Dear Editor,

I read with interest the paper by McHaffie [1] et al on the follow up of bereaved parents after treatment withdrawal from newborns. They comment how they could find no evidence in the literature to support the recommendations for timing of follow up given by the Stillbirth and Neonatal Death Society and how bereavement care is largely an "intuitive response". I wish to offer the following comments:

In a study by Benfield [2] in 1978 of parental grief following neonatal death 50 mother/father pairs were asked to schedule a follow up appointment at the time of their choosing. The average time of this was 40 days (range 11 to 97 days). The same study found no significant differences in parental grief score if treatment had been withdrawn after discussion with the parents compared with those parents whose baby had died on a ventilator.

In a Glasgow study in 1984 [3] the parents of 12 babies who had died were interviewed at a mean of 6.3 months after death to establish how death had been handled and what the wishes of bereaved parents were. 10 (83%) wanted a review with a paediatrician and 9 (75%) of the families suggested 5 weeks after death as optimum timing. All parents wished to have a discussion on the risk of recurrence and 10 (83%) wanted a memento. Half of the group would have liked bereavement counselling in their home. Parents stressed the importance of the postmortem result in alleviating questioning and guilt.

Asking bereaved parents about their needs is important so that guidelines for follow up can be made. McHaffie et al are to be congratulated on their important study.

Madeleine White
Consultant Paediatrician

References

(1) McHaffie H E, Laing I A, Lloyd D J. Follow up care of bereaved parents after treatment withdrawal from newborns. Arch Dis Child Fetal Neonatal Ed.2001; 84:F125-128
(2) Benfield D G, Leib S A, Vollman J H. Grief response of parents to neonatal death and parent participation in deciding care. Pediatrics 1978;62:171-177.
(3) White M P, Reynolds B, Evans T J. Handling of death on special care nurseries and parental grief. Br Med J 1984;289:167-169.

Dear Editor, We read the article by Reece et al [1] and followed the subsequent correspondence with interest. In light of the recent review commissioned by The Chief Medical Officer for England, physicians must be aware of potential complications of peripherally inserted central catheters (PICC).[2] While the true incidence of such events will only be known with prospective data collection, retrospective studies suggest a complication rate (pleural/pericardial effusions) of 0.5% per line insertion.[3] The Department of Health (DoH) paper in response to this review recommends placement of central venous lines outwith the cardiac chambers.[4] However, complications related to central lines are not only confined to the thorax. We report 3 cases of delayed detection of peritoneal extravasation related to central venous catheters.

Case 1: An eight-week old malnourished infant was intubated and ventilated for acute onset severe respiratory distress following a brief flu-like illness. His endotracheal secretions were positive for RSV and a previously undetected myopathy was suspected and investigated. He required prolonged ventilation and received blood transfusions through a triple-lumen right femoral venous catheter for anaemia. On the fifth day after admission he developed abdominal distension and a diagnostic tap under ultrasound guidance revealed haemorrhagic ascites. A contrast radiograph of the femoral catheter showed extravascular spillage of dye, in this case in the extraperitoneal space. In retrospect, the infant showed no rise in haemoglobin following 2 packed cell transfusions. Extravascular migration of the catheter tip was diagnosed and the catheter was promptly removed.

Case 2: A 24-week preterm female infant was admitted to the neonatal intensive care unit where she was ventilated and treated with surfactant. Severe respiratory distress of prematurity, patent ductus arteriosus and sepsis complicated the initial course. The PDA did not respond to 2 courses of indomethacin and surgical ligation was scheduled on day 13 of life. A PICC was removed due to suspected catheter sepsis and she was treated with intravenous antibiotics. She had a right femoral venous central single-lumen catheter through which she received parenteral nutrition and blood transfusions on the unit. Her anaemia failed to respond to the three packed cell transfusions and when she developed abdominal distension with bluish discolouration in the groin, the femoral line was radiographically reviewed after injecting contrast material. Extravascular spillage of the dye was noted in the extraperitoneal space and the subcutaneous tissue of the lower abdominal wall.

Case 3: A – week preterm infant with PICC in the leg developed a skin abscess at the xyphisternum. Abdominal radiograph with contrast injected through the catheter, revealed retroperitoneal extravasation of contrast. The PICC was removed and the infant made a full recovery.

In each of these case reports, femoral catheter tip migration was detected following extravascular extravasation of blood or parental nutrition fluid. Haemoperitoneum has been reported in the past as a complication of central catheters but may not be widely recognised. In comparison with PICC, these catheters are shorter and more rigid, hence more likely to perforate through vessel wall. Femoral venous access is readily obtained in infants and is commonly used in intensive care settings for parenteral nutrition, maintenance fluids, blood transfusions and other parenteral therapy. Whilst malpositioning of femoral catheter is readily detected in most instances during placement, a spontaneous extravascular migration of a previously well-placed catheter tip is possible in some cases. As opposed to frank rupture of the blood vessel and haemorrhage into the retroperitoneum, slow extravascular infusion of blood in the low resistance extraperitoneal space may not be promptly detected in the absence of a high index of suspicion. In preterm newborns and malnourished infants the vessel wall integrity may be compromised and migration of a previously normally positioned catheter tip may be more likely. Femoral venous catheter tip positions must be reviewed in all cases of unexplained ascites and abdominal distension. Contrast radiography, digitalized image inversion and ultasonography have a role in determining catheter tip position and diagnosing malpositioned intravascular catheters.[5]

We agree with the DoH recommendation that there should be a prospective National Audit of such cases.

References

(1) Reece A, Ubhi T, Craig AR and Newell SJ. Positioning long lines: contrast versus plain radiography. Arch. Dis. Child 2001; 84: F129-130.

(2) Nadroo AM, Lin J, Green RS, Magid MS, Holzman IR. Death as a complication of peripherally inserted central catheters in neonates. J. Pediatr 2001 Apr; 138(4): 599-601.

(3) Keeney SE, Richardson CJ. Extravascular extravasation of fluid as a complication of central venous lines in the neonate. J Perinatology 1995: 15;No 4, p284-288.

(4) Review of four neonatal deaths due to cardiac tamponade associated with the presence of a Central Venous Catheter. Recommendations and Department of Health response. [http://www.doh.gov.uk/manchesterbabies/manchestersummary/]

(5) Bernard I, Banerjee I. E-letter. Arch. Dis. Child, 14th May 2001.

Authors:

1] Nilesh M Mehta
Specialist Registrar

2] Richard M Nicholl
Consultant Neonatologist, Hon. Senior Clinical Lecturer

Northwick Park Hospital
NorthWest London Hospitals NHS Trust
Harrow HA1 3UJ, UK

Dear Sir,

We noted with interest Noar et al's letter of 20th July 2001 describing their as yet unpublished work on outcomes of infants from multiple gestation pregnancies. We look forward to seeing the data and methods of analysis on which their conclusions were based.

We discussed Nielsen et al's work in our paper where we noted that 'the sample size and analytical approach may explain discrepancies with our results'. Nielsen and colleagues investigated 203 infants from multiple gestations and did not take into account the sibling relationship between twin pairs, perhaps explaining their inability to find the significant difference between sibling pairs observed in our series of 602 infants.

Yours sincerely

Doug Hacking
Andrew Watkins
Simon Fraser
Rory Wolfe
Terry Nolan

Lee et al compare routine neonatal examinations by SHOs and ANNPs. They claim that ANNPs were more sensitive and equally specific at detecting all three conditions examined. The study proves this however only for hip abnormalities, referred directly by the ANNPs and SHOs for specialist assessment.

Referrals for eye and heart abnormalities were routed through senior paediatricians in both hospitals. The sensitivity and specificity measured for these conditions therefore reflects those of the senior paediatricians, not the ANNPs and SHOs. Differences in referral practices between the paediatricians at the two hospital sites and different rates of non-attendance from the two hospitals could also have affected the numbers seen at the specialist clinics, particularly for the smaller arms of the study, and should have been acknowledged in the report.

The study therefore encourages the role of ANNPs in neonatal checks but has not yet proved their competence compared to the existing system.