We read with great interest the article by Sinead J Glackin 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 it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of...
We read with great interest the article by Sinead J Glackin 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 it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of feeds. Most of the units practice cue based feeding initiation and hiking. There is enough evidence to suggest that non-nutritive sucking reduces the time infants need to transition from tube to full oral feeding,[2] here it is worth to mention about this practice in the study population.
A prospective cohort study by Shetty et al,[3] is inappropriately mentioned as case series at multiple places in the article.
Overall this trial succeeds in giving a clear message on feasibility and safety of oral feeding while on nasal CPAP or high flow nasal cannula.
Competing interests: None
Source of funding: None
References:
1. Glackin SJ, O’Sullivan A, George S, et al. High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2017;102:F329–32.
2. Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2016 Oct 4;10:CD001071.
3. Shetty S, Hunt K, Douthwaite A, et al. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 2016;101:F408-411.
We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
Despite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis an...
We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
Despite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis and with good follow up to look for differences in need of blood transfusion in postnatal age and neurodevelopmental outcome.
Competing interests: None
Source of funding: None
References:
1. Verbeek L, Zhao DP, Middeldorp JM, et al. Haemoglobin discordances in twins: due to differences in timing of cord clamping? Arch Dis Child Fetal Neonatal Ed. 2017;102: F324–8.
2. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132: S543-560.
3. Verbeek L, Zhao DP, Te Pas AB, et al. Hemoglobin Differences in Uncomplicated Monochorionic Twins in Relation to Birth Order and Mode of Delivery. Twin Res Hum Genet Off J Int Soc Twin Stud. 2016;19:241–5.
4. Lopriore E, Sueters M, Middeldorp JM, et al. Haemoglobin differences at birth in monochorionic twins without chronic twin-to-twin transfusion syndrome. Prenat Diagn. 2005;25:844–50.
Dear Editor,
We read with interest the article by Verbeek L. et al [1], showing that
the second-born twin has higher levels of hemoglobin (Hb) than first-born
co-twins after vaginal delivery (VD; Hb differential effect does not occur
in twins delivered by Caesarean section. Since Hb difference is present in
both uncomplicated monochorionic (MC) and dichorionic (DC) twin pairs,
authors focused on the time difference of umbi...
Dear Editor,
We read with interest the article by Verbeek L. et al [1], showing that
the second-born twin has higher levels of hemoglobin (Hb) than first-born
co-twins after vaginal delivery (VD; Hb differential effect does not occur
in twins delivered by Caesarean section. Since Hb difference is present in
both uncomplicated monochorionic (MC) and dichorionic (DC) twin pairs,
authors focused on the time difference of umbilical cord clampings (UCC)
for the two twins, rather than vascular anastomoses (absent in DC twins).
Precise timing data unfortunately were not recorded.
However, beside UCC timing, other factors should be taken into account for
the VD management. Recent observations have provided compelling evidence
demonstrating that UCC timing is not the only determinant of net placental
-to-infant blood transfusion [2]; uterine contractions and lung aeration
result to be determinant factors influencing umbilical artery and venous
blood flows[2]. Specifically the uterine contractions during the third
stage of labor significantly increase the placental-to-neonatal gradient
and may facilitate 50% of placental transfusion [3]; such effect is also
reported in single term neonates when the "two step" head-to-body delivery
method is used [4].
In our opinion, uterine contractions can affect the placental transfusion
more than UCC timing in the vaginally born twins: the second-born twin is
exposed to the contractions that lead to the birth of the first twin!
These additional contractions can increase the placental transfusion and
the risk of polycithemia both in DC and MC twins; moreover, in second-born
MC twin, contractions can determine acute inter-twin blood transfusion
through placental vascular anastomoses.
In agreement with authors [1], targeted studies in the twins delivered
vaginally should be carried out to establish the optimal UCC timing;
anyway we recommend evaluating also the effect of uterine contractions as
well as medications administered to the mothers, such as oxytocin-like
components.
REFERENCES
1. Verbeek L, Zhao DP, Middeldorp JM, et al. Haemoglobin discordances in
twins: due to differences in timing of cord clamping? Arch Dis Child Fetal
Neonatal Ed. 2016 Dec 9. pii: fetalneonatal-2016-311822.
2. Hooper SB, Binder-Heschl C, Polglase GR, et al. The timing of umbilical
cord clamping at birth: physiological considerations. Matern Health
Neonatol Perinatol. 2016 Jun 13;2:4. Review.
3. Katheria AC, Lakshminrusimha S, Rabe H, et al . Placental transfusion:
a review. J Perinatol. 2016 Sep 22.
4. Zanardo V, Gabrieli C, de Luca F, et al . Head-to-body delivery by "two
-step" approach: effect on cord blood hematocrit. J Matern Fetal Neonatal
Med. 2013 Aug;26(12):1234-8.
We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.
Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]
We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.
Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]
Reference List
1. McDonald SJ, Middleton P, Dowswell T, Morris PS: Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2013;CD004074.
2. Westgate JA, Wibbens B, Bennet L, Wassink G, Parer JT, Gunn AJ: The intrapartum deceleration in center stage: a physiologic approach to the interpretation of fetal heart rate changes in labor. Am J Obstet Gynecol 2007;197:236-11.
3. Hooper SB, Binder-Heschl C, Polglase GR, Gill AW, Kluckow M, Wallace EM, Blank D, Te Pas AB: The timing of umbilical cord clamping at birth: physiological considerations. Matern Health Neonatol Perinatol 2016;2:4.
I read with interest your article on spontaneous ping pong parietal fracture in newborns with impressive color images .The word 'fracture' can be quite traumatic to the parents and should avaoided if there is no radiological evidence of break in the cortex 1. It should then just be labelled as depression of skull bone without a fracture rather than labelling as DCF( depressed calvarial fracture) as mentioned in your article .You have also clearly demonstrated in your 3D CT image also that there was no break but only invagination of parietal bone .The management would also not change whether the depression is with or without fracture .
References -
Tayeh,et al.BMJCase Rep2016.doi:1136/bcr-2016-215437
Neonatal health-care providers have the duty to fully inform parents
about the prognosis of their sick, extremely preterm infant.
Prognostication is however difficult since survival and long-term outcome
are multifactorially influenced, and the quality of prognosis research is
often poor. [1] By reporting "Determinants of developmental outcomes in a
very preterm Canadian cohort" [2], Synnes et al. extend the previous wor...
Neonatal health-care providers have the duty to fully inform parents
about the prognosis of their sick, extremely preterm infant.
Prognostication is however difficult since survival and long-term outcome
are multifactorially influenced, and the quality of prognosis research is
often poor. [1] By reporting "Determinants of developmental outcomes in a
very preterm Canadian cohort" [2], Synnes et al. extend the previous work
of the Canadian Neonatal Network [3], thereby refining the possibility of
long-term prognostication. Forward stepwise logistic regression analyses
were performed for neurodevelopmental impairment (NDI), severe NDI (sNDI)
and "sNDI or death". Unfortunately, the paper does not include the
logistic regression equations. I kindly request the authors to further
document their findings by sharing the following data: for each of the
studied outcomes, the full logistic regression equation of Step 4 (with
standard errors of the regression coefficients) and the variance or
covariance matrix (enabling to calculate the confidence interval for the
risk estimates). It would be regrettable if this useful information would
remain concealed from the reader.
References
1. Hemingway H, Riley RD, Altman DG. Ten steps towards improving prognosis
research. BMJ 2009;339:b4184 doi: 10.1136/bmj.b4184[published Online
First: Epub Date]|.
2. Synnes A, Luu TM, Moddemann D, et al. Determinants of developmental
outcomes in a very preterm Canadian cohort. Arch Dis Child Fetal Neonatal
Ed 2016 doi: 10.1136/archdischild-2016-311228[published Online First: Epub
Date]|.
3. Ge WJ, Mirea L, Yang J, et al. Prediction of neonatal outcomes in
extremely preterm neonates. Pediatrics 2013;132(4):e876-85 doi:
10.1542/peds.2013-0702[published Online First: Epub Date]|.
We read this article with considerable interest as it confirms that
Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate
within seconds of birth, much earlier than is possible with oximetry and
much more reliably than with auscultation. As the authors state "Handheld
Doppler use for measuring newborn HR has been described in the literature"
(by Goenka et al and by Hutchon) "but needs further investigat...
We read this article with considerable interest as it confirms that
Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate
within seconds of birth, much earlier than is possible with oximetry and
much more reliably than with auscultation. As the authors state "Handheld
Doppler use for measuring newborn HR has been described in the literature"
(by Goenka et al and by Hutchon) "but needs further investigation before
being used clinically.". Dyson et al chose to use a Hadeco Smartdop 45
(Hadeco--2-7-11 Arima, Miyamae-ku, Kawasaki, 216-0003, Japan), which is a
bidirectional handheld Doppler usually used for measuring arterial and
venous blood flow in the extremities although it can also detect a fetal
HR. In 2014 we demonstrated the use of a readily available and low cost
dedicated fetal doppler machine and found the 2mHz probe readily detected
the neonatal heart rate when placed on the chest(1). We reported on the
Contec Sonoline C2 Pocket Fetal Doppler which also provides a digital
display of heart rate and records the signal for subsequent computer
download, and documentation and review.
We have also shown that if the transducer is separated from the hand
held probe of the machine and connected with light flexible wiring, the
lightweight transducer can sit on the neonate's chest held in place simply
by the surface tension of the ultrasound gel. This allows hands-free use
and avoids the risk of excessive pressure by a handheld probe on the
neonate's chest. The position of the transducer on the chest is not
critical and can easily be adjusted. By aligning with the skin the
transducer automatically scans at 90 degrees.
https://www.youtube.com/watch?v=ut0vpZxkidI
Precordial Doppler Ultrasound (PDU) can be readily adapted to provide
a measurement of the neonatal heart rate at caesarean section without
compromising the sterile surgical field. The Doppler machine is connected
to a bluetooth transmitter and placed inside a sterile polythene bag
ensuring that transducer is coated in ultrasound gel and in contact with
the wall of the bag. The transducer can then be handled by a member of the
scrubbed team and applied to the neonatal chest through a further
application of ultrasound gel. The signal is received by a matching
bluetooth receiver outside the sterile field. This can be used to provide
an audible signal to the neonatologist and team and recorded for
documentation and audit.
For the preterm neonate at risk of hypothermia it is important to
avoid exposure of the skin and PDU can be carried out through the
recommended polythene wrap without the exposure of the neonatal skin
required by ECG or oximetry.
Although we reported on the Contec Sonoline C2 Pocket Fetal Doppler,
other machines without a recording facility have been shown to be as
effective. After a few minutes when oximetry is functional the PDU becomes
redundant.
References
Goenka S, Khan M, Koppel RI, Heiman HS. Precordial Doppler Ultrasound
Achieves Earlier and More Accurate Newborn Heart Rates in the Delivery
Room. Pediatric Academic Societies and Asian Society for Pediatric
Research
2014; 590p.
Hutchon DJR. Technological Developments in Neonatal Care at Birth. J
Nurs Care 2014; 3: 218.
We thank Dr Hutchon for his interest in our article and acknowledge
his contribution to developing this technique of measuring heart rate
rapidly and efficiently in newborns. We were particularly interested to
hear of his experience with a Doppler that displays an averaged heart
rate. We can see that having a displayed rather than counted Doppler
heart rate would be highly practical in the delivery room providing that...
We thank Dr Hutchon for his interest in our article and acknowledge
his contribution to developing this technique of measuring heart rate
rapidly and efficiently in newborns. We were particularly interested to
hear of his experience with a Doppler that displays an averaged heart
rate. We can see that having a displayed rather than counted Doppler
heart rate would be highly practical in the delivery room providing that
it is accurate, able to detect heart rates of <60bpm and has a suitably
short averaging time. During our study we found that counting the audible
Doppler sound was considerably more accurate than using the displayed
heart rate provided by our Doppler machine Hadeco Smartdop 45(Hadeco--2-7-
11 Arima, Miyamae-ku, Kawasaki, 216-0003, Japan) (1) and cannot find other
published data to the contrary. We also agree that there are clearly
practical and ergonomic advantages to having a hands free transducer as
has been described by Dr Hutchon, particularly if this can be used with a
Doppler that is used for fetal heart rate monitoring and therefore already
present in the delivery room.
We think that the focal depth of the probe is likely to have an
impact on the accuracy of the device given the variation in size of the
neonatal population and found that our 8MHz probe was more accurate in
smaller babies <1.5kg (1). We found that while it has been shown that
the using a 2MHz probe is effective in detecting the heart rate in
newborns over 35 weeks gestation in the delivery room (2), we wonder if
the focal depth of 10cm of a 2MHz probe might make it difficult to obtain
accurate measurements in smaller preterm newborns and feel that this
should be a direction of further research.
1. Dyson A, Jeffrey M, Kluckow M, Measurement of Newborn Heart Rate
Using Handheld Doppler ultrasound, Arch Dis Child Fetal Neonatal Ed
doi:10.1136/archdischild-2016-310669
2. Goenka S, Khan M, Koppel RI, Heiman HS. Precordial Doppler
Ultrasound Achieves Earlier and More Accurate Newborn Heart Rates in the
Delivery Room. Pediatric Academic Societies and Asian Society for
Pediatric Research 2014; 590p.
This paper highlights some limitations in the use of infant car-seat
challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior
to hospital discharge[1]. Current practice is non-standardised and
unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks
gestation or birth-weight <2500g should have a period of observation in
a car-seat prior t...
This paper highlights some limitations in the use of infant car-seat
challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior
to hospital discharge[1]. Current practice is non-standardised and
unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks
gestation or birth-weight <2500g should have a period of observation in
a car-seat prior to hospital discharge[2]. This is based on reports of
preterm infants experiencing cardiorespiratory compromise in car-seats.
There is no national UK guidance.
We evaluated current practice in England and Wales by conducting a
postal survey of the 179 level I-III Neonatal Units between December 2013
- January 2014.
The response rate was 62.6% (n=112). Our results showed that 27.7% of
respondents regularly tested infants in car-seats pre-discharge; compared
to 10% of 200 UK units contacted in 2005[3] and 30% of 30 units in
2006[4].
In our survey, 51.6% of units had no gestational age or weight
criteria for performing the ICSC. 25.8% had no formal failure criteria.
Parameters tested and duration of monitoring varied widely.
Arya reported the static ICSC does not reflect the angle or motion of
a moving vehicle. Infants, in a more upright seat (40 degrees) with
vibration experienced in a car, showed significantly increased heart rate,
respiratory rate and decreased oxygen saturations[1]. Of note, 83.8% of
units in our survey placed the car-seat on the floor (~30 degrees) rather
than more upright in a seat.
The 2006 Cochrane review of ICSCs found no eligible randomised
controlled trials and concluded that further studies were required to
determine if ICSCs accurately predict risk of clinically significant
adverse events[5].
Schutzman compared an ICSC and polysomnogram (PSG). The ICSC negative
predictive value was 0.45 when compared with PSG. They concluded that
although less time consuming, the ICSC is not a reliable substitute[6].
However, current ICSCs are time consuming. In a previous study we
performed 181 ICSCs over 18 months[7]. Each ICSC observation period was
120 minutes, which totaled 362 hours (30.2 working days) of nursing time.
Thus, implementing a national policy that advocates ICSC would impact on
nursing staff and may have a significant financial impact on neonatal
units.
This is an important problem. Car-seats are vital and 71% effective
in reducing infant fatality in road traffic accidents[2]. However, car-
seats are frequently observed to be used inappropriately; Callahan
reported infants spending a mean of 5.7+/- 3.5 hours per day in a car-seat
or similar sitting device[8]. Bamber identified 14 car-seat associated
deaths; 70% occurred whilst the seat was being used inappropriately or
outside the car[9]. In a recent review, Davis discusses observations of
infants in the semi-upright position and the continued unanswered
questions regarding ICSCs[10].
Our survey highlights that significant nursing time is being spent on
performing ICSCs in UK units in disparate ways. At present there is not
enough evidence regarding testing or how to interpret results. Therefore,
education of parents about appropriate use of car-seats must remain
paramount whilst further research establishes the appropriate use of ICSCs
in UK hospitals.
References:
1. Arya R, Williams G, Kilonback A et al. Is the infant car sear
challenge useful? A pilot study in a simulated moving vehicle. Arch. Dis.
Child. Fetal Neonatal Ed. 2016.doi:10.1136/archdischild-2016-310730.
2. Bull M, Agran P, Laraque D et al. American Academy of Pediatrics,
Committee on Injury and Poison Prevention. Safe transportation of newborns
at hospital discharge. Pediatrics. 1999;104:986-987.
3. N Joffe, J Hall (2006) Limiting the risks of apnoea and
bradycardia in low birth weight infants using car seats.. Journal of
Neonatal Nursing 12, 91-96.
4. Bhojani S., Desai P., Skeoch C. Car seat challenge - the current
practice. Infant 2008; 4(6): 211-13.
5. Pilley E, McGuire W. Pre-discharge "car seat challenge" for
preventing morbidity and mortality in [preterm infants. The Cochrane
Library 2008 Issue 3.
6. Schutzman DL, Salvador A, Janeeczko M et al. A comparison of the
infant car seat challenge and the polysomnogram at the time of hospital
discharge. Arch Dis Child Fetal Neonatal Ed 2013; 98: F411-F415.
7. Towler R, Eastwood R, Ballentyne B, Arya R. The car seat challenge
- 18 months experience in a district general hospital. Arch Dis Child
Fetal Neonatal Ed 2013; 98: F411-F415
8. Callahan CW, Sisler C. Use of seating devices in infants too young
to sit. Arch Pediatr Adolesc Med. 1997 Mar;151(3):233-5.
9. Bamber AR, Pryce J, Ashworth MT et al. Sudden unexpected infant
deaths associated with car seats. Forensic Sci Med Pathol. 2014
Jun;10(2):187-92.
10. Davis NL Screening for cardiopulmonary events in neonates: a
review of the infant car seat challenge. Journal of Perinatology (2015)
35, 235-240.
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence...
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence were likely underestimated due to underreporting, particularly the low incidence of neonate antibiotic exposure for suspected sepsis... which [was] substantially lower than estimates described in the literature at academic institutions". However, despite likely overall underreporting, antibiotic treatment for sepsis would be reported non-differentially between epidural and non-epidural groups. Therefore, we believe the comparisons between groups and associations identified to be valid and an important step in describing the issue of neonatal sepsis evaluation. The issue the writer raises highlights the need to improve administrative data collection tools, such as the birth certificate database, in order to provide more precise estimates, but does not impact the validity of the conclusions of this study.
We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
Show MoreEven though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of...
We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
Show MoreDespite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis an...
Dear Editor, We read with interest the article by Verbeek L. et al [1], showing that the second-born twin has higher levels of hemoglobin (Hb) than first-born co-twins after vaginal delivery (VD; Hb differential effect does not occur in twins delivered by Caesarean section. Since Hb difference is present in both uncomplicated monochorionic (MC) and dichorionic (DC) twin pairs, authors focused on the time difference of umbi...
We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.
Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]
Reference List
1. McDonald SJ, Middleton P, Dowswell T, Morris PS: Eff...
Show MoreI read with interest your article on spontaneous ping pong parietal fracture in newborns with impressive color images .The word 'fracture' can be quite traumatic to the parents and should avaoided if there is no radiological evidence of break in the cortex 1. It should then just be labelled as depression of skull bone without a fracture rather than labelling as DCF( depressed calvarial fracture) as mentioned in your article .You have also clearly demonstrated in your 3D CT image also that there was no break but only invagination of parietal bone .The management would also not change whether the depression is with or without fracture .
References -
Tayeh,et al.BMJCase Rep2016.doi:1136/bcr-2016-215437
Neonatal health-care providers have the duty to fully inform parents about the prognosis of their sick, extremely preterm infant. Prognostication is however difficult since survival and long-term outcome are multifactorially influenced, and the quality of prognosis research is often poor. [1] By reporting "Determinants of developmental outcomes in a very preterm Canadian cohort" [2], Synnes et al. extend the previous wor...
We read this article with considerable interest as it confirms that Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate within seconds of birth, much earlier than is possible with oximetry and much more reliably than with auscultation. As the authors state "Handheld Doppler use for measuring newborn HR has been described in the literature" (by Goenka et al and by Hutchon) "but needs further investigat...
We thank Dr Hutchon for his interest in our article and acknowledge his contribution to developing this technique of measuring heart rate rapidly and efficiently in newborns. We were particularly interested to hear of his experience with a Doppler that displays an averaged heart rate. We can see that having a displayed rather than counted Doppler heart rate would be highly practical in the delivery room providing that...
This paper highlights some limitations in the use of infant car-seat challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior to hospital discharge[1]. Current practice is non-standardised and unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks gestation or birth-weight <2500g should have a period of observation in a car-seat prior t...
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence...
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