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
We read with great interest the consensus article on the
investigation and management of hyperinsulinism in infancy (1). The
authors discuss the value of the intra-arterial calcium stimulation test,
but speculate that there is a significant risk of bowel infarction.
Intra-arterial calcium stimulation for localisation of insulinomas in
adult patients has been described by several authors (2,3,4). To our
knowledge...
We read with great interest the consensus article on the
investigation and management of hyperinsulinism in infancy (1). The
authors discuss the value of the intra-arterial calcium stimulation test,
but speculate that there is a significant risk of bowel infarction.
Intra-arterial calcium stimulation for localisation of insulinomas in
adult patients has been described by several authors (2,3,4). To our
knowledge, bowel infarction has never been reported as a complication.
We have used the intra-arterial calcium stimulation test in infants
with hyperinsulinism to localise the site of hypersecretion of insulin,
and to determine whether it is focal or diffuse (5). In six procedures
performed on children (age range 2 months to 3 years) there has been no
clinical or radiological evidence of bowel ischaemia or infarction, and no
evidence of arterial spasm has been demonstrated on coeliac or mesenteric
arteriograms.
We conclude that this is a safe and valuable investigation, and we
believe that it is less invasive than the alternative technique of
transhepatic portal venous sampling.
L J Abernethy Consulatant Paediatric Radiologist
G L Lamont Consultant paediatric Surgeon
D C Davidson Consulatant Paediatrician
References:
1.
A Aynsley-Green, K Hussain, J Hall, J M Saudubray, C Nihoul-Fékété, P De
Lonlay-Debeney, F Brunelle, T Otonkoski, P Thornton, and K J Lindley
Practical management of hyperinsulinism in infancy
Arch. Dis. Child. Fetal Neonatal Ed. 2000; 82: F98-F107
2. Doppman JL, Miller DL, Chang R, Shawker TH, Gorden P, Norton JA.
Insulinomas: localization with selective intra-arterial injection of
calcium.
Radiology 178: 237 - 241.
3. O'Shea D, Rohrer-Theurs AW, Lynn JA, Jackson JE, Bloom SR
Localization of insulinomas by selective intaarterial calcium injection.
J Clin Endocrinol Metab 1996 81: 1623-7.
4. Pereira PL, Roche AJ, Maier GW, Huppert PE, Dammann F, Farsworth
CT, Duda SH, Claussen CD.
Insulinoma and islet cell hyperplasia: value of the calcium intarterial
stimulation test when finding of other preoperative studies are negative.
Radiology 1998: 206: 703-9.
5. Abernethy LJ,Davidson DC, Lamont G, Shepherd RM, Dunne MJ
Intra-arterial calcium stimulation test in the investigation of
hyperinsulinaemic hypoglycaemia.
Arch Dis Child 1998; 78:359-63
Wonderful work by Vyas et al on ROP and its incidence in different
cities of Britain. The statistically significant difference in the
incidence of ROP in different centres may be related to the differences in
the level of care provided. The advancements in neonatal care,
particularly the use of surfactant and the resultant reduction in the
requirements of O2 has greatly influenced outcome and possible development
of ROP (...
Wonderful work by Vyas et al on ROP and its incidence in different
cities of Britain. The statistically significant difference in the
incidence of ROP in different centres may be related to the differences in
the level of care provided. The advancements in neonatal care,
particularly the use of surfactant and the resultant reduction in the
requirements of O2 has greatly influenced outcome and possible development
of ROP (Hussain et al, Pediatrics 1999). Obviously all factors need to be
taken into account while comparing results at widely differing centres.
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.
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...
We read with great interest the consensus article on the investigation and management of hyperinsulinism in infancy (1). The authors discuss the value of the intra-arterial calcium stimulation test, but speculate that there is a significant risk of bowel infarction.
Intra-arterial calcium stimulation for localisation of insulinomas in adult patients has been described by several authors (2,3,4). To our knowledge...
Wonderful work by Vyas et al on ROP and its incidence in different cities of Britain. The statistically significant difference in the incidence of ROP in different centres may be related to the differences in the level of care provided. The advancements in neonatal care, particularly the use of surfactant and the resultant reduction in the requirements of O2 has greatly influenced outcome and possible development of ROP (...
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...
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