelines which are actually a very
useful and relevant set of guidelines.
We are grateful to our colleagues Haines and Davis from the UK for
their comments confirming many of our findings in their British population
-based cohort. We agree that differences in findings (e.g., different
rates of syndromal anomalies associated with congenital chylothorax) may
simply be due to small numbers. It is nice to see that this rare but
serious condition is receiving more scientific attention
We are grateful to our colleagues Haines and Davis from the UK for
their comments confirming many of our findings in their British population
-based cohort. We agree that differences in findings (e.g., different
rates of syndromal anomalies associated with congenital chylothorax) may
simply be due to small numbers. It is nice to see that this rare but
serious condition is receiving more scientific attention
I read this Randomised controlled trial with great interest. I
applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside
round is appropriate is of limited value and so deeper qualitative
discourse is needed. This can consider more meaningful questions such as
'how', 'why' and 'when' such parental presence impacts the neonatal
j...
I read this Randomised controlled trial with great interest. I
applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside
round is appropriate is of limited value and so deeper qualitative
discourse is needed. This can consider more meaningful questions such as
'how', 'why' and 'when' such parental presence impacts the neonatal
journey.
This is where I feel the authors do not fulfil the full potential of
this work. Whilst some limited analysis is made, it appears that a huge
volume of rich qualitative data has either not been analysed or analysed
in a manner that does not synthesise useful outcomes.
By not employing appropriate qualitative synthesis I feel we are left
with a piece that only tantalisingly points to the questions that will
help us to understand the value of parental presence during this aspect of
neonatal care.
I appeal to the authors to complete and publish such analysis of the
data from their focus group discussions.
We appreciate the feedback and clarity provided by the letter in
response to our review article. We agree in principle with the authors
that beta-blockers have rapidly become the standard of care for infantile
haemangiomas (IHs), and for this reason listed it first in our short
review of treatment options. Indeed, a recent meta-analysis of 35 studies
(representing 572 paediatric patients with IHs) strongly supported the...
We appreciate the feedback and clarity provided by the letter in
response to our review article. We agree in principle with the authors
that beta-blockers have rapidly become the standard of care for infantile
haemangiomas (IHs), and for this reason listed it first in our short
review of treatment options. Indeed, a recent meta-analysis of 35 studies
(representing 572 paediatric patients with IHs) strongly supported the
superior efficacy of propranolol in comparison to alternative therapeutic
options including steroids, vincristine, and laser treatment.(1) Patients
with periorbital IHs should be urgently referred to both paediatric
ophthalmology and dermatology in order to initiate treatment with
propranolol when clinically indicated.
Although propranolol is generally well tolerated by infants, systemic
beta-blockers are not without potential risks and side effects. A number
of serious adverse effects have been reported with propranolol use in
children, including bradycardia, hypotension, hypoglycaemia, bronchospasm,
and hyperkalemia.(2) A consensus conference was held in 2011 to develop
guidelines for the use of propranolol in children and the following
relative contraindications were suggested: cardiogenic shock, sinus
bradycardia, hypotension, heart failure, bronchial asthma, and
hypersensitivity to propranolol.(2) Therefore, for cases in which
propranolol is either ineffective or contraindicated, it remains important
to be aware of alternative therapeutic options for IHs.
References
1. Lou Y, Peng W-J, Cao Y, Cao D-S, Xie J, Li H-H. The effectiveness
of propranolol
in treating infantile haemangiomas: a meta-analysis including 35
studies. Br J
Clin Pharmacol. 2014 Jul 1;78(1):44-57.
2. Drolet BA, Frommelt PC, Chamlin SL, Haggstrom A, Bauman NM, Chiu
YE, et al.
Initiation and use of propranolol for infantile hemangioma: report of
a
In the report "Heart rate characteristics index monitoring for bloodstream infection in an NICU: a 3-year experience", Coggins and colleagues make several observations that are important for properly using the HRC (HeRO) monitor in the NICU: 1) Continuous monitoring is more effective than intermittent. Coggins analyzed scores recorded in the medical record every 12 hours, or 8% of the hourly scores; high scores may have...
We very much welcome Martin Ward Platt's review of the MBRRACE-UK perinatal surveillance report and would like to respond to a number of points that he has highlighted. The article focussed on the first perinatal surveillance report (1) from the MBRRACE-UK team and noted that it was produced from a new system of data collection after a three year gap in national perinatal surveillance. As well as changing the approach to...
We read with interest the article by Eryigit-Madzwamuse et al (1) on the personality of young adults who were born preterm. We would like to draw the attention of the journal's readers to our recent work in the same field (2) with some important similarities and some interesting differences.
We also studied approximately 200 cases and 200 controls and also assessed the 'big five' personality traits (neuroticism...
I read with interest the editorial by D Wilkinson and B Stenson commenting on a series of papers which suggest that current outcomes of neonates with APGAR scores of zero at 10 minutes are not universally poor. Given that stopping at 10 minutes in all cases will then lead to a number of unnecessary death they rightly ask what stopping time is appropriate.
I wonder if this is the right question. A baby who has fa...
A culture-negative neonatal sepsis is more than herpes virus infection
Ying Dong a, Christian P. Speer b
a Department of Paediatrics, Children's Hospital of Fudan University, Shanghai, China
b University Children's Hospital, University of Wurzburg, Wurzburg, Germany
We highly appreciate the authors' contribution to the full picture of pathogens causing systemic late-onset neonatal inf...
Prognostication using whole genome and whole exome (WG/WE) sequencing depends on the use of a tool which - currently - has the potential to add to rather than decrease uncertainty. A problem in using information from genomic testing as a prognostic tool is the self-fulfilling nature of these 'diagnoses'. Many of these will initially be hypotheses, which become untestable unless the same genotypes are seen in family member...
Unfortunately the authors have failed to understand the utility of CRP at 18-24 hours. This has a high negative predictie value but low positive predictive value. This means that while a low CRP is reassuring but a high value has to be evaluated in the clinical context. A high CRP should not be equal to a lumbar puncture. I should point that NICE guidelines do not recommend using CRP in isolation and clinical acumen sho...
We are grateful to our colleagues Haines and Davis from the UK for their comments confirming many of our findings in their British population -based cohort. We agree that differences in findings (e.g., different rates of syndromal anomalies associated with congenital chylothorax) may simply be due to small numbers. It is nice to see that this rare but serious condition is receiving more scientific attention
Confl...
I read this Randomised controlled trial with great interest. I applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside round is appropriate is of limited value and so deeper qualitative discourse is needed. This can consider more meaningful questions such as 'how', 'why' and 'when' such parental presence impacts the neonatal j...
We appreciate the feedback and clarity provided by the letter in response to our review article. We agree in principle with the authors that beta-blockers have rapidly become the standard of care for infantile haemangiomas (IHs), and for this reason listed it first in our short review of treatment options. Indeed, a recent meta-analysis of 35 studies (representing 572 paediatric patients with IHs) strongly supported the...
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