We thank Drs Nistala and Nichol for their comments on our leading
article concerned with management of catheter related blood stream
infection in chldren receiving long term parenteral nutrition. The points
they make with regard to neonates may well have some validity, but our
paper relates to children on parenteral nutrition for many months, and
sometimes years. The balance of risk and benefits when tre...
We thank Drs Nistala and Nichol for their comments on our leading
article concerned with management of catheter related blood stream
infection in chldren receiving long term parenteral nutrition. The points
they make with regard to neonates may well have some validity, but our
paper relates to children on parenteral nutrition for many months, and
sometimes years. The balance of risk and benefits when treating infected
central venous catheters in situ is clearly quite different in this group
in whom loss of venous access may well jeopardise survival. We emphasise
the point that experience in adults has established that eradication of
catheter sepsis is possible, because it has been common clinical practice
in some centres to remove catheters on suspicion of sepsis rather than
even attempt treatment with antibiotics. This has relevance to children on
long term parenteral nutrition, notwithstanding that findings of studies
in one population should not be mechanically applied to another. Our own
experience with treating catheter related infection in children well
beyond the newborn period was cited.[1,2]
We suspect that Nistal and Nichol have been mislead by an arguably
perverse editorial decision to place our review in the Fetal and Neonatal
Edition of Archives. We can only agree that it is not appropriate to apply
our observations based on a review of the adult and paediatric literature
to short term PN via percutaneous catheters in the newborn. Perhaps some
intimation of our area of focus might have been gained from the fact that
we did not include a single paper on the subject of their letter (i.e.
central lines in the neonate) among the 55 references cited in our review?
References
(1) Page S, Abel G, Stringer MD, et al. Management of septicaemic
infants during long term parenteral nutrition. Int J Cln Pract 2000;54:147
-50
(2) Hoy CM, Kite P, Abel G, et al. The role of quantitative blood
culture surveillance in the diagnosis and management of central venous
catheter sepsis. Clin Nutr 2000;19(suppl 1):38.
Hodge and Puntis[1] suggest that "up to 80 % of coagulase negative
staphylococcus infection... in young children can be eradicated with
antibiotics". The study referenced, Raad et al.[2] was carried out in
adults (mean age 43 yr) with underlying malignancy, most of whom had non-tunnelled subclavian lines. It may not be appropriate to apply Raad et
al.’s results to children with long term...
Hodge and Puntis[1] suggest that "up to 80 % of coagulase negative
staphylococcus infection... in young children can be eradicated with
antibiotics". The study referenced, Raad et al.[2] was carried out in
adults (mean age 43 yr) with underlying malignancy, most of whom had non-tunnelled subclavian lines. It may not be appropriate to apply Raad et
al.’s results to children with long term parental nutrition, in view of the
differences in age, illness, and catheter type.
The authors endorse the treatment of infected central venous
catheters in situ without an adequate appraisal of the risks. In the
neonatal population retention of catheters has a lower success rate than
suggested them with only 50 % of catheters being
successfully treated.[3] Importantly, treating catheters rather than
immediate removal significantly prolonged the bacteremia. The risk of
bacterial end organ damage increases with each day that there are positive
cultures.[4]
R Nicholl
Neonatal Consultant
Northwick Park Hospital
K Nistala
Neonatal SPR
Northwick Park Hospital
References
(1) D Hodge, JWL Puntis. Diagnosis, prevention and the management of
catheter related bloodstream infection during long term parental
nutrition. Arch Dis Child Fetal Neonatal Ed 2002;87:F21-F24.
(2) Radd I, Davis S, Khan A, Tarrand J, Elting L, Bodey G.
Impact of central venous catheter removal on the recurrence of catheter-
related coagulase negative staphylococcal bacteremia. Infect Control Hosp
Epidemiol 1992;13:215-21.
(3) Karlowicz MG, Furigay PJ, Croitoru DP, Buescher ES. Central venous catheter removal versus in situ treatment in neonates with coagulase-negative staphylococcal bacteremia. Pediatr Infect Dis J 2002
Jan;21(1):22-7.
(4) Benjamin DK Jr, Miller W, Garges H, Benjamin DK, McKinney RE Jr, Cotton
M, Fisher RG, Alexander KA. Bacteremia, central catheters, and neonates:
when to pull the line. Pediatrics 2001 Jun;107(6):1272-6.
Drs Williams and Sunderland[1] and the accompanying commentary from
Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated
with chest physiotherapy in very preterm infants. Rosenbloom is correct
that the topic lacks topicality, but mainly because neonatal chest
physiotherapy is now used very little if at all. I disagree that there is
an abundant literature detailing appropriate treatm...
Drs Williams and Sunderland[1] and the accompanying commentary from
Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated
with chest physiotherapy in very preterm infants. Rosenbloom is correct
that the topic lacks topicality, but mainly because neonatal chest
physiotherapy is now used very little if at all. I disagree that there is
an abundant literature detailing appropriate treatment and the absence of
brain damage associated with neonatal chest physiotherapy. Older data
suggested benefit,[3-5] but more recent publications demonstrate none.[6-8]
The reported benefits were transient improvements in oxygenation and
slight increased removal of secretions. The older studies are all too
small to adequately address safety. Chest physiotherapy, by whatever
method has little or no place in neonatal intensive care.
There are several lessons to be learned from the experience of the
units who found these brain lesions. The first is that a treatment
generally recognised as being beneficial may not be so, especially with
other changes in care over the passage of time. Continued reassessment of
the usefulness of treatment is needed. The second is that side effects can
appear, even when a treatment has supposedly passed the test of time.
Ongoing audit is needed. The third is that there is a dilemma that
clinicians face in reporting complications. The first hospital to find
this lesion did not further investigate the cause or report its suspicions.[9] The second hospital did.[10] That hospital has been subject to a long
official public inquiry, law suites and had twenty medical, nursing and
physiotherapy staff investigated by registration authorities, lasting 8
years. All this happened in the supposedly non-litigious medicolegal
environment of New Zealand. There needs to be the ability to be open about
complications and side effects and have an atmosphere of learning from,
rather than blame for them.
I would like to correct one statement by Williams and Sunderland. In
our nursery there was no change in the vigour of chest physiotherapy from
the introduction of the technique in 1985 until we stopped all chest
physiotherapy at the end of 1994. The cerebral lesions appeared from 1992
to 1994. From 1985, the same physiotherapist was teaching and supervising
the technique. During those three years, babies who developed the brain
lesion had more chest physiotherapy than matched concurrent controls, but
considerably less than many infants in previous years. Why the brain
lesion began to appear remains a mystery.
References
(1) Williams AN, Sunderland R, Neonatal shaken baby syndrome: an
aetiological view from Down Under. Arch Dis Child 2002; 87: F29-30
(2) Rosenbloom L, Ryan S, Neonatal shaken baby syndrome: an
aetiological view from Down Under. Commentary. Arch Dis Child 2002; 87:
F30
(3) Finer NN, Boyd J. Chest physiotherapy in the neonate: a controlled
study. Pediatrics 1978; 61: 282-85.
(4) Etches PC, Scott B. Chest physiotherapy in the newborn: effect on
secretions removal. Pediatrics 1978; 62: 713-15.
(5) Tudehope DI, Bagley C. Techniques of physiotherapy in intubated
babies with the respiratory distress syndrome. Aust Paediatr J 1980; 16:
226-28.
(6) Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post-
extubation atelectasis. Pediatr Pulmonol 1996; 21: 227-30.
(7) Bloomfield FH, Teele RL, Voss M, Knight DB, Harding JE. The role
of neonatal chest physiotherapy in preventing postextubation atelectasis.
J Pediatr 1998; 133: 269-71.
(8) Bagley CE, Flenady VJ, Tudehope DI, Gray PH, Lamont A, Shearman A.
The role of routine prophylactic post-extubation chest physiotherapy in
neonates: a randomised controlled trial. Proc Perinatal Society of
Australia and New Zealand, Brisbane. 2000; page 73.
(9) Rushton DI. Neonatal shaken baby syndrome – historical inexactitudes. [electronic
response to Williams AN et al. Neonatal shaken baby syndrome: an aetiological view from Down Under] archdischild.com 2002 http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;87/1/F29#139
(10) Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB. Chest
physiotherapy may be associated with brain damage in extremely preterm
infants. J Pediatr 1998; 132: 440-44.
I read with interest the article on Neonatal Shaken Baby
Syndrome.[1] While a fascinating account
of the sequence of events in this saga it is factually
incorrect in several respects.
As the perinatal pathologist involved in the Birmingham
series I raised the possibility that the brain damage was
due to the effects of physiotherapy prior to the publication
of our report. My co-authors felt tha...
I read with interest the article on Neonatal Shaken Baby
Syndrome.[1] While a fascinating account
of the sequence of events in this saga it is factually
incorrect in several respects.
As the perinatal pathologist involved in the Birmingham
series I raised the possibility that the brain damage was
due to the effects of physiotherapy prior to the publication
of our report. My co-authors felt that the suggestion was
too speculative to be included. It is however of note that
the physiotherapy regime was changed at this time as a
precaution and as I remember I encountered only one further
case until my retirement in 2000. At the time I presented
the pathological data at several scientific meetings both in
the UK and abroad suggesting physiotherapy was relevant and
also discovered that the method used in Birmingham appeared
to be unique in allowing free movement of the babies head
during treatment of the chest.
Some years later I received a telephone call from Dr David
Becroft the perinatal pathologist concerned with the New
Zealand cases which pathologically appeared very similar to
our own. They had no explanation for their cases at this
time and I indicated that I had always been of the opinion
that physiotherapy was responsible. As I understand it this
resulted in changes in the physiotherapy regime in New
Zealand and the disappearance of the lesion.
In retrospect I should have insisted that my hypothesis
however speculative was included in our original paper or
expressed the view in the correspondence columns at the time
since it might have prevented or at least reduced the number
of affected cases in New Zealand. Certainly today I would
not have been so reticent. In the event it is gratifying
that detailed clinical analysis of the cases confirmed my
original opinion.
As to the pathology of the condition detailed unpublished
studies of the affected brains in our series suggest the
lesion is more akin to that of hydranencephaly than
infantile shaken baby syndrome and leads me to raise the
possibility that hydranencephaly may be the result of
intra-uterine brain trauma.
D Ian Rushton MB ChB FRCPCH FRCP
Reference
(1) Williams AN, Sunderland R, Rosenbloom L and Ryan S. Neonatal shaken baby syndrome: an aetiological view from Down Under. Arch Dis Child Fetal Neonatal Ed 2002;87: F29-F30.
We read this article with interest, and it prompted us to review
our own experience with progressive ventricular dilatation (PVD)
over the past 22 years at the Maine Medical Center (MMC) in
Portland, Maine.
Since 1980, we have used a single approach to
management of PVD. As noted in previous publications, we
have considered the need for intervention to be rapid head growth
defined as an increase in OFC...
We read this article with interest, and it prompted us to review
our own experience with progressive ventricular dilatation (PVD)
over the past 22 years at the Maine Medical Center (MMC) in
Portland, Maine.
Since 1980, we have used a single approach to
management of PVD. As noted in previous publications, we
have considered the need for intervention to be rapid head growth
defined as an increase in OFC of 2 cm per week or more rather
than relying on imaging.[1,2] As this degree of head growth
suggests increased intracranial pressure,[3] we have intervened
by directly draining ventricular fluid via a 21 gauge angiocath
placed through the right coronal suture into the right lateral
ventricle. This catheter is connected to a ventriculostomy
drainage system and drainage is continued for 7 days if possible.
The catheter is then removed and the drop in head circumference
and ventricular size recorded. The infant is watched for return
of rapid head growth and an angiocath is reinserted as needed.
This procedure is repeated until the infant reaches approximately
2 kg, and if rapid head growth continues, a permanent VP shunt is
placed.[2] We do not use pharmacological treatment or repeat LP
to treat PVD.
As pointed out by the authors, PVD sufficient to
require intervention occurs almost exclusively in infants with
grade 3 or 4 IVH. As expected, the VLBW infants with high grade
IVH have a high mortality. The table below shows a comparison
between the outcomes for grade 3-4 IVH at MMC during the 1980s
and over the past 5 years (1997-2001 inclusive), and the authors'
data grouped in the same way. As noted, there is little
difference over time or between studies. Overall mortality for
grade 3-4 IVH was 33 % (26/79) for Murphy et al, 33 % (31/94) for
MMC 1980s and 31 % (9/29) for MMC 1997-2001. Until grade 3-4 IVH
can be eliminated, post-haemorraghic hydrocephalus will continue
to occur with high morbidity and mortality.
Murphy, et al [4]
MMC 1980s [2]
MMC 1997-2001
Grade 3-4 IVH
(% of all <1500g)
79 (7%)
94 (6%)
29 (6%)
Death <14 days
18/79 (23%)
29/94 (30%)**
8/29 (28%)**
PVD req.ing Rx
34/61 (56%)
24/65 (37%)
11/21 (52%)
VP shunt/late death
(% of PVD Rx)
18/8
(26/34 = 76%)
12/3
(15/24 = 63%)
6/1
(7/11 = 63%)
* Rate for all infants <_35 weeksbr="weeksbr"/>
** Rate for all deaths <_30 days="days" _="_" font="font"/>
References
(1) Allan WC, Holt PJ, Sawyer LR, et al. Ventricular
dilation after neonatal periventricular-intraventricular
hemorrhage. Natural history and therapeutic implications. American
Journal of Diseases in Children 1982;136:589-93.
(2) Marro PJ, Dransfield DA, Mott SH, et al.
Posthemorrhagic hydrocephalus: Use of an intravenous-type
catheter for cerebrospinal fluid drainage. American Journal
of Diseases in Children 1991;145:1141-6.
(3) Hill A, Volpe JJ. Normal pressure hydrocephalus in the newborn
Pediatrics 1981;68:623-9.
(4) Murphy BP, Inder TE, Rooks V, et al. Posthaemorrhagic
ventricular dilatation in the premature infant: natural history
and predictors of outcome. Arch Dis Child Fetal Neonatal Ed
2002;87:F37-F41
This is in response to the letter from SA Ali et al.[1]
1. The total number (1598)and the culture positive babies (1003)in
our article [1] represent cases after the patients meeting the exclusion
criteria were taken out. We did grow isolated cases of Strp sp. Salmonella
and Enterococci which happened to fall in the excluded group. In the
spectrum as a whole, these oganisms accounted for...
This is in response to the letter from SA Ali et al.[1]
1. The total number (1598)and the culture positive babies (1003)in
our article [1] represent cases after the patients meeting the exclusion
criteria were taken out. We did grow isolated cases of Strp sp. Salmonella
and Enterococci which happened to fall in the excluded group. In the
spectrum as a whole, these oganisms accounted for <_0.5 _="_" of="of" the="the" organisms.="organisms." this="this" is="is" similar="similar" to="to" study="study" done="done" by="by" maryam="maryam" w="w" i="i"/>et al[2]in a
public sector institution with population of exactly similar
socioeconomic, cultural, religious and climatic background as ours. Their
study was done in the same time period as ours but completely independent
and blinded from ours. In their series of 284 cases, they grew E. Coli 130
cases (45.77 %), Klebsiella 49 cases (17.25 %), Pseudomonas 46 cases (16.2 %),
Staph A 39 cases (13.73 %), Staph Epi 18 cases (6.34 %), Strep sp 1 case
(0.35 %) and Salmonella 1 case (0.35 %). The numbers are slightly different
among the studies from south of Pakistan. This is not surprising because
neonatal sepsis is known for the temporal and regional variation of the
spectrum of its organisms even in different hospitals within the same
city.
2. The basic message from the majority of studies from Pakistan is
the same "Gram Negative organisms are the main caues of neonatal sepsis in
Pakistan followed by Staph A". This group of organisms is responsible for
>99 % of the spectrum and unfortunately the grave situation of multidrug
resistance is emerging among these organisms. That is where one needs to
concentrate instead of the organisms responsible for <_0.5 _="_" of="of" the="the" spectrum="spectrum" i="i"/>Salmonella, Strep sp etc) which do not carry any significane for
overall neonatal mortality and morbidity.
3. Out of 296 cases of Staph A in our series, Ampicillin was tested
on 285 cases with 171 (60 %)sensitive to it while 279 were tested for
Augmentin with 75(26.88 %) sensitive to it. I agree with S Ali et al. that
this pattern of sensitivity looks unusual as for as Staph A is concerned
though this phenomenon is known to occurr with Beta lactamase producing E.
Coli. It may be due to the varying strengths of Augmentin discs available
or known biochemical instability of Clavulonic acid or difficulty of
interpretation when a combination of two antibiotics is used in one disc
using disc diffusion technique. However, I would love to listen some more
expert opinion about this. Our series did not exclude hospital acquired
infections.
4. The longitudinal analysis of our data shows an increasing
sensitivity to Penicillin and decreasing sensitivity to Cephalosporins,
particularly Cefotaxime, over the last half decade. This is consistent
with the change in antibiotic use in Pakistan since early 1990s when
Penicillin/Gentamicin was switched over to Cephalosporins/ Amikacin as the
first line antibiotic regime. Most of the Gram negative organisms in
Pakistan still maintain a very high degree of sensitivity to Amikacin
[2,3]but not to Gentamicin. I feel Penicillin/Amikacin may be a very good
choice as the first line antibiotic in the neonatal units in Pakistan.
This is a high time to review our antibiotic policies and at the same time
approach the government to rationalise the antibiotic marketing in the
country.
References
(1) Rahman S, Hameed A, RoghaniM T , and Ullah Z. Multidrug resistant neonatal sepsis in Peshawar
Pakistan. Arch Dis Child Fet Neo Ed 2002;87:F52-4
(2) Maryam W et al. Neonatal sepsis spectrum of antibiotic resistance.
Proceedings of 10th Annual National Pediatric Conference PPA. 2001; 57.
(3) Anwar SK et al. Neonatal Sepsis: an etiological study. JPMA. 2000
Mar; 50(3)91-4.
We wish to raise a few concerns regarding the study reported by S
Rahman and colleagues.[1]
We found it surprising that only five species of micro-organisms were
isolated in this series of over a 1000 blood cultures obtained from
neonates with sepsis. Similar studies done in other major cities of
Pakistan, with much smaller sample sizes have shown a wider spectrum of
pathogens . Anwer SK (2000)[2...
We wish to raise a few concerns regarding the study reported by S
Rahman and colleagues.[1]
We found it surprising that only five species of micro-organisms were
isolated in this series of over a 1000 blood cultures obtained from
neonates with sepsis. Similar studies done in other major cities of
Pakistan, with much smaller sample sizes have shown a wider spectrum of
pathogens . Anwer SK (2000)[2] showed 11 species types in 109 blood
cultures, Bhutta ZA (1997)[3] showed 13 species types in 38 cultures, and 11
species types in a series of 276 positive blood cultures (2001)[5]. Khan IA
(1987)[4] showed more than 8 different species types from 89 cultures. In
addition to the 5 species causing neonatal sepsis reported by Rahman et al
(Esherichia coli 36.6 %, Staphylococcus aureus 29.5 %, Pseudomonas 22.4 %,
Klebsiella 7.6 % and Proteus 3.8 %), all the other investigators have also
reported Serratia spp and Enterococcus, and most reported Streptococcus
pneumoniae, Salmonella spp and group B Streptococcus. Although the authors
do not clearly state whether they excluded hospital-acquired infections in
their series, the studies reported by Bhutta ZA5 did exclude nosocomial
infections.
The antimicrobial susceptibility data reported by Rahman et al. are
not interpretable as the number of micro-organisms on which antimicrobial
susceptibility testing was performed is not presented. In addition, the
susceptibility results are not internally consistent; 60 % of the
Staphylococcus aureus tested are reported to be ampicillin-sensitive but
only 27 % were Amoxicillin + Clavulanate (Augmentin) sensitive. This
represents a highly unusual susceptibility result with a high percentage
of S. aureus not producing beta-lactamase enzymes to inactivate penicillin
(ampicillin), but still showing resistance to a penicillin-beta-lactamase
combination such as Augmentin. We wonder if the 60 % reported sensitivity
of S. aureus to ampicillin is erroneous since the vast majority of
S.aureus even in developing countries, are now penicillin (ampicillin)-
resistant [5,6,7,8]. We also find the 73 % resistance rate of S. aureus to
amoxicillin-clavulanate (which is equivalent to methicillin-resistance for
S. aureus) surprisingly high, and question if this indicates the presence
of hospital-acquired infections in this series.
Syed A Ali Tauseef A Khan Anita KM Zaidi
Department of Paediatrics
The Aga Khan University
Karachi, Pakistansyed.ali@aku.edu
References
(1) S Rahman, A Hameed, M T Roghani, Z Ullah. Multidrug resistant
neonatal sepsis in Peshawar, Pakistan. Arch Dis Child Fetal Neonatal Ed
2002;87:F52-F54.
(2) Anwer SK, Mustafa S, Pariyani S, Ashraf S, Taufiq KM. Neonatal sepsis:
An etiological study. J Pak Med Assoc 2000; 50(3): 91-93.
(3) Bhutta ZA, Yusuf K. Early onset neonatal sepsis in Pakistan: A case
control study of risk factors in a birth cohort. Am J Perinatol 1997;
14(9): 577-581.
(4) Khan IA, Akram DS. Neonatal sepsis – Etiological study. J Pak Med Assoc
1987;37: 327-30.
(5) Bhutta ZA. Spectrum of nonnosocomial neonatal sepsis. State of the
World's newborns: Pakistan. Saving Newborn LivesOct 2001.
(6) Kuruvilla KA, Pillai S, Jesudason M, Jana AK. Bacterial profile of sepsis in a neonatal unit in South India. Indian Pediatr 1998;35: 851-8.
(7) Tallur SS, Kasturi AV, Nadgir SD, Krishna BVS. Clinico-bacteriological
study of neonatal septicemia in Hubli. Indian J Pediatr 2000;67(3):169-74.
(8) Ako-Nai AK, Adejuyigbe EA, Ajayi FM, Onipede AO. The Bacteriology of
Neonatal Septicemia in Ile-Ife, Nigeria. J Trop Pediatr 1999;45:146-51.
This symposium on CLD by Kotecha et al.[1] covered important aspects and
controversies in the management of CLD. We accept the authors' inability
to cover all aspects of management.
We feel that some space could have been devoted to diuretics in management
of CLD. Nearly all patients with CLD of some stage of their disease
will recieve diuretics and most of them will be on them for a long time. We...
This symposium on CLD by Kotecha et al.[1] covered important aspects and
controversies in the management of CLD. We accept the authors' inability
to cover all aspects of management.
We feel that some space could have been devoted to diuretics in management
of CLD. Nearly all patients with CLD of some stage of their disease
will recieve diuretics and most of them will be on them for a long time. We came across only one systemic review by Brion et al.[2]
in the Cochrane database. Conclusion of the authors was that there was no
beneficial effect of using distal tubular diuretics for more than 4 weeks
after initial stage. There was also no benefit in adding potassium sparing
diuretics or newer diuretics like metalozone.
Inspite of very little evidence base for diuretics in CLD, one finds
nearly all CLD patients on a diuretic cocktail. In addition to their effect
on electrolytes, they affect Ca/PO4 metabolism. This may
exacrebate osteopenia of prematurity and may have adverse effect on lung
compliance.
There is a need for more discussion or clear guidelines on this issue.
References
(1) Management issues in CLD of prematurity. S Kotecha
Arch Dis Child Fetal Neonatal Ed 2002;87:F2.
(2) Cochrane Database Systemic Review. LP Brion, RA Primhak 2002:(1):CD001453.
We thank Professor Dellagrammaticas for his comments on our study.
[1] Dellagrammaticas et al. [2] hypothesised that the combination of the
prone posture and the 45 degree head up tilt position could facilitate
diaphragmatic activity. We however, propose that the improvement in
oxygenation seen in the head up tilt position1 was more likely to be due
to a change in lung volume. In the head up...
We thank Professor Dellagrammaticas for his comments on our study.
[1] Dellagrammaticas et al. [2] hypothesised that the combination of the
prone posture and the 45 degree head up tilt position could facilitate
diaphragmatic activity. We however, propose that the improvement in
oxygenation seen in the head up tilt position1 was more likely to be due
to a change in lung volume. In the head up tilt position, the weight of
the abdominal contents on the diaphragm is reduced, tending to increase
functional residual capacity.[3] In contrast, ultrasonographic
examination [4] has demonstrated that the diaphragm was significantly
thicker at end expiratory volume in the prone rather than the supine
position, which is likely to result in reduced diaphragm strength.
Indeed, we demonstrated [1] Pimax (a measure of respiratory muscle
strength) was lower in the prone compared to the supine position and the
supine posture with 45° head tilt.
Anne Greenough MD FRCP FRCPCH DCH
Academic Head of Paediatrics
Children Nationwide Professor of Neonatology and Clinical Respiratory
Physiology
Gabriel Dimitriou MD
Lecturer in Perinatology
References
(1) Dimitriou G, Greenough A, Pink L, McGhee A, Hickey A, Rafferty GF.
Effect of posture on oxygenation and respiratory muscle strength in
convalescent neonates. Arch Dis Child 2002;86:F147-50.
(2) Dellagrammaticas Hd, Kapetankis J, Papadimitriou M, Kourakis G.
Effect of body tilting on physiological functions in stable very low birth
weight neonates. Arch Dis Child 1991;66: 429-32.
(3) Thoresen M, Cowan F, Whitelaw. Effect of tilting on oxygenation
in newborn infants. Arch Dis Child 1988;63: 315-7.
(4) Rehan VK, Nakashima JM, Gutman A, Rubin LP, McCool FD. Effects of
supine and prone position on diaphragmatic thickness in healthy term
infants. Arch Dis Child 2000;83:234-8.
We read with interest the report of Rechner et al [1] regarding the use of the HemoCue haemoglobinometer on their neonatal unit. The development and use of accurate microsample techniques could make an important contribution in reducing transfusion requirements of multiply bled infants, time spent by junior staff in obtaining, labelling and chasing results of formal laboratory samples and laboratory costs...
We read with interest the report of Rechner et al [1] regarding the use of the HemoCue haemoglobinometer on their neonatal unit. The development and use of accurate microsample techniques could make an important contribution in reducing transfusion requirements of multiply bled infants, time spent by junior staff in obtaining, labelling and chasing results of formal laboratory samples and laboratory costs.
In a study of 52 paired blood samples (24 arterial, 15 capillary and 13 venous) from 16 infants of various gestational ages we compared haemoglobin, sodium, potassium and bilirubin results obtained from our haematology (Celldyne 3500 analyser, Abbott Laboratories, Illinois, USA) and biochemistry (Advia 1650 analyser, Bayer, Newbury, UK) laboratories with those from the blood gas analyser (ABL 735, Radiometer, Copenhagen) used on our neonatal unit. The volume of blood required for laboratory testing was 0.5-1ml, whereas that for the blood gas analyser was 0.1ml.
There was no significant difference between the mean results from the laboratory and the blood gas analyser for haemoglobin, sodium, potassium, and bilirubin using two-sample t-test. In addition there was a high degree of correlation between the two sets of results for haemoglobin and sodium, and to a lesser degree for potassium and bilirubin (Table 1).
We agree with Rechner and colleagues that instruments such as the HemaCue may be useful in reducing the volume of blood taken from infants. However, for those units with a blood gas analyser capable of measuring haemoglobin and electrolytes, to achieve this may not require the purchase of new equipment, rather, as in our case, the appreciation of an existing piece. Perhaps the greatest hurdle to cross is that of staff trust in a result from a non-laboratory source. This can be achieved with education. Units should also address the appropriateness of ‘routine’ blood taking, which is often performed with little thought as to why.
References:
(1) Rechner IJ, Twigg A, Davies AF, Imong S. Evaluation of the HemoCue compared with the Coulter STKS for measurement of neonatal haemoglobin. Arch. Dis. Child. Fetal Neonatal Ed 2002;86:F188-F189.
Table 1: Mean haemoglobin, sodium, potassium and bilirubin
measurements for laboratory and blood gas analyser results, with correlations.
Mean result (range) p-value
*g/l
†mmol/l
Correlation between gas analyser and laboratory result:
Co-efficient
(95% CI)
p-value.
Dear Editor
We thank Drs Nistala and Nichol for their comments on our leading article concerned with management of catheter related blood stream infection in chldren receiving long term parenteral nutrition. The points they make with regard to neonates may well have some validity, but our paper relates to children on parenteral nutrition for many months, and sometimes years. The balance of risk and benefits when tre...
Dear Editor
Hodge and Puntis[1] suggest that "up to 80 % of coagulase negative staphylococcus infection... in young children can be eradicated with antibiotics". The study referenced, Raad et al.[2] was carried out in adults (mean age 43 yr) with underlying malignancy, most of whom had non-tunnelled subclavian lines. It may not be appropriate to apply Raad et al.’s results to children with long term...
Dear Editor
Drs Williams and Sunderland[1] and the accompanying commentary from Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated with chest physiotherapy in very preterm infants. Rosenbloom is correct that the topic lacks topicality, but mainly because neonatal chest physiotherapy is now used very little if at all. I disagree that there is an abundant literature detailing appropriate treatm...
Dear Editor
I read with interest the article on Neonatal Shaken Baby Syndrome.[1] While a fascinating account of the sequence of events in this saga it is factually incorrect in several respects.
As the perinatal pathologist involved in the Birmingham series I raised the possibility that the brain damage was due to the effects of physiotherapy prior to the publication of our report. My co-authors felt tha...
Dear Editor
We read this article with interest, and it prompted us to review our own experience with progressive ventricular dilatation (PVD) over the past 22 years at the Maine Medical Center (MMC) in Portland, Maine.
Since 1980, we have used a single approach to management of PVD. As noted in previous publications, we have considered the need for intervention to be rapid head growth defined as an increase in OFC...
Dear Editor
This is in response to the letter from SA Ali et al.[1]
1. The total number (1598)and the culture positive babies (1003)in our article [1] represent cases after the patients meeting the exclusion criteria were taken out. We did grow isolated cases of Strp sp. Salmonella and Enterococci which happened to fall in the excluded group. In the spectrum as a whole, these oganisms accounted for...
Dear Editor
We wish to raise a few concerns regarding the study reported by S Rahman and colleagues.[1]
We found it surprising that only five species of micro-organisms were isolated in this series of over a 1000 blood cultures obtained from neonates with sepsis. Similar studies done in other major cities of Pakistan, with much smaller sample sizes have shown a wider spectrum of pathogens . Anwer SK (2000)[2...
Dear Editor
This symposium on CLD by Kotecha et al.[1] covered important aspects and controversies in the management of CLD. We accept the authors' inability to cover all aspects of management. We feel that some space could have been devoted to diuretics in management of CLD. Nearly all patients with CLD of some stage of their disease will recieve diuretics and most of them will be on them for a long time. We...
Dear Editor
We thank Professor Dellagrammaticas for his comments on our study. [1] Dellagrammaticas et al. [2] hypothesised that the combination of the prone posture and the 45 degree head up tilt position could facilitate diaphragmatic activity. We however, propose that the improvement in oxygenation seen in the head up tilt position1 was more likely to be due to a change in lung volume. In the head up...
We read with interest the report of Rechner et al [1] regarding the use of the HemoCue haemoglobinometer on their neonatal unit. The development and use of accurate microsample techniques could make an important contribution in reducing transfusion requirements of multiply bled infants, time spent by junior staff in obtaining, labelling and chasing results of formal laboratory samples and laboratory costs...
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