The finding of Pladys et al (1), that preterm infants are able to
compensate for deficiencies in hematocrit by increasing cardiac output is
reassuring. However, it would seem to be a good idea to attempt to
minimize the need for such efforts, which are another added stress to an
already overburdened newborn’s system.
There is a simple procedure with little, if any risk that can
increase red cell transport or...
The finding of Pladys et al (1), that preterm infants are able to
compensate for deficiencies in hematocrit by increasing cardiac output is
reassuring. However, it would seem to be a good idea to attempt to
minimize the need for such efforts, which are another added stress to an
already overburdened newborn’s system.
There is a simple procedure with little, if any risk that can
increase red cell transport or oxygen-carrying capacity and help reduce
the need for increased stress on the cardiovascular system. I am
referring to the practice of delayed clamping of the umbilical cord.
I would like to take this opportunity to extol some of the virtues of
this practice, since there are numerous health benefits that can be
reaped, especially in regards to increased red cell transport and other
hematological factors.
Hematocrit levels and neonatal blood volume have been shown to
increase significantly, with clamping being delayed for 3 minutes (2). The
increase in blood volume due to placental transfusion is especially
significant in premature infants due to the fact that a lower percentage
of the total feto-placental circulation is in the fetal circulation, as
compared with term infants. The hypovolemic state that most preterm
infants face, can thereby be eliminated or at least reduced.
It has also been shown to increase iron stores substantially, which
may help in the prevention of a later deficiency (3). Additionally,
initial packed cell volume and blood viscosity increases and median red
cell transfusion requirements decrease with late clamping (4). Lastly,
losses of crucial stem cells are reduced, providing numerous benefits (5).
In addition to the clinical benefits of late clamping, it has also
been proposed to result in significant healthcare cost savings (4,5).
Unfortunately, immediate cord clamping is apparently the standard
practice with preterm deliveries, in most areas, although I hope that this
may change. Although there is still ongoing research on this topic,
changes in standard practice need not wait for these results. This is
because it is the practice of immediate clamping that is the intervention,
which requires justification. Delayed clamping is the normal
physiological approach that should not be abandoned without just cause.
References:
1. Pladys P, Beuchee A, Wodey E, Tison L, Betremieux P. Haematocrit
and red blood cell transport in preterm infants: an observational study.
Arch Dis Child Fetal Neonatal Ed 2000; 82: F150-155.
2. Linderkamp O, Nelle M, Kraus M, Zilow EP. The effect of early and
late cord clamping on blood viscosity and other hemorheological parameters
in full-term neonates. Acta Paediatr 1992; 81: 745-50.
3. Pisacane A. Neonatal prevention of iron deficiency. Placental
transfusion is a cheap and physiological solution. BMJ 1996; 312: 136-
137.
4. Kinmond S, Aitchison TC, Holland BM, Jones JG, Turner TL, Wardrop
CA. Umbilical cord clamping and preterm infants: a randomised trial. BMJ
1993; 306: 172-175.
5. Wardrop CA, Holland BM. The roles and vital importance of
placental blood to the newborn infant. J Perinat Med 1995; 23: 139-143.
In a recent, elegant study Govaert et al published their ultrasonographical observations in newborn infants with perinatal cortical infarctions (1). Like many others before them, they could not find a cause for stroke in a
high proportion in (25%) of cases. They also confirmed an association between stroke and pulmonary hypertension requiring assisted ventilation (2).
In a recent, elegant study Govaert et al published their ultrasonographical observations in newborn infants with perinatal cortical infarctions (1). Like many others before them, they could not find a cause for stroke in a
high proportion in (25%) of cases. They also confirmed an association between stroke and pulmonary hypertension requiring assisted ventilation (2).
We have previously published observations on arteficially
ventilated newborn piglets with pneumothorax and pulmonary hypertension, where we demonstrated cerebral arterial air microembolisations microscopically (3,4). In the case of arteficial ventilation, which is accompanied frequently by
pulmonary air leak syndrome (pulmonary interstitial emphysema, pneumomediastinum, pneumothorax), air can reach easily the cerebral vasculature, especially when there
is persistent pulmonary hypertension and right-to-left intracardial shunts.
In the light of our observations, as air microemboli could not be detected ultrasonographically, I have a suspicion that perinatal cortical infarction might have been due to cerebral arterial air embolisation in some patient in the study by Govaert et al.
References
1. Govaert P, Matthys E, Zecic A, Roelens F, Oostra A, Vanzieleghem B. Perinatal cortical infarction within middle cerebral artery trunks. Arch Dis Child 2000;82:F59-F63.
2. Klesh KW, Murphy TF, Scher MS, Buchanan DE, Maxwell EP, Guthrie RD. Cerebral infarction in persistent pulmonary hypertension of the newborn. Am J Dis Child 1987;141:852-7.
3. Temesvári P, Kovács J, Rácz K. Cerebral arterial air embolisation in experimental neonatal pneumothorax. Arch Dis Child 1989;64:179.
4. Temesvári P, Kovács J, Ábrahám CS. Pneumothorax and neonatal stroke. Neuropediatrics 1996;27:167-8.
Péter Temesvári
University Teaching Hospital
Department of Pediatrics
Kecskemét, Hungary
Sir,
We read with interest the article by Isaacs on the rationing of antibiotic
use in neonatal units.(1) This encourages the use, where possible, of
flucloxacillin and an aminoglycoside as empiric therapy of late onset
sepsis.
While this represents a valid approach to the empiric therapy of late
onset infection, the epidemiology of bacterial sepsis will vary from unit
to unit. In our unit we use a combination...
Sir,
We read with interest the article by Isaacs on the rationing of antibiotic
use in neonatal units.(1) This encourages the use, where possible, of
flucloxacillin and an aminoglycoside as empiric therapy of late onset
sepsis.
While this represents a valid approach to the empiric therapy of late
onset infection, the epidemiology of bacterial sepsis will vary from unit
to unit. In our unit we use a combination of vancomycin and cefotaxime as
empiric treatment of late onset sepsis. In 1999, of 159 positive blood
cultures, coagulase negative staphylococci were isolated from 124 (80%).
All were sensitive to vancomycin. Sixty-three (63%) were resistant to
netilmicin, 89% to cefotaxime and 91% to flucloxacillin. In the majority
of cases there was a sudden rather than insidious deterioration in the
baby with elevation of the CRP suggesting true infection rather than
contamination. This is further supported by the fact that in 94% of
cases a coagulase negative staphylococcus was the sole isolate and the
patients responded to appropriate therapy.
Although we consider the use of vancomycin to be essential for
empiric therapy of late onset sepsis, we are aware of the problems
associated with its overuse. The emergence of vancomycin resistant
organisms including vancomycin resistant enterococci and vancomycin
insensitive staphylococcus aureus is, of coarse, a concern but in spite of
continuing surveillance this has not been observed in our unit. In order
to prevent the emergence of resistant gram positive organisms we agree
that it is vitally important to stop vancomycin therapy if cultures are
negative after 48 hours. Ninety 96 (96%) of blood cultures that grow an
organism do so within 48 hours,(2) and discontinuation after this time is
not associated with increased morbidity.(3)
In conclusion, we would suggest that antibiotic policies remain unit
specific based on the prevalent microorganisms and their known
sensitivities.
Dr Laura Stewart
Dr Charles H Skeoch
Neonatal Unit, Glasgow Royal Maternity Hospital
Rottenrow, Glasgow G4 ONA, UK
Dr Brian Jones
Department of Microbiology
Glasgow Royal Infirmary
Glasgow
References:
1. Isaacs D. Rationing antibiotic use in neonatal units. Arch Dis
Child Fetal Neonatal Ed 2000:82:F1-F2
The paper by Bhutada et al (1) adds to the growing body of evidence
that premedication for tracheal intubation in neonates both improves
physiological stability and makes the procedure easier to perform. The
results of the telephone survey of premedication use in UK neonatal units
by Whyte et al (2) helps to define current practice. In a similar study,
we recently tried to define the routine use of premedication for trac...
The paper by Bhutada et al (1) adds to the growing body of evidence
that premedication for tracheal intubation in neonates both improves
physiological stability and makes the procedure easier to perform. The
results of the telephone survey of premedication use in UK neonatal units
by Whyte et al (2) helps to define current practice. In a similar study,
we recently tried to define the routine use of premedication for tracheal
intubation in term and pre-term neonates in Australia and the UK -
allowing comparisons to be made.
A survey was conducted of practice in Australian level 3 units (21)
and UK units with 6 or more intensive care cots (52). The format was a
semi-structured telephone interview of the nurse in charge of the shift
when the call was made. All interviews were conducted by one of two of the
authors (SWH and JB) in September 1999.
There was a 100% response rate. Results were:
United Kingdom
Australia
Term
Pre-term
Term
Pre-term
Routine premedication (%)
22(42)
18(34)
15(71)
14(67)
Opiate
13
11
2
4
Benzodiazepine (BDZ)
1
0
2
1
Opiate + BDZ
1
1
0
0
Opiate + muscle relaxant +/- atropine
6
6
11
9
BDZ + muscle relaxant +/- atropine
1
0
0
0
Seven different combinations of premedication drugs were in routine
use in Australia compared to 14 different combinations in the UK.
In Australian units, the routine administration of premedication for
non-emergency tracheal intubation of term and pre-term neonates is common
practice and there is some uniformity in the combinations of drugs used.
In contrast this practice is less common in the UK and there is more
diversity of prescribing. In both countries premedication was more
commonly used for term neonates. This difference in practice may reflect
the fact that larger babies are more likely to struggle when intubated -
making the procedure more technically demanding.
We agree with Whyte et al that there is a strong evidence-based
argument for premedication for tracheal intubation in neonates to be
routine. Our work brings added clarity to the existing picture and
confirms that there is little consensus as to the best combination of
drugs to use. Further work to define best practice is urgently required.
1 Bhutada A, Sahani R, Rastogi S, Wung J-T. Randomised controlled
trial of thiopental for intubation in neonates. Arch Dis Child Fetal
Neonatal Ed 2000;82:F34-F37.
2 Whyte S, Birrell G, Wyllie J. Premedication before intubation in UK
neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41.
Neonates are exposed to many procedures, including intubation, IV
access, central line placement, chest tube insertion, lumber puncture,
catheterisation, suprapubic aspiration etc. These procedures are
associated with pain and stress. No clear guidelines are available for
alleviating the distress by premedication before such procedures.
Researchers are looking for methods to minimise the pain and distre...
Neonates are exposed to many procedures, including intubation, IV
access, central line placement, chest tube insertion, lumber puncture,
catheterisation, suprapubic aspiration etc. These procedures are
associated with pain and stress. No clear guidelines are available for
alleviating the distress by premedication before such procedures.
Researchers are looking for methods to minimise the pain and distress in
neonates during these procedures.
Examples include the use of thiopental as premedication before
intubation,(1) local anaesthetics before heel prick,(2) and response to
cutaneous stimulus.(3) In the recent issue of the journal three articles (1,3,4) were on the issue of
premedication before procedures in neonates. However, there is no
consensus regarding the policy and protocol for use of premedication
before procedures in neonates. The issue of is not so simple. In the
present era of evidence medicine, more
randomised control trials are needed so that the experts can reach to a
consensus. The questions need research are: the type of drug (analgesic,
sedative or anaesthetics), the mode of administration (IM, IV, ET) and the
dose to be used.
Yours sincerely,
Dr.Shabih Manzar,FAAP
Assistant Professor, Department of Pediatrics
King Fahd University Hospital
P.O.Box 40211, Al-Khobar 31952
Saudi Arabia
References:
1. Bhutada A, Sahni R,Rastogi S, Wung JT. Randomised controlled trial
of thiopental for intubation in neonates. Arch Dis Child Fetal Neonatal Ed
2000;82:F34-F37
2. Barker DP, Rutter N. Lignocaine ointment and anaesthesia in
preterm infants. Arch Dis Child Fetal Neonatal Ed 1995;72:F203-4
3. Jain A, Rutter N. Local anaesthetic effect of topical amethocaine
gel in neonates: randomised controlled trial. Arch Dis Child Fetal
Neonatal Ed 2000;82:F42-F45
4. Whyte S, Birrell G, Whyllie J. Premedication before intubation in
UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41
We note with interest the paper by Ng et al[1]. Their study concluded
that corticosteriod treatment could be lifesaving in severely hypotensive
preterm infants who do not respond to conventional treatment with volume
expanders and inotropes. The use of steroids in the management of
hypotension in very low birthweight has already been shown to be effective
[2].
We note with interest the paper by Ng et al[1]. Their study concluded
that corticosteriod treatment could be lifesaving in severely hypotensive
preterm infants who do not respond to conventional treatment with volume
expanders and inotropes. The use of steroids in the management of
hypotension in very low birthweight has already been shown to be effective
[2].
We wrote to this Journal in 1993 [3] followed by an oral presentation
at the Summer Meeting of the Neonatal Society regarding our experience in
hydrocortisone (HC) as a prophylaxis used in babies less than 28 weeks
gestation. We used the dose of 1.5mg/kg/dose four doses per day for the
first 2-3 days and then tapered off over 7 days. We reviewed the six month
experience and compared it with the preceding six months prior to the use
of prophylaxis. We concluded that the prophylactic use of HC decreased the
incidence of refractory hypotension and the need for dopamine and
dobutamine. No significant difference was noted in the incidence of
intraventricular haemorrhage and mortality. However, there was suggestion
of an increase of incidence of sepsis and especially after the study
period there were two deaths associated with systemic fungal infections.
Therefore, from March 1998, we changed our policy from prophylatic
use to treatment in infants less than 28 weeks gestation before intropes
are used. We also reduced the dose to 1mg/kg/dose two doses per day for 3
days and weaned over 6 days by assuming a normal basal secretion of
6mg/m2/day and stress production rate of 24mg/m2/day and the surface area
in 1kg baby is 0.1m2. From March 1998 to December 2000, 105 babies less
than 28 weeks were admitted to the unit and 48 babies received HC for
treatment of hypotension. 44 also required dopamine 5-15mcg/kg/min and 20
also required dobutamine 5-20mcg/kg/min. None of the babies required other
inotropic support or a higher dose of HC. There was one case of systemic
candidiasis and incidence of intraventricular haemorrhage and bacteria
sepsis are comparable with the published data.
Although most of the babies still required dopamine, we have not seen
severe and refractory hypotension for more than three yeras and the lower
dose of HC can be used.
References
(1) Ng PC et al. Refractory Hypotension in Preterm infants with Adrenal
cortical insufficiency. Arch Dis Child 2001;84:F122-124
(2) Pourchierd, Western P. Randomised Trial of Dopamine compared with
Hydrocortisone for the treatment of Hypotensive Very low birthweight
infants. Arch Dis Child 1997; 76:F174-183
(3) Rajah V. Treatmant of Hypotension in Very low birthweight
infants.(letter) Arch Dis Child 1998; 78:F158
A Soe, R Ebel, B Jani, T Ducker
Oliver Fisher Neonatal Unit
Medway Maritime Hospital
Gillingham. Kent ME7 5NY
I read with interest the article by Marlow et al(1) on sensorineural
hearing loss and prematurity. In their study of preterm infant of less
that 33 weeks gestation, they put the cut-off value of serum creatinine
(as one of the variables) as 60 mmol/l. My comment is regarding the cut-
off of 60. In a recent study from Leeds, UK, Miall et al(2) have shown
that preterm babies have higher serum creatinine an...
I read with interest the article by Marlow et al(1) on sensorineural
hearing loss and prematurity. In their study of preterm infant of less
that 33 weeks gestation, they put the cut-off value of serum creatinine
(as one of the variables) as 60 mmol/l. My comment is regarding the cut-
off of 60. In a recent study from Leeds, UK, Miall et al(2) have shown
that preterm babies have higher serum creatinine and the mean value was
reported to be 73 micromol/l. (95% CI: 68-79 micromol/l). Similarly, in
another study from Royal Hospital London, Finney et al (3) have described
the serum creatinine ranges for 29-36 weeks gestation as 27-175 micromol/l
(median 75 micromol/l).
In addition to this low cut-off value of serum creatinine in preterm
infants, the unit reported by Marlow et al (1)was mmol/l instead of
micromol/l, which was probably a typing error, but still needed to be
corrected.
Your's sincerely,
Shabih Manzar
Assistant Professor, Department of Pediatrics
King Fahd University Hospital
P.O.Box 40211, Al-Khobar 31952
Saudi Arabia
References:
1. Marlow ES, Hunt LP, Marlow N.Sensorineural hearing loss and
prematurity. Arch Dis Child Fetal Neonatal Ed 2000;82:F141-F144
2. Miall LS, Henderson MJ, Turner AJ, et al. Plasma creatinine rises
dramatically in the first 48 hours of life in preterm infants. Pediatrics
1999;104:e76
3. Finney H, Newman DJ, Thakkar H, et al. References ranges for
plasma cystatin C and creatinine measurements in premature infants,
neonates and older children. Arch Dis
Child 2000;82:71-75
Evans and Levene have endeavoured to review the published survival
data for infants born at less than 28 weeks, to identify bias and to make
recommendations facilitating more accurate comparison of the published
survival rates [1].
Practices regarding resuscitation vary between institutions and may
change over time. In one study from a large regional centre in British
Columbia, not includ...
Evans and Levene have endeavoured to review the published survival
data for infants born at less than 28 weeks, to identify bias and to make
recommendations facilitating more accurate comparison of the published
survival rates [1].
Practices regarding resuscitation vary between institutions and may
change over time. In one study from a large regional centre in British
Columbia, not included in this review, a cohort from 1991-3 demonstrated a
substantial increase in the proportion of labour and delivery room deaths
in 23-week infants compared with an earlier cohort [2].
Initial treatment decisions are clearly important for the
interpretation of survival data. Thus, in addition to the proposed minimum
data set, it would be useful to have an indication of whether active
resuscitation was commenced or not. A possible alternative to this is
reporting delivery room deaths and deaths in the neonatal unit separately
but this is not perfect as resuscitation may have been initiated but
failed.
(1) Evans DJ, Levene MI. Evidence of selection bias in preterm survival
studies: a systematic review. Arch Dis Child Fetal Neonatal Ed.
2001;84:F79-84.
(2) M Battin, EW Ling, MF Whitfield, SB Effer. Has the outcome for
extremely low gestational age (ELGA) infants improved following recent
advances in neonatal intensive care? Am J Perinatol. 1998;15:469-77.
This review on alloimmune thrombocytopenic purpura (ATP) by OUWEHAND et al is excellent and describes the current
knowledge on ATP. Regarding the management of this condition, since no
randomised trials have been performed using IVIg or intravenous
corticosteroids during pregnancy, no evidence-based guidelines for the use
of either treatment exist. I believe it is necessary for a
multi-institutuional trial on the preventio...
This review on alloimmune thrombocytopenic purpura (ATP) by OUWEHAND et al is excellent and describes the current
knowledge on ATP. Regarding the management of this condition, since no
randomised trials have been performed using IVIg or intravenous
corticosteroids during pregnancy, no evidence-based guidelines for the use
of either treatment exist. I believe it is necessary for a
multi-institutuional trial on the prevention of ATP to be performed. Since
ATP is relatively rare, with an estimated incidence of 1 in 1100 births,
it is rather difficult even for hospitals with 10,000-15,000
deliveries/year to have enough patients for study. On the other hand, a
multi-institutional comparison of the two preventive modalities, in women
whose previous pregnancies were affected by ATP, is feasible and will
provide firm evidence of efficacy (or lack of) for IVIg or
corticosteroids.
I read with interest the recommendation of Reece and colleagues
regarding the positioning of long lines in preterm neonates. [1]
In their methods the authors state that they aimed to place the tip of the
line up to 10 mm into the right atrium (upper limb insertions).
Manufacturer and standard text book of neonatology recommend that the line
tip should not be sited in the right atrium as there are potenti...
I read with interest the recommendation of Reece and colleagues
regarding the positioning of long lines in preterm neonates. [1]
In their methods the authors state that they aimed to place the tip of the
line up to 10 mm into the right atrium (upper limb insertions).
Manufacturer and standard text book of neonatology recommend that the line
tip should not be sited in the right atrium as there are potential serious
complications.[2] I am sure the authors are aware of the recent media
attention, and the enquiry into deaths in neonates due to cardiac
complications of long lines. [3]
The authors commented that almost 50% of the line tips could not be
visualised on plain x-ray examination. Some of the currently available
lines with guide wires (27 G CV Single lumen catheter Medex Medical Inc.
Haslingdon, Lancashire UK ) are particularly suited to the needs of
preterm infant. The radio opaque wire enables adequate visualisation on
plain x-ray. I would welcome the authors’ views on the use of these lines.
Although the study did not have the power to study the adverse effects of
contrast used, unless safety of the material is well established it seems
premature to recommend its routine use.
References:
(1) Reece A, Ubhi T, Craig AR, Newell SJ. Positioning long lines: contrast
versus plain radiography. Arch Dis Child Fetal Neonatal Ed 2001; 84: F129-
30
(2) Brain AJ, Roberton NRC, Rennie JM. Textbook of neonatology. London:
Churchill Livingstone 1999:1376
(3)Charter D. Baby heart deaths force inquiry. The Times 2000 Nov 25
The finding of Pladys et al (1), that preterm infants are able to compensate for deficiencies in hematocrit by increasing cardiac output is reassuring. However, it would seem to be a good idea to attempt to minimize the need for such efforts, which are another added stress to an already overburdened newborn’s system.
There is a simple procedure with little, if any risk that can increase red cell transport or...
Sir,
In a recent, elegant study Govaert et al published their ultrasonographical observations in newborn infants with perinatal cortical infarctions (1). Like many others before them, they could not find a cause for stroke in a high proportion in (25%) of cases. They also confirmed an association between stroke and pulmonary hypertension requiring assisted ventilation (2).
We have previously published...
Sir, We read with interest the article by Isaacs on the rationing of antibiotic use in neonatal units.(1) This encourages the use, where possible, of flucloxacillin and an aminoglycoside as empiric therapy of late onset sepsis.
While this represents a valid approach to the empiric therapy of late onset infection, the epidemiology of bacterial sepsis will vary from unit to unit. In our unit we use a combination...
The paper by Bhutada et al (1) adds to the growing body of evidence that premedication for tracheal intubation in neonates both improves physiological stability and makes the procedure easier to perform. The results of the telephone survey of premedication use in UK neonatal units by Whyte et al (2) helps to define current practice. In a similar study, we recently tried to define the routine use of premedication for trac...
Editor,
Neonates are exposed to many procedures, including intubation, IV access, central line placement, chest tube insertion, lumber puncture, catheterisation, suprapubic aspiration etc. These procedures are associated with pain and stress. No clear guidelines are available for alleviating the distress by premedication before such procedures. Researchers are looking for methods to minimise the pain and distre...
Dear Editor
We note with interest the paper by Ng et al[1]. Their study concluded that corticosteriod treatment could be lifesaving in severely hypotensive preterm infants who do not respond to conventional treatment with volume expanders and inotropes. The use of steroids in the management of hypotension in very low birthweight has already been shown to be effective [2].
We wrote to this Journal in 199...
Editor,
I read with interest the article by Marlow et al(1) on sensorineural hearing loss and prematurity. In their study of preterm infant of less that 33 weeks gestation, they put the cut-off value of serum creatinine (as one of the variables) as 60 mmol/l. My comment is regarding the cut- off of 60. In a recent study from Leeds, UK, Miall et al(2) have shown that preterm babies have higher serum creatinine an...
Dear Editor,
Evans and Levene have endeavoured to review the published survival data for infants born at less than 28 weeks, to identify bias and to make recommendations facilitating more accurate comparison of the published survival rates [1].
Practices regarding resuscitation vary between institutions and may change over time. In one study from a large regional centre in British Columbia, not includ...
This review on alloimmune thrombocytopenic purpura (ATP) by OUWEHAND et al is excellent and describes the current knowledge on ATP. Regarding the management of this condition, since no randomised trials have been performed using IVIg or intravenous corticosteroids during pregnancy, no evidence-based guidelines for the use of either treatment exist. I believe it is necessary for a multi-institutuional trial on the preventio...
Dear Editor,
I read with interest the recommendation of Reece and colleagues regarding the positioning of long lines in preterm neonates. [1] In their methods the authors state that they aimed to place the tip of the line up to 10 mm into the right atrium (upper limb insertions). Manufacturer and standard text book of neonatology recommend that the line tip should not be sited in the right atrium as there are potenti...
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