92 e-Letters

published between 2014 and 2017

  • Response to Hewson M, Resuscitation saturation targets

    We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.

    Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.

    We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).

    We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...

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  • Resuscitation saturation targets

    This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .

    The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.

    It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.

    The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).

    I suggest a target of 90...

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  • Moral distress is always a burden. Moral stress is not. The importance of a priori conceptual clarity.

    It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...

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  • 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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  • Time to explore the variation in outcome at 22-23 weeks

    I congratulate the authors for putting the results of this much needed study together and exploring the differences in survival for extremely preterm babies at 22-23 weeks. The outcome for babies born at < 26 weeks hasn't been looked at nationally since the EPICURE 2 study in 2006.
    It is interesting to note the regional variation in survival at 22-23 weeks and it warrants further exploring the following issues:
    1. Is there a variation nationally in administering antenatal steroids at <24 weeks gestation? The NICE guideline 2015 advocates:
    For women between 23+0 and 23+6 weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P-PROM, discuss with the woman (and her family members or carers as appropriate) the use of maternal corticosteroids in the context of her individual circumstances. This is open to interpretation and may not provide consistency in administration of antenatal steroids at 23 to 23+6 weeks. There is no guidance for <23 weeks. It will be useful to explore the practice nationally.
    2. The practice for resuscitation at <23 weeks is likely to be variable. The latest national guideline BAPM 2008 advocates If gestational age is certain and less than 23+0 (i.e. at 22 weeks) it would be considered in the best interests of the baby, and standard practice, for resuscitation not to be carried out. The units who were resuscitating babies <23 weeks were deviating from...

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  • 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.

  • 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?

    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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  • 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