We read with interest the article "Fever in healthy asymptomatic
newborns during the first days of life" by Maayan-Metzger et al.[1]
The
article reinforced awareness about the occurrence of fever in term
asymptomatic newborns during early neonatal life. It brought out
association of risk factors viz. weight loss, exclusive breast feeding,
Caesarean delivery & higher birth weight w...
We read with interest the article "Fever in healthy asymptomatic
newborns during the first days of life" by Maayan-Metzger et al.[1]
The
article reinforced awareness about the occurrence of fever in term
asymptomatic newborns during early neonatal life. It brought out
association of risk factors viz. weight loss, exclusive breast feeding,
Caesarean delivery & higher birth weight with fever in otherwise
asymptomatic newborns & showed that sepsis was the least common cause
of fever in such babies.
The authors are requested to comment on following
observations for better confidence and implication of their research outcome.
1.In the study, the mean duration of fever mentioned is 2.9 hrs which is
too less a time for early detection in a routine busy maternity ward and also as compared to other similar studies.[2]
2. In the study it has been observed that total leukocyte count > 5000/µl has been considered normal, but upper cutoff of normal count is
not defined. In newborns, sepsis can present either as neutropenia or
neutrophilia and hence there was a scope of missing babies who had sepsis and had higher leucocyte counts >15000/µl.[3]
3. In contemporary practice of neonatology, febrile newborns with no
other symptoms or signs with negative rapid diagnostic tests for sepsis
are being managed safely as inpatients for further observation without
antibiotic therapy.[4] Hence, it would be useful to know the criteria
applied to administer antibiotics to neonates in the present study with
stated negative laboratory results for infection.
4. Gaudelus J et al. in his study recommended performing spinal tap in all
suspected cases of neonatal sepsis presenting as fever alone.[5] With the
mean fever duration of only 2.9hrs, how was a decision taken to perform
CSF examination only in 109 out of 122 neonates in the study?
5. As viral infections can also present initially with only fever while
other clinical manifestations may appear late and will have negative
markers for bacterial infection, it would be useful to observe such
febrile babies for a longer period of time so as to avoid missing viral
sepsis.[6]
In tropical countries like India, during summer months, healthy
neonates on exclusive breast feeds commonly develop fever on day 2 or 3 of
life which at times is associated with hypernatraemia, renal failure &
occasionally mortality. Such babies are managed with effective
environmental cooling, better feeding, intravenous fluids, supportive
& symptomatic therapies. The important component of management always
includes focused attention to enhance maternal lactation.
References
(1) A Maayan-Metzger, R Mazkereth and J Kuint. Fever in healthy
asymptomatic newborns during the first days of life.Arch Dis Child Fetal
Neonatal Ed.2003; 88:F312.
(2) Dagan R, Sofer S, Phillip M,Shachak E. Ambulatory care of febrile
infants younger than 2 months of age classified as being low risk for
having serious bacterial infections. J Pediatr. 1988 Mar; 112(3);355-60)
(3) Jaskiewicz Ja, McCarthy CA, Richardson AC, White KC, Fisher DJ, dagan
R, Powell KR Febrile infants at low risk for serious bacterial infection--
an appraisal of the Rochester criteria and implications for management.
Febrile Infant Collaborative Study Group.Pediatrics. 1994 Sep;94(3):390-6.
(4) Chiu CH, Lin TY, Bullard MJ. Identification of febrile neonates
unlikely to have bacterial infections.Pediatr Infect Dis J. 1997
jan;26(1):59-63.
(5) Gaudelus J., Fever in infants under the age of three months without
sign of focal infection. Criteria of therapeutic decision.Presse Med.1994
Apr 30-may 7; 23(17): 785-7.
(6) Filippine MM, Katz BZ. Neonatal herpes simplex virus infection
presenting with fever alone. J Hum Virol. 2001 Jul-Aug;4(4):223-5.)
There is one reason why I was initally interested to read the
systematic review of intravenous immunoglobulin in haemolytic diseases of
the newborn [1] and then concerned by the published responses.
Neither the authors of the systematic review published in Archives
nor the respondents to that article cited or discussed the 2002 Cochrane
systematic review on exactly the same neonatal topic...
There is one reason why I was initally interested to read the
systematic review of intravenous immunoglobulin in haemolytic diseases of
the newborn [1] and then concerned by the published responses.
Neither the authors of the systematic review published in Archives
nor the respondents to that article cited or discussed the 2002 Cochrane
systematic review on exactly the same neonatal topic (Alcock and Liley,
2002).[2] The Cochrane reviewers (who analysed the 1966 to 2002 literature)
came to different conclusions. They stated that although the results show
a significant reduction in the need for exchange transfusion in those
treated with intravenous immunoglobulin, the applicability of the results
is limited. Alcock and Liley concluded that the number of studies (3) and
infants (189) included "is small and none of the three included studies of
high quality". Two
of the studies mandated the use of early exchange transfusion, limiting
the generalizability of the results. The final conclusion was that further
well designed studies are needed before routine use of intravenous
immunoglobulin can be recommended for the treatment of isoimmune
haemolytic jaundice.
Please reassure the readers that Cochrane has not been banished from
Archives.
References
(1) Gottstein R, Cooke RWI. Systematic review of intravenous
immunoglobulin in haemolytic disease of the newborn. Arch Dis Child Fetal
Neonatal Ed 2003;88:F6–F10.
(2) Alcock GS, Liley H. Immunoglobulin infusion for isoimmune
haemolytic jaundice in neonates. Cochrane Database Syst Rev
2002;(3):CD003313.
Robert's and Murray has given an excellent review on the above topic
and shared their experiences in the management of neonatal
thrombocytopenia. Truely it is very controversial when to transfuse
platelets in babies with thrombocytopenia. It is a well known fact that
platelet transfusions do not save babies but give enough time for the
antibiotic to act if the underlying cause is sepsis. We had experie...
Robert's and Murray has given an excellent review on the above topic
and shared their experiences in the management of neonatal
thrombocytopenia. Truely it is very controversial when to transfuse
platelets in babies with thrombocytopenia. It is a well known fact that
platelet transfusions do not save babies but give enough time for the
antibiotic to act if the underlying cause is sepsis. We had experienced
situautions where platelets have gone down to <_10000 but="but" later="later" recovered="recovered" without="without" sequelae="sequelae" eventhough="eventhough" no="no" platelets="platelets" were="were" transfused.="transfused." p="p"/> Authors have not mentioned about the benign thrombocytopenia of
pregnancy and its effects in the newborn. In 1996 I have conducted a study
in Sultanate of Oman among pregnant mothers with gestational
thrombocytopenia and their newborns (unpublished data). 1.8%(11/600) of
mothers had thrombocytopenia without any underlying cause. Among the
babies born to these mothers with gestational thrombocytopenia the
incidence of thrombocytopenia was 27%(3/11). One baby had platelet count
below 30,000 and was asymptomatic. Baby spontaneously recovered over a
period of 5 days. Others had counts above 50,000 and spontaneous recovery
was recorded over a period of 3-4 days.
A knowledge of this type of benign thrombocytopenia is useful for
Obstetricians as well as to Pediatricians when confronted with a newborn
having thrombocytopenia but clinically well.
We read with interest the article entitled “Contamination of a milk
bank pasteuriser causing a Pseudomonas aeruginosa outbreak in a neonatal
intensive care unit” by Gras-Le Guen et al.[1]
This article dealt with
clinical features of Pseudomonas infection in neonates after milk
contamination. Pseudomonas is a rare pathogen in neonatal populations but
the associated mortality and morbidity a...
We read with interest the article entitled “Contamination of a milk
bank pasteuriser causing a Pseudomonas aeruginosa outbreak in a neonatal
intensive care unit” by Gras-Le Guen et al.[1]
This article dealt with
clinical features of Pseudomonas infection in neonates after milk
contamination. Pseudomonas is a rare pathogen in neonatal populations but
the associated mortality and morbidity are huge. Leigh et al. [2] found a
mortality rate of 50% in a population of very low birth weight infants
with Pseudomonas infections. Gupta et al.[3] found a mortality rate of 23%
amongst a cross-section of babies of all birth weights with Pseudomonas
infections.
One major complication of Pseudomonas infection which did not arise
in the recently reported1 outbreak is Pseudomonas endophthalmitis. The
exact incidence of this infection is unknown. However an estimated 75% of
cases of endophthalmitis are thought to be due to Pseudomonas infection.[4]
Thus any abnormal ophthalmological examination in a sick or septic neonate
should raise the possibility of Pseudomonas infection. The clinical
manifestations of endophthalmitis include corneal injection, eye discharge
and, in severe cases, proptosis, corneal clouding and complete corneal
opacification.
A very important and possibly under-recognised association of
endophthalmitis is meningitis.[5] The severe morbidity and mortality
associated with endophthalmitis is possibly related to the co-existence of
meningitis. In one series 6 of 4 patients with Pseudomonas endophthalmitis,
3 died of overwhelming sepsis and 1 suffered enucleation of the affected
eye but had no other complications.
In summary, any unwell or septic neonate with an abnormal eye
examination merits empiric treatment with antipseudomonal antibiotics.
Pseudomonas endophthalmitis is a neonatal and ophthalmological emergency.
Endophthalmitis and meningitis co-exist frequently: the presence of one
does not preclude the other and the presence of endophthalmitis should
prompt a search for meningitis.
References
(1) Gras-Le Guen C, Lepelletier D, Debillon T, Gournay V, Espaze E, Roze J
C. Contamination of a milk bank pasteuriser causing a Pseudomonas
aeruginosa outbreak in a neonatal intensive care unit. Arch Dis Child
Fetal Neonatal Ed 2003;88:F434-F435.
(2) Leigh L, Stoll BJ, Rahman M, McGowan J Jr. Pseudomonas aeruginosa
infection in very low birth weight infants: a case-control study. Pediatr
Infect Dis J 1995;14(5):367-71.
(3) Gupta AK, Shashi S, Mohan M, Lamba IM, Gupta R. Epidemiology of
Pseudomonas aeruginosa in a neonatal intensive care unit. J Trop Paediatr
1993;39(1):32-6.
We read with interest the article “Noise levels within the ear and post-nasal space in neonates in Intensive care” by SS Surenthiran et al.[1] The article makes neonatal care providers conscious of the
respiratory support generated turbulence of air in the post nasal space
with potentially dangerous high levels of noise. Therefore, the article
has potential to change the attitude of neonatal...
We read with interest the article “Noise levels within the ear and post-nasal space in neonates in Intensive care” by SS Surenthiran et al.[1] The article makes neonatal care providers conscious of the
respiratory support generated turbulence of air in the post nasal space
with potentially dangerous high levels of noise. Therefore, the article
has potential to change the attitude of neonatal ventilatory support
providers with long term neonatal benefits . However, we wish to seek
clarifications on following points which are of research relevance.
1. In this study all the babies were nursed inside incubator. As
per study of Gupta V et al,[2] it is known that incubators of different
make produce varying levels of noises. Therefore it is pertinent to know
whether all babies were kept in the incubators of same or different make,
and what were their baseline sound preserve levels (SPL). This will
permit adjustment to external confounder.
2. The sound produced by CPAP which was nasal has been compared with
conventional mechanical ventilation (CMV). It would be relevant for
research analysis to know that how many babies were given CMV with
Nasotracheal tube and how many with orotracheal tube? As the nasal
endotracheal tube is likely to have more SPL in post nasal space than
orotracheal tube.
3. The SPL of various flow rates has been analyzed for CPAP. It would be
relevant to know the effects on SPL of flow variations during CMV.
We therefore, solicit author’s comments for more effective answer to
such an important research question.
References
(1) Surenthiran S S, Wilbrham K, May J, Chant T, Emmerson AJB, Newton
VE. Noise levels within the ear and post-nasal space in neonates in
intensive care. Arch Dis Child Fetal Neonatal Ed 2003;88;F315-F318.
(2) Gupta V, Gupta G, Nair MNG, Soodan KS. Sound levels in NICU. (ICMR supported research Yr 2003, not yet published)
Whilst the leading article by Menon [1] provides an
excellent overview of the use and complications of
different types of neonatal venous lines. We must
point out that in our retrospective study,[2] we
demonstrated that pericardial effusions (PCE) were
extremely rare with an incidence of 1.8/1000 (0.18%)
lines inserted not 1.8%. as stated by Dr Menon.
Whilst the leading article by Menon [1] provides an
excellent overview of the use and complications of
different types of neonatal venous lines. We must
point out that in our retrospective study,[2] we
demonstrated that pericardial effusions (PCE) were
extremely rare with an incidence of 1.8/1000 (0.18%)
lines inserted not 1.8%. as stated by Dr Menon.
We agree with Menon1 and the Associate Editor [3] that a
prospective study would provide more accurate
information about the many potential complications,
including PCE associated with percutaneous long lines
(PLL). An audit of parenteral nutrition and central
venous line use in neonatal units was proposed by the
National Institute for Clinical Excellence (NICE) in 2001
following publication of the Department of Health review
of neonatal deaths due to cardiac tamponade.[4]
The National Collaborating Centre for Women and
Childrens Health approached us for guidance on
drafting their study proposal that was sent to the British
Association of Perinatal Medicine in 2002 for
consultation. Since then clinical practice and the
priorities of NICE have changed. Could a national
survey be conducted and would it be worthwhile? The
manufacturers of PLLs have indicated a willingness to
include a survey form with each line that could be used
to provide denominator data in a national survey.
However our experience of conducting a 12 month
prospective audit of PLL use in neonatal units across
the Eastern Region has proved challenging. We have
obtained accurate information on more than 500 lines
but this has required careful liaison with consultants,
specialist registrars and named nurses in the
participating units to ensure that audit forms were
properly completed.
We are concerned that considerable motivation would
be required for a national prospective study to obtain
accurate data. Incomplete data collection runs the risk
of producing more misinformation and
recommendations that do not necessarily positively
influence medical care. We believe that paediatricians
are much more aware of the risks and benefits of PLLs,
and take more care in siting and using lines. Even
though PCE is a rare complication the signs of
presentation are being recognised earlier by neonatal
staff leading to potentially life saving interventions.
We submitted a phase one application to the British
Paediatric Surveillance Unit (BPSU) in early 2002 to
prospectively determine the incidence and outcome of
neonatal PCE associated with PLL. The BPSU
executive recognised the importance of the problem but
rejected the study proposal because of the difficulties in
determining an accurate denominator figure for number
of lines inserted. However, we believe it would be
important in defining the number of cases per year and
potential risk factors. May be we should send them
your recommendation.
References
(1) G Menon. Neonatal long lines. Arch Dis Child Fetal
Neonatal Ed 2003;88:F260-F262.
(2) K Beardsall, D K White, E M Pinto, and A W R Kelsall.
Pericardial effusion and cardiac tamponade as
complications of neonatal long lines: are they really a
problem? Arch Dis Child Fetal Neonatal Ed 2003;
88:F292-F295.
(3) Martin Ward Platt. Fantoms. Arch Dis Child Fetal
Neonatal Ed 2003;88:F260.
(4) Department of Health. Review of the deaths of four
babies due to cardiac tamponade associated with the
presence of central venous.
As relatively new milk bank (3 years old) we are constantly on the
look out for ways of reducing the risks involved. With the article by Gras
-Le Guen et al[1] we thought we might learn
some valuable lessons.
However the substance of the article would seem to be that a
pasteuriser was being used to thaw frozen milk. The water in the
pasteuriser became contaminated by pseudomonas and thi...
As relatively new milk bank (3 years old) we are constantly on the
look out for ways of reducing the risks involved. With the article by Gras
-Le Guen et al[1] we thought we might learn
some valuable lessons.
However the substance of the article would seem to be that a
pasteuriser was being used to thaw frozen milk. The water in the
pasteuriser became contaminated by pseudomonas and this pseudomonas was
probably transmitted to the neonatal unit on the cover of the milk bottles
and became established in a bottle warmer.
It transpires that on this occasion we have nothing to learn. We
operate in accordance with the guidelines of the UK milk bank association
both for donor milk [2] and mothers own milk.[3] Under these guidelines
frozen donor milk is thawed either in a refrigerator over 24 hours or
"rapidly .. in running cold or lukewarm water" or for mothers own milk "
Frozen milk should ideally be thawed in a fridge … in an emergency the
preferred method is to hold the bottle under cold or tepid running water".
We cannot help wondering if the pasteuriser in question was being
used as a pasteuriser at the time in question or merely as a milk
warmer. The latter is clearly a relatively high risk environment for
culture of pseudomonas – warm and moist. A pasteuriser is a much lower
risk area – relatively short burst of relatively high temperature followed
by periods of draining and drying.
The authors acknowledge the rarity of human milk banks as a source of
contamination. Part of the reason, at least in the UK, is undoubtedly the
high standards promoted by the UK Human Milk Bank Association. These are
currently being updated. Any milk bank that does not have a local
supervisory organisation would be well advised to acquire a copy and they
could do worse than make them the basis of their working practice.
References
(1) Gras-Le Guen C, Lepelletier D, Debillon T, Gournay V, Espaze E, Roze JC. Contamination of a milk bank pasteuriser causing a Pseudomonas aeruginosa outbreak in a neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2003;88:F434-F435.
(2) Royal College of Paediatrics and Child Health and United Kingdom
Association for Milk Banking. Guidelines for the Establishment and Operation of Human Milk Banks in UK, 2nd Edition.
(3) Association for Milk
Banking. Guidelines for the collection, storage and handling of breast milk
for a mothers own baby in hospital United Kingdom, 2nd Edition, 2001.
We were concerned to read of the contamination of a pasteuriser in
the milk bank in Nantes, Western France. The details of milk banking
procedures in the report were sketchy and in particular we were unclear as
to why breastmilk was thawed in a pasteuriser.
Guidelines for the Establishment and Operation of Human Milk Banks in
the UK have been available since 1994 and a revised (3rd) edition will...
We were concerned to read of the contamination of a pasteuriser in
the milk bank in Nantes, Western France. The details of milk banking
procedures in the report were sketchy and in particular we were unclear as
to why breastmilk was thawed in a pasteuriser.
Guidelines for the Establishment and Operation of Human Milk Banks in
the UK have been available since 1994 and a revised (3rd) edition will be
available from UKAMB (United Kingdom Association for Milk Banking) in
October 2003. These evidence-based guidelines fully describe how human
milk can be safely collected, processed and stored. Amongst other things
they require donor milk to be tested both prior to and after
pasteurisation, and recommend that the milk be thawed either by defrosting
slowly in a refrigerator or by the careful use of running water, ensuring
the bottle cap remains dry.
The UKAMB website http://www.ukamb.org offers further information about
milk banking and how to obtain the Guidelines.
It is interesting to hear of the French experience of long lines reported
by Bedu et al.[1]
It is difficult to come to conclusions about real
differences in incidence of pericardial effusion (PCE) with different
catheter types with just one adverse event in each group in the AFSSPS
survey.[2] The results of this survey may hide other factors, including
type of unit (amount of experien...
It is interesting to hear of the French experience of long lines reported
by Bedu et al.[1]
It is difficult to come to conclusions about real
differences in incidence of pericardial effusion (PCE) with different
catheter types with just one adverse event in each group in the AFSSPS
survey.[2] The results of this survey may hide other factors, including
type of unit (amount of experience with use of long lines) and case-mix
(smaller babies may be more likely to develop some complications), which
confound the difference in outcome with the two types of catheter.
It is conceivable that there is a real difference in risk of PCE with
catheters made of different materials. This could be related to
differences in thrombogenic potential (thus the likelihood of catheter
adhesion to a vascular wall, creating the circumstances for vascular
erosion) or elasticity (thus the risk of direct perforation or looping of
redundant catheter within a cardiac chamber). The published literature
about the effect of catheter material is not clear-cut, being based on
retrospective surveys, one of which suggested that technical problems were
more frequent with silicone then polyurethane catheters, although there
were no cases of PCE in this small study.[3]
There is no mention of catheter tip position in the French survey.
The observations of Dr Bedu and colleagues serves to stress the
complicated nature of the interaction between catheter and baby which
results in PCE, a complication which cannot be abolished by a simple
change in practice. There is the need for constant vigilance both with
individual babies and at unit level in the use of long lines in neonatal
care in order to ensure that there is a careful balancing of risks.
We welcome the comment by Hassib Narchi on our paper.[1]
We (and our statistical advisor)
think we did analyze our data properly, but it is possible that methods
description was lacking. Matching a control new born to each of the study
babies was only for the purpose of creating a gestational age balanced
control group. From that point on, we compared the statistics of the two
groups rather than...
We welcome the comment by Hassib Narchi on our paper.[1]
We (and our statistical advisor)
think we did analyze our data properly, but it is possible that methods
description was lacking. Matching a control new born to each of the study
babies was only for the purpose of creating a gestational age balanced
control group. From that point on, we compared the statistics of the two
groups rather than the individual case-control pairs. Therefore we think
that using logistic regression was justified in this case.
We do not have a definite answer to the question about the
responsibility raised by Dr Narchi, however we agree that careful and
critical reading should precede any clinical use of evidence, even when it
is published in a very distinguished publication like the ADC.
Reference
(1) Narchi H. Results after incorrect analysis: with whom does the responsibility lie? [electronic response to Maayan-Metzger et al. Fever in healthy asymptomatic newborns during the first days of life] archdischild.com 2003 http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;88/4/F312#221
Dear Editor
We read with interest the article "Fever in healthy asymptomatic newborns during the first days of life" by Maayan-Metzger et al.[1]
The article reinforced awareness about the occurrence of fever in term asymptomatic newborns during early neonatal life. It brought out association of risk factors viz. weight loss, exclusive breast feeding, Caesarean delivery & higher birth weight w...
Dear Editor
There is one reason why I was initally interested to read the systematic review of intravenous immunoglobulin in haemolytic diseases of the newborn [1] and then concerned by the published responses.
Neither the authors of the systematic review published in Archives nor the respondents to that article cited or discussed the 2002 Cochrane systematic review on exactly the same neonatal topic...
Dear Editor
Robert's and Murray has given an excellent review on the above topic and shared their experiences in the management of neonatal thrombocytopenia. Truely it is very controversial when to transfuse platelets in babies with thrombocytopenia. It is a well known fact that platelet transfusions do not save babies but give enough time for the antibiotic to act if the underlying cause is sepsis. We had experie...
Dear Editor
We read with interest the article entitled “Contamination of a milk bank pasteuriser causing a Pseudomonas aeruginosa outbreak in a neonatal intensive care unit” by Gras-Le Guen et al.[1]
This article dealt with clinical features of Pseudomonas infection in neonates after milk contamination. Pseudomonas is a rare pathogen in neonatal populations but the associated mortality and morbidity a...
Dear Editor
We read with interest the article “Noise levels within the ear and post-nasal space in neonates in Intensive care” by SS Surenthiran et al.[1] The article makes neonatal care providers conscious of the respiratory support generated turbulence of air in the post nasal space with potentially dangerous high levels of noise. Therefore, the article has potential to change the attitude of neonatal...
Dear Editor
Whilst the leading article by Menon [1] provides an excellent overview of the use and complications of different types of neonatal venous lines. We must point out that in our retrospective study,[2] we demonstrated that pericardial effusions (PCE) were extremely rare with an incidence of 1.8/1000 (0.18%) lines inserted not 1.8%. as stated by Dr Menon.
We agree with Menon1 and the Associate E...
Dear Editor
As relatively new milk bank (3 years old) we are constantly on the look out for ways of reducing the risks involved. With the article by Gras -Le Guen et al[1] we thought we might learn some valuable lessons.
However the substance of the article would seem to be that a pasteuriser was being used to thaw frozen milk. The water in the pasteuriser became contaminated by pseudomonas and thi...
Dear Editor
We were concerned to read of the contamination of a pasteuriser in the milk bank in Nantes, Western France. The details of milk banking procedures in the report were sketchy and in particular we were unclear as to why breastmilk was thawed in a pasteuriser.
Guidelines for the Establishment and Operation of Human Milk Banks in the UK have been available since 1994 and a revised (3rd) edition will...
Dear Editor
It is interesting to hear of the French experience of long lines reported by Bedu et al.[1]
It is difficult to come to conclusions about real differences in incidence of pericardial effusion (PCE) with different catheter types with just one adverse event in each group in the AFSSPS survey.[2] The results of this survey may hide other factors, including type of unit (amount of experien...
Dear Editor
We welcome the comment by Hassib Narchi on our paper.[1]
We (and our statistical advisor) think we did analyze our data properly, but it is possible that methods description was lacking. Matching a control new born to each of the study babies was only for the purpose of creating a gestational age balanced control group. From that point on, we compared the statistics of the two groups rather than...
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