482 e-Letters

published between 2014 and 2017

  • Neonatal ethanol/isopropanol exposure in isolettes


    We read Hsieh et al's paper with much interest. In an experimental study of ethanol introduction in an empty isolette, they conclude that neonates in isolettes are at risk of of inadvertent exposure to ethanol from hands cleaned with ethanol-based hand sanitiser.
    We would like to share with the readers of Arch Dis Child Fetal Neonatal, the results of a similar study conducted in 2011. Measurements of isopropanol/ethanol exposure were conducted for 9 neonates nursed in incubators1. We found very variable exposure profiles with peak isopropanol/ethanol value of 1982, respectively 906 ppm. A wide range of possible exposure situations were also investigated using a one-box dispersion model2. Both our clinical and experimental papers offered different approaches to reduce the potential isopropanol/ethanol exposure for neonates nursed in isolettes.
    We were delighted to read that the results from Hsieh et al. were concordant with our findings. We believe that this new publication gives further evidence and emphasis on the, unfortunately often underestimated, issue of neonatal exposure to gaseous pollutants.

    1 Paccaud et al. Hand-disinfectant alcoholic vapors in incubators. JNPM 4(1):15-19, 2011
    2 Vernez et al. Solvent vapours in incubators: a source of exposure among neonates? Gefahrstoffe -Reinhaltung der Luft 71 (5):209-214, 2011

  • Re: Logistic regression equation and (co)variance matrix for estimating developmental outcome in very preterm infants

    Dear Dr. Degraeuwe,

    We thank you very much for your question and we would appreciate having the opportunity to share the full results of the regression analyses for our 3 outcomes: neurodevelopmental impairment, significant neurodevelopmental impairment and significant neurodevelopmental impairment or death. The omission of this information was due solely to the manuscript restrictions on words and tables. We agree with you that this information is useful. As we are not able to provide tables in an e-letter, we would be happy to share this information via e-mail with any interested reader.


    Anne Synnes, MDCM, MHSC, FRCPC
    Neonatologist, BC Women’s Hospital and Health Centre,
    Clinical Professor, Department of Pediatrics, University of British Columbia
    Director, Canadian Neonatal Follow-Up Network
    Vancouver, Canada

  • Response: High flow nasal cannula versus NCPAP: No difference in time to full oral feeds

    We are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
    The first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstru...

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  • RE: Hemoglobin discordances in twins: Still unanswered!!!

    We thank dr. Kumar and dr. Yadav for their interest in our study. We hope that by stating ‘delayed cord clamping may not be advisable in second-born MC twins after vaginal birth’, we expressed that gynecologists could consider to deviate from the international guidelines in some cases. It is possible that not all babies will benefit from placental transfusion in a similar way. However, we certainly agree with dr. Kumar and dr. Yadav that the optimal timing of umbilical cord clamping in twins warrants further investigation.

  • Physiology of umbilical blood flow with uetrotonics?; in reply

    Thank you for your interest in our study and your comment. When you read the 6th paragraph of the discussion of the article, you will find that we completely agree that Oxytocin could have influenced the observations. This was an observational study and moment of oxytocin was given to the discretion of the midwife. Nevertheless, we still observed umbilical circulation much longer than previously described. This study was performed in 2015, but our local guideline has recently been changed to administering oxytocin after cord clamping. A new study is currently undertaken using the same methodology.

  • Physiology of umbilical blood flow with uetrotonics?

    Thank you for this interesting and highly needed piece of knowledge on physiological umbilical bllod flow. Just one remark: uterotonics were given to all women directly after birth. Oxytocin may alter umbilical blood flow due to modifications in timing and strength of contractions, and influence timing of placental disattachment. Possibly, true physiological blood flow may be still different (and continue for even longer), if medication were administered after clamping (quite possibly with no significant disadvantage for the parturient).

  • PreROP Trial - Intention to treat analysis and Hypoglycemia monitoring

    Dear Editor
    We genuinely appreciate the readers keen interest in our paper and critical comments.1 Here are our clarifications regarding their comments.
    1. The readers have perhaps misunderstood the concept of “intention to treat analysis” and “per protocol analysis”.2 Infants were analysed as they were randomized in their respective groups (intention to treat analysis). Per protocol analysis excludes the patients who deviate from the protocol. In our study, we needed to exclude the infants who were lost to follow-up and therefore their outcomes were not known. We did not exclude them because there was a protocol deviation or violation.
    2. Blood dextrose levels were monitored as per unit protocol and once stable on full enteral feeds they were done once a week along with weekly routine blood evaluations up to discharge. No additional testing for blood sugars was done for the study.
    3. We believe that propranolol at lower doses of 0.5mg/kg/dose 12 hourly is unlikely to affect the normal vascularization in other organs. This drug has been previously used in newborns including preterm newborns for different indications. Till date there have been no reports of deranged neuro-developmental outcome attributed to propranolol. However, we agree with the readers thoughts that long term neuro-developmental outcome would have been useful but this was beyond the scope of this study.
    4. In our study, for babies born at 31-32 weeks post menstrual age the...

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  • Letter to editor

    Dear Sir/Madam,
    We read with great interest the article by Sanghvi et al1 titled “Sanghvi KP, Kabra NS, Padhi P, Singh U, Dash SK, Avasthi BS. Prophylactic propranolol for prevention of ROP and visual outcome at 1 year (PreROP trial). Arch Dis Child Fetal Neonatal Ed. 2017 Jan 13. pii: fetalneonatal-2016-311548. doi: 10.1136/archdischild-2016-311548. [Epub ahead of print]” published in your journal which concluded that prophylactic propranolol in the prescribed dose of 1 mg/kg/day showed a decreasing trend in all outcomes of ROP though statistically not significant. We appreciate that it was a double blinded study which tried to see the effect of propranolol prophylaxis on ROP prevention in lower doses without any serious adverse events.

    This trial was need based and addressed a very important and clinically relevant issue. However, we would like to address a few important concerns which came to our notice while reading through the article.

    The authors state that the analysis was planned according to intention to treat(ITT) analysis, but if we see the final analysis in flow diagram, the babies which were lost to follow up are not included in the analysis. Thus, it is not a ITT but a per protocol analysis.2

    The babies received study drug till 37 weeks or till complete vasularization of retina. Were blood dextrose levels monitored till this time? If the response is yes, then this would expose these tiny neonates to unnecessary daily pricks and pa...

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  • Implementation of an automated oxygen Control system- Are we ready?

    We read with great interest the article by Van Zanten HA et al., published in this journal and found it very useful.1 The author rightly stated that the results reflect the real situation as data were collected for the duration infants were admitted, while nurses taking care of them and where workload varied. It will be very relevant for developing countries where nurse patient ratio is poor. But; at the same time would like to offer following comments, clarification to which would benefit the readers of this journal and will help in replication of these results in different settings also.
    It is not very clear whether it was a prospective study or retrospective. In Introduction section, in the end, the author mentioned that we performed a retrospective study in preterm infants to evaluate automated fraction of inspired oxygen (FiO2) control when it was used as standard care and thus for a longer period. While in “Methods” section it is mentioned that it was a prospective observational study. These contradictory statements create confusion to the reader.
    The author mentioned that during the manual period, the nurses manually titrated the supplemental oxygen following local guidelines. However; these guidelines are not given in the current paper. It would be better if clear guidelines would have been described like other studies to improve the external validity and generalizability.2
    In the present study, FiO2 and pulse oximeter saturation (SpO2) were sa...

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  • Implementation of an automated oxygen Control system- Are we ready?

    We read with great interest the article by Van Zanten HA et al., published in this journal and found the results impressive.[1] However, we have certain observations about the conduct of the study
    Even though the authors state that this report was part of a quality improvement initiative in their NICU, the authors have neither reported the results in the format suitable for a quality improvement study nor have clearly stated the design; at the end of introduction they seem to mention that this was a retrospective data analysis; whereas, in the first line of the methods they state the design as a prospective observational study. Even though the automatic oxygen controller group would not have been affected much by any one of the design, the impact would have been in the manual group, keeping especially the training of the NICU staff in mind. It’s also worth emphasizing here that the authors mention about the local guidelines practiced for manual titration of supplemental oxygen based on the saturations, for the sake of external validity.[2]
    Minute wise data points used in this study may have significantly underestimated the hypoxemic episodes and thereby the proportion of times an infant remained in the ‘below target range’ saturations. In a logical sense, manual titration would have happened sooner than expected for a hypoxemic event and hence would not have been captured if more frequent data points are not considered. Using the same technology and a lesser in...

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