We congratulate the authors on this study of neonatal transitional circulation performed so quickly after birth. The authors state that the ductal flow ratio reported in their study reflects pulmonary and haemodynamic transition and can be used to monitor neonatal transition in healthy infants. The implication is that their study describes a physiological transition in healthy term infants, but we question that this is the case.
Delivery by elective caesarean section is not a physiological birth but it does permit the neonate an atraumatic birth. We are particularly concerned that the transition may have been disrupted by the timing of cord clamping which was between 30 and 60 seconds. While this is considered delayed cord clamping by some, most guidelines recommend a minimum of 60 seconds have elapsed before the circulation is interrupted by cord clamping. The WHO advises 3 minutes.(1) Not all of the babies in the series had established respiration before clamping and cord clamping before the onset of respiration has a marked effect on cardiac output.(2) It is therefore questionable that the mean and range of results published represents a normal transition in healthy infants.
The normal fetal circulation is well described with the two ventricles pumping in parallel, the right ventricular output being significantly more than the left and the flow across two shunts, right to left in the ductus arteriousus and right to left across the foram...
We congratulate the authors on this study of neonatal transitional circulation performed so quickly after birth. The authors state that the ductal flow ratio reported in their study reflects pulmonary and haemodynamic transition and can be used to monitor neonatal transition in healthy infants. The implication is that their study describes a physiological transition in healthy term infants, but we question that this is the case.
Delivery by elective caesarean section is not a physiological birth but it does permit the neonate an atraumatic birth. We are particularly concerned that the transition may have been disrupted by the timing of cord clamping which was between 30 and 60 seconds. While this is considered delayed cord clamping by some, most guidelines recommend a minimum of 60 seconds have elapsed before the circulation is interrupted by cord clamping. The WHO advises 3 minutes.(1) Not all of the babies in the series had established respiration before clamping and cord clamping before the onset of respiration has a marked effect on cardiac output.(2) It is therefore questionable that the mean and range of results published represents a normal transition in healthy infants.
The normal fetal circulation is well described with the two ventricles pumping in parallel, the right ventricular output being significantly more than the left and the flow across two shunts, right to left in the ductus arteriousus and right to left across the foramen ovale. The normal neonatal circulation is also well described with equal outputs by both ventricles and closed shunts. A closer look at the results suggest some anomalous flow not readily compatible with the end result of the neonatal circulation. For example at ten minutes the mean right ventricular output is 343 mls/kg/min and mean left ventricular output is 212 mls/kg/min and the DA flow is 8mls/kg/min left to right. (ratio R to L =0.9). Where does the right ventricle get the 343 output as only 212 - 8 are reaching the systemic circulation and returning to the right atrium. Also if the pulmonary blood flow is 343+8 = 351, the excess of 141 must be spilling left to right across the foramen ovale. Reverse flow in the foramen ovale is described but has not been quantified. We question that these flows are evidence that this heart is now close to transitioning to a parallel ventricular pattern with equal outputs. Reverse flow across the foramen ovale of 141 is contributing to over 40% of the right ventricular output. This blood has just been through the pulmonary circulation and is oxygenated but is now returning to the right ventricle to be pumped through the pulmonary circulaton once more. Such flow is completely inefficient. Can the authors explain this anomaly in physiogical terms or could this finding in fact be a demonstration that the early clamping at under 60 seconds sometimes before the onset of respiration has indeed disrupted the transitional circulation ?
Reference 1. World Health Organization (WHO), US Agency for International Development (US AID), Maternal and Child Health Integrated Program (MCHIP). (2013). Delayed cord clamping of the umbilical cord to reduce infant anaemia. Updated 2013. Available from: http://www.mchip.net/node/1562 (Accessed June 12, 2014). 2. Bhatt S, Alison BJ,Wallace EM, Crossley KJ, Gill AW, Kluckow M, et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 2013 591(Pt 8): 2113-26.
Dear Editor
I would like to thank Dr's Madar and Kariholu for their interest in the
recent review article on use of ultrasound to assess the haemodynamic
status of the sick neonate(1,2). They raise an important point that
highlights the current disconnect between the recognition of the
usefulness of ultrasound in general for assessment of sick neonates and
the lack of availability of suitable training courses to learn th...
Dear Editor
I would like to thank Dr's Madar and Kariholu for their interest in the
recent review article on use of ultrasound to assess the haemodynamic
status of the sick neonate(1,2). They raise an important point that
highlights the current disconnect between the recognition of the
usefulness of ultrasound in general for assessment of sick neonates and
the lack of availability of suitable training courses to learn these
skills. They further propose that ultrasound is an essential skill for the
neonatologist and thus a training syllabus in neonatal functional cardiac
assessment should be developed, and foreshadow the incorporation of this
training into neonatal training programs.
Neonatology is not alone in this realisation and there is a steady push to
incorporate ultrasound to help guide clinical care into many specialty
training programs ranging from intensive care, accident and emergency to
surgery and renal medicine(3). Separation of the use of point of care
ultrasound to guide clinical care from a high level consultational
ultrasound to exclude structural pathology is key to gaining acceptance
for the use of ultrasound in this way. In Neonatology it is important to
avoid describing a focused clinical cardiac ultrasound as an
echocardiogram, as this is a term that is usually interpreted as meaning a
high level cardiology based examination, with different expectations and
outcomes. In Australia and New Zealand we have developed a point of care
ultrasound training program for both cardiac and cranial ultrasound(4).
The course has a basic and an advanced module and is based on the
following principles:
1] A physics and safety module
2] An initial introductory theory and hands on course
3] Self directed learning, logbooking and supervision of ultrasound in a
clinical neonatal setting
4] Logbook and competency assessment
5] Reaccreditation requirements
We have found that learning neonatal ultrasound in this "apprenticeship"
setting, similar to that of learning neonatology generally, results in
clinicians who have a clear understanding of the uses and limitations of
ultrasound use in the NICU. Contrary to concerns raised by traditional
users of ultrasound in the neonatal unit, we have found that not only is
physiological management of the sick neonate made easier, but that
significant structural cardiac defects are often identified earlier in the
neonatal course than had been the case before the increased use of
ultrasound to guide clinical care. We have not as yet mandated this
training as part of the national neonatal training program, mainly because
we are unable to guarantee access to training to all trainees. This will
change as the critical mass of neonatologists using ultrasound increases.
I encourage Dr's Madar and Kariholu to engage with colleagues interested
in developing a neonatal ultrasound training program in the United Kingdom
and make it a reality.
(1).Kluckow M Use of ultrasound in the haemodynamic asessment of the
sick neonate. Arch. Dis. Child. Fetal Neonatal Ed. 2014 99:F332-F337;
doi:10.1136/archdischild-2013-304926
(2). John Madar, Ujwal Kariholu. Cardiac assessment using echocardiography
in the sick neonate - An unmet need for a training syllabus for aspiring
neonatologists.Arch. Dis. Child. Fetal Neonatal Ed. 2014
(3). Moore CL and Copel JA. Point of care ultrasonography. N Engl J Med.
2011 Feb 24;364(8):749-57
(4). http://www.asum.com.au/newsite/Education.php?p=CCPU-Neonatal
In the UK speciality training through the grid scheme has been in
existence for about a decade with a well-defined syllabus of knowledge and
skills deemed necessary for the qualified neonatologist. Although much
emphasis is laid on various aspects of neonatal care and the acquisition
of procedural skills including cranial ultrasound, cardiac assessment
using echocardiography is still considered to be an optional skill (1)...
In the UK speciality training through the grid scheme has been in
existence for about a decade with a well-defined syllabus of knowledge and
skills deemed necessary for the qualified neonatologist. Although much
emphasis is laid on various aspects of neonatal care and the acquisition
of procedural skills including cranial ultrasound, cardiac assessment
using echocardiography is still considered to be an optional skill (1).
There are many reasons why this position should now be challenged.
Not least the greatly enhanced armentarium of the neonatologist when
considering therapy, coupled to the relative ease of access to the
equipment necessary to undertake such an evaluation.
Hence our question 'Should cardiac assessment using echocardiography
be considered an essential skill for the neonatologist?'
The recent article by Kluckow (2) highlights the value of clinician
performed cardiac ultrasound in neonatal practice. The ability to
undertake a timely competent functional cardiac assessment - even of
limited parameters - might help optimise therapy, reduce morbidity and
potentially mortality. Yet this ability is not yet deemed essential in the
training of those looking after the most vulnerable babies.
A syllabus in functional cardiac assessment for the neonatologist
needs to be developed as a matter of priority, with access to structured
training in order that all those aspiring to be neonatologists learn the
potential of these techniques and are able to acquire the skills during
their time as a trainee. It might be argued that it would be advantageous
for those already working in the field but who lack these abilities to do
likewise.
2. Kluckow M. Use of ultrasound in the haemodynamic assessment of the
sick neonate. Arch Dis Child Fetal Neonatal Ed. 2014 Apr 15. doi:
10.1136/archdischild-2013-30492
We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a docum...
We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a document on the bioethical questions regarding the resuscitation of extremely preterm infants 1. Briefly, the document states the following recommendations: 1. The resuscitation of extremely preterm infants must be made without considering the gestational age, using criteria similar to that adopted for children and adults; 2. The sole high probability of severe disabilities does not justify a decision not to resuscitate an infant in the delivery room; 3. Neonatologists can discontinue the assistance (starting palliative care) when it appears futile and inappropriate; 4.Parental opinion is central, but when it is in contrast with that of Neonatologists, this late must prevail. The Italian Society on Neonatology, the most important Italian association of Neonatologists, substantially agree this document. Thus, in the majority of Italian Hospitals extremely preterm infants are resuscitated in the delivery room on the basis of their viability and not merely evaluating their gestational age.
Prof. Carlo Dani,
Division of Neonatology, Careggi University Hospital of Florence, Italy.
Prof. Costantino Romagnoli,
Division of Neonatology, Sacred Heart Catholic University of Rome, Italy.
President of Italian Society of Neonatology
Prof. Giovanni Corsello,
Department of Sciences for Health Promotion and Mother and Child Care,
University of Palermo
President of Italian Society of Pediatrics.
Dr Essex and Mr Mercer highlight many of the reasons why we undertook
the Bristol Tongue Tie trial.
Ankloglossia is a spectrum condition, which overlaps with 'normal'
variation in anatomy, and milder forms do not result in feeding
impairment. There is very limited evidence of the need for frenotomy in
mild-moderate degrees of tongue tie. However, it is also true that at
the severe end of the spectrum infants can be limi...
Dr Essex and Mr Mercer highlight many of the reasons why we undertook
the Bristol Tongue Tie trial.
Ankloglossia is a spectrum condition, which overlaps with 'normal'
variation in anatomy, and milder forms do not result in feeding
impairment. There is very limited evidence of the need for frenotomy in
mild-moderate degrees of tongue tie. However, it is also true that at
the severe end of the spectrum infants can be limited in their ability to
breastfeed efficiently because they are not able to latch effectively.
We agree that it is easy to blame a visible tongue tie for breast
feeding difficulties which may be due to other factors, and entirely
support the view that good breastfeeding support is essential in helping
mothers with feeding difficulties.
The inequity in the use of frenotomy worldwide and within the UK is
exactly why well conducted trials are needed, to clarify which babies
should be offered frenotomy and when. The widespread use of social media,
and campaigning by some pressure groups, has resulted in an increase in
demand for the procedure. Good quality evidence from randomised trials is
needed to inform evidence- based clinical practice and the rational
commissioning of services.
We thank Dr. Verd and colleagues for their comments [1] on our review
of the use of human milk for preterm infants. Our aim was certainly not to
discourage the use of donor human milk, but rather to look objectively at
the evidence base that currently exists for its use.
The authors of the letter refer to a 1984 study by Narayanan et al
[2] which appeared to show a reduction in the risk of infection in infants
fe...
We thank Dr. Verd and colleagues for their comments [1] on our review
of the use of human milk for preterm infants. Our aim was certainly not to
discourage the use of donor human milk, but rather to look objectively at
the evidence base that currently exists for its use.
The authors of the letter refer to a 1984 study by Narayanan et al
[2] which appeared to show a reduction in the risk of infection in infants
fed pasteurised human milk. This study, which looked at 226 low birth
weight infants, randomised them to receive unpasteurised human milk or
pasteurised human milk, with or without formula. Many of the anti-
infective factors in human milk are preserved after pasteurisation, and we
therefore do not dispute the potential of donor breast milk (DEBM) to
protect against infection. However, deductions from this paper about the
benefits of pasteurised DEBM have to be made with caution because (a) no
distinction was made in the analysis between mothers' own milk (MEBM) and
DEBM, (b) there is no description of anti-infective precautions in
reconstituting and feeding formula in a study carried out in a very
different setting to a modern NICU, and (c) there is no suggestion of
masking of analysis to study group. The second study referred to, the
R?nnestad study [3], is a national survey of late onset sepsis which
relates to babies who were predominantly fed unpasteurised human milk, and
thus does not have direct relevance to our practice -we are aware of only
one country in Europe (Norway) in which unpasteurised donor milk is
routinely used. A Cochrane review which we cited in our article [4] looked
at whether donor human milk might be better than formula in terms of rates
of invasive infection. They found only one study that they judged to be of
sufficient quality to include in their analysis, the final study quoted by
Verd and colleagues, that by Schanler et al [5]. This study found no
statistically significant difference in the incidence of one or more
episodes of invasive infection when donor milk, rather than formula, was
used to feed preterm infants. Babies were randomised to receive DEBM or
PTF to make up any shortfall of MEBM in preterm infants. Although there
was a (barely statistically significant) lower rate of chronic lung
disease in infants fed DEBM as opposed to PTF, the authors rightly state
that this is one of several outcomes assessed which the study was not
designed to look at, and requires more research.
We welcome an open discussion of the evidence base for the use of
DEBM. Currently, the use of DEBM varies from not at all to extensive use
in preterm infants in place of formula milk. If we over-interpret the
current data, there is the very real risk that we may discourage the
funding of research studies which have the potential to measure the cost-
effectiveness of DEBM more fully and thus the potential to benefit the
care of a larger number of infants by allowing the development of evidence
-based guidelines.
References
1. Verd S, Porta R and Ginovart G. Human milk feeding. Arch Dis Child
Fetal Neonatal Ed, 2014. 99(2): F172-3.
2. Narayanan I, Prakash K, Murthy NS, et al. Randomised controlled
trial of effect of raw and holder pasteurised human milk and of formula
supplements on incidence of neonatal infection. Lancet 1984;2:1111-13.
3. Ronnestad A, Abrahamsen TG, Medb? S, et al., Late-Onset Septicemia
in a Norwegian National Cohort of Extremely Premature Infants Receiving
Very Early Full Human Milk Feeding. Pediatrics, 2005. 115(3): p. e269-
e276.
4. Quigley MA, Henderson G, Anthony MY, et al. Formula milk versus
donor breast milk for feeding preterm or low birth weight infants.
Cochrane Database Syst Rev 2007;(4):CD002971.
5. Schanler RJ, Lau C, Hurst NM, et al. Randomized trial of donor
human milk versus preterm formula as substitutes for mothers' own milk in
the feeding of extremely premature infants. Pediatrics 2005;116:400-6.
The tongue remains with in the boundaries of the mandible during
suckling and so it is difficult to see the anatomical or the physiological
basis for how a frenulectomy works in reducing breast and nipple
discomfort during feeding. This randomised trial does not seem to assess
the potential, positive psychological impact of the mother being told
their child has had a frenulectomy. That is the question that...
The tongue remains with in the boundaries of the mandible during
suckling and so it is difficult to see the anatomical or the physiological
basis for how a frenulectomy works in reducing breast and nipple
discomfort during feeding. This randomised trial does not seem to assess
the potential, positive psychological impact of the mother being told
their child has had a frenulectomy. That is the question that must be
answered before a procedure performed on the most sensitive organ in the
body, with out anaesthesia is undertaken routinely.
Tongue tie is not proven to impact upon speech and if a release is
performed in a child with a small chin, with or without a cleft palate, it
can cause airway obstruction. A significant tongue tie causes social
embarrassment in later life but it has no other proven physical impact on
the child and so more concrete evidence of benefit for the procedure being
performed upon a neonate, with out anaesthesia, must be provided before
the practice is offered routinely. Every surgical procedure has
complications and surely there must be greater proof of benefit than
relieving nipple pain in the mother? When else is a procedure inflicted
on any patient, let alone a child, for the benefit of reducing discomfort
in a third party? With out this additional proof, practitioners may well
be performing unnecessary procedures on a defenceless infant.
With out a "sham" group, the psychological impact on the mother
cannot be excluded.
Lawson's editorial and Emond and colleagues' article exposes
potentially bad medicine: lack of knowledge of normal and variations of
normal; lack of knowledge of the natural history of a condition; a desire
to do something - Ulysses syndrome (1); medicalising the child by giving
the condition a name; and then ascribing any improvement to the
intervention, forgetting that association does not mean causation.
Lawson's editorial and Emond and colleagues' article exposes
potentially bad medicine: lack of knowledge of normal and variations of
normal; lack of knowledge of the natural history of a condition; a desire
to do something - Ulysses syndrome (1); medicalising the child by giving
the condition a name; and then ascribing any improvement to the
intervention, forgetting that association does not mean causation.
This writer did many years of community child health clinics seeing
babies with a variety of problems that never went near a hospital: a W-
shaped tongue [M-shaped from the baby's perspective] is a normal finding.
To describe it as tongue tie and to intervene are medicalising normality
in the majority of cases. As Illingworth says in The Normal Child (2)
[which should be required reading for all health professionals involved
with children] "The tongue is always short at birth but as the infant
grows the tongue becomes longer and thinner. Many mothers [and health
professionals - my insertion] ascribe their children's feeding
difficulties and lateness in speaking to tongue tie".
Unfortunately blaming tongue tie becomes self-perpetuating. The fact
that parents want subsequent children to have a frenotomy after their
first child has had one and doctors acquiesce to this or lactation experts
believe it is the cause of breastfeeding difficulties does not represent
proof nor does it justify performing the operation. Countries with
initial and sustained high breastfeeding rates such as New Zealand, where
this writer worked for several years, do not have high rates of frenotomy
to ensure that breastfeeding is successful. Rather it is good
breastfeeding support.
Recently a tongue-tie service was set up in my local area. I can
predict the outcome. In 12 months' time those who promoted and run the
service will announce how many tongue tie operations they done, how
parents are pleased and feel the baby is feeding better and how
"successful" the service is. The specious conclusion will be that tongue
tie was a significant problem for these babies which frenotomy cured. I
consider this is 21st Century charlatanism.
Signed
Dr Charles Essex
Consultant Neurodevelopmental Paediatrician
Suite 115
41 Oxford Street
Leamington Spa CV32 4RB
References
1. Essex C. Ulysses syndrome. BMJ 2005; 330: 1268.
2. Illingworth RS. The Normal Child. Churchill Livingstone, Edinburgh
1983.
We read Val Finigan's letter with interest, and agree with her
experience that most mothers do report an improvement in the comfort and
efficacy of breastfeeding after their baby has had a frenotomy. The
difficulty is in showing objective improvement in breastfeeding after
division of less severe degrees of tongue tie.
In the Bristol Tongue Tie Trial, the median age of the babies at...
We read Val Finigan's letter with interest, and agree with her
experience that most mothers do report an improvement in the comfort and
efficacy of breastfeeding after their baby has had a frenotomy. The
difficulty is in showing objective improvement in breastfeeding after
division of less severe degrees of tongue tie.
In the Bristol Tongue Tie Trial, the median age of the babies at
recruitment was 5 days, and the median age at follow-up for the primary
outcome was 11 days. We are now planning a larger trial of frenotomy,
involving all degrees of tongue tie, with a primary outcome 2 weeks after
recruitment, using a more detailed tool to assess breastfeeding.
For more information on the proposed trial design, please contact
alan.emond@bristol.ac.uk
Yours sincerely,
Alan Emond
Jenny Ingram
Centre for Child and Adolescent Health, University of Bristol
I am writing to express my concern regarding the discordance between the results and conclusions of this paper. The paper compares a point of
care glucose measurement with a laboratory "gold standard". The results
are presented in a number of forms (and with no consistency regarding
units of measurement). The error-grid analysis is unhelpful as high
levels will be high and low levels will be low for both methods and the
scale...
I am writing to express my concern regarding the discordance between the results and conclusions of this paper. The paper compares a point of
care glucose measurement with a laboratory "gold standard". The results
are presented in a number of forms (and with no consistency regarding
units of measurement). The error-grid analysis is unhelpful as high
levels will be high and low levels will be low for both methods and the
scale of the graph is too large to see what the real differences are. The
"accurate estimate zone" includes potential values 4mmol/l above and below
zero in the lower glucose range.
Whilst the authors are to be applauded for inserting a Bland Altman plot,
this plot demonstrates "limits of agreement" which are around 0.5mmol/l
above and below the line of zero. 6 points lie outside the limits of
agreement with the extremes being 0.7mmol/l above and below zero.
Therefore the plot demonstrates that in an unpredictable manner the
glucometer may be over reading or under reading by a value as great as
0.7mmol/l. This is not of clinical significance in the normoglycaemic or
hyperglycaemic range, but acquires clinical significance when blood
glucose levels are low. For example if a glucometer reading is 2.0mmol/,
the accurate level (at the extreme) could be 1.3-2.7mmol/l which will
result in over diagnosis and treatment or under diagnosis and treatment.
The authors state in the results section that the plot shows "good
correlation", but the plot does not represent correlation, and the
agreement between the values is not good.
The conclusion that there is good "correlation" between the glucometer and
the laboratory measurement draws on the wrong statistical method.
Correlation does not provide accuracy data. Under "what this study adds"
it is stated that the glucometer provides accurate results and is suitable
for measuring glucose levels in premature infants. I suggest that the
results as plotted on Bland Altman plot are directly counter to this
conclusion.
Dear Sir,
We congratulate the authors on this study of neonatal transitional circulation performed so quickly after birth. The authors state that the ductal flow ratio reported in their study reflects pulmonary and haemodynamic transition and can be used to monitor neonatal transition in healthy infants. The implication is that their study describes a physiological transition in healthy term infants, but we question that this is the case.
Delivery by elective caesarean section is not a physiological birth but it does permit the neonate an atraumatic birth. We are particularly concerned that the transition may have been disrupted by the timing of cord clamping which was between 30 and 60 seconds. While this is considered delayed cord clamping by some, most guidelines recommend a minimum of 60 seconds have elapsed before the circulation is interrupted by cord clamping. The WHO advises 3 minutes.(1) Not all of the babies in the series had established respiration before clamping and cord clamping before the onset of respiration has a marked effect on cardiac output.(2) It is therefore questionable that the mean and range of results published represents a normal transition in healthy infants.
The normal fetal circulation is well described with the two ventricles pumping in parallel, the right ventricular output being significantly more than the left and the flow across two shunts, right to left in the ductus arteriousus and right to left across the foram...
Show MoreDear Editor I would like to thank Dr's Madar and Kariholu for their interest in the recent review article on use of ultrasound to assess the haemodynamic status of the sick neonate(1,2). They raise an important point that highlights the current disconnect between the recognition of the usefulness of ultrasound in general for assessment of sick neonates and the lack of availability of suitable training courses to learn th...
In the UK speciality training through the grid scheme has been in existence for about a decade with a well-defined syllabus of knowledge and skills deemed necessary for the qualified neonatologist. Although much emphasis is laid on various aspects of neonatal care and the acquisition of procedural skills including cranial ultrasound, cardiac assessment using echocardiography is still considered to be an optional skill (1)...
Dear Dr. Gallagher,
We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a docum...
Dr Essex and Mr Mercer highlight many of the reasons why we undertook the Bristol Tongue Tie trial. Ankloglossia is a spectrum condition, which overlaps with 'normal' variation in anatomy, and milder forms do not result in feeding impairment. There is very limited evidence of the need for frenotomy in mild-moderate degrees of tongue tie. However, it is also true that at the severe end of the spectrum infants can be limi...
We thank Dr. Verd and colleagues for their comments [1] on our review of the use of human milk for preterm infants. Our aim was certainly not to discourage the use of donor human milk, but rather to look objectively at the evidence base that currently exists for its use.
The authors of the letter refer to a 1984 study by Narayanan et al [2] which appeared to show a reduction in the risk of infection in infants fe...
Sirs
The tongue remains with in the boundaries of the mandible during suckling and so it is difficult to see the anatomical or the physiological basis for how a frenulectomy works in reducing breast and nipple discomfort during feeding. This randomised trial does not seem to assess the potential, positive psychological impact of the mother being told their child has had a frenulectomy. That is the question that...
Lawson's editorial and Emond and colleagues' article exposes potentially bad medicine: lack of knowledge of normal and variations of normal; lack of knowledge of the natural history of a condition; a desire to do something - Ulysses syndrome (1); medicalising the child by giving the condition a name; and then ascribing any improvement to the intervention, forgetting that association does not mean causation.
Th...
Dear Editors:
We read Val Finigan's letter with interest, and agree with her experience that most mothers do report an improvement in the comfort and efficacy of breastfeeding after their baby has had a frenotomy. The difficulty is in showing objective improvement in breastfeeding after division of less severe degrees of tongue tie.
In the Bristol Tongue Tie Trial, the median age of the babies at...
I am writing to express my concern regarding the discordance between the results and conclusions of this paper. The paper compares a point of care glucose measurement with a laboratory "gold standard". The results are presented in a number of forms (and with no consistency regarding units of measurement). The error-grid analysis is unhelpful as high levels will be high and low levels will be low for both methods and the scale...
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