We thank the letter authors for commending most of our protocol decisions. A multicenter trial is always associated with a number of compromises, e.g. between standardization and freedom of therapy, between insufficient and overzealous data collection, and between too few and too many exploratory statistical tests.
For detecting BPD, we used criteria that included all cases with requirement of supplemental oxygen or mechanical support at a postmenstrual age of 36 weeks. This definition was the same as moderate or severe BPD in the more recently formulated consensus definition, and has been used in many other previous trials, testing ventilation modes, high-frequency ventilation, steroid use, permissive hypercapnia, and many others. This made our results comparable to previously published data.
We thank the letter authors for commending most of our protocol decisions. A multicenter trial is always associated with a number of compromises, e.g. between standardization and freedom of therapy, between insufficient and overzealous data collection, and between too few and too many exploratory statistical tests.
For detecting BPD, we used criteria that included all cases with requirement of supplemental oxygen or mechanical support at a postmenstrual age of 36 weeks. This definition was the same as moderate or severe BPD in the more recently formulated consensus definition, and has been used in many other previous trials, testing ventilation modes, high-frequency ventilation, steroid use, permissive hypercapnia, and many others. This made our results comparable to previously published data.
Few authors have previously chosen to limit their BPD definition to the severe cases only. The letter's authors are correct that when analyzing the severe BPD cases separately, there were significantly more cases in the high PCO2 target group in comparison to the control group, which may indicate harm associated with the high target group, especially as BPD is also associated with other adverse outcomes. However, the numbers were small and a possibility of just seeing random noise remains. Specifically, the cited difference of more cases of severe BPD in the high target group was in part compensated by fewer infants in the high PCO2 target group having moderate BPD. If the high PCO2 target was consistently harmful, there should have been both, more infants with severe BPD and more infants with moderate BPD, in the high target group. This situation, with opposite differences regarding the moderately and severely affected infants, increases suspicions that the significant difference regarding severe BPD may be just random noise, and strongly cautions against over-interpreting this piece of data. The risk of random noise being incidentally found statistically significant increases with the number of exploratory analyses performed.
Following the suggestion in the letter, we have also recalculated the logistic regression analysis with 'severe BPD' replacing 'moderate or severe BPD'. The results were similar to the ones published: a significant association of 'severe BPD' with PDI<70 (p=0.13) or MDI<70 (p=0.12) was not found. Logistic regression analyses were not used to estimate the magnitude of risks, but rather, to identify important risk factors. For this purpose, logistic regression analyses are well-suited.
The letter's authors further point out, that permissive hypercapnia is increasingly used as a ventilation strategy. We hope, that this is not the case, since our trial certainly does not provide a scientific basis for such a management change. While there is some evidence that mild hypercapnia may be associated with minor benefits, higher PCO2 targets, as the letter authors point out correctly, have not been shown to improve outcome. This holds also true for our trial, where all trends pointed in the opposite direction, and a significant increase of NEC was found (see Thome UH et al., Lancet Respir Med 3: 534-43, 2015). We have also carefully tested multiple subgroups in search for conditions in which the high PCO2 target may be associated with significant outcome differences in one direction or the other. We did not find a singlesubgroup that showed benefits associated with the high PCO2 target. The most striking result in this search was found in the subgroup of infants with the most severe lung disease. These infants had a significantly worse outcome when randomized to the high PCO2 target, a finding that had been included in our initial publication (see also Thome UH et al., Lancet Respir Med 3: 534-43, 2015).
Since significant differences were only found in subgroups or when using non-predefined outcomes, harmful effects of high PCO2 targets, as used in our trial, cannot be proven, although we sympathize with the view that some results may suggest this interpretation.
Prof. Dr. med. Ulrich H. Thome
Facharzt für Kinder- und Jugendmedizin / Neonatologie / Pädiatrische Intensivmedizin Leiter der Selbständigen Abteilung Neonatologie Universitätsklinik für Kinder- und Jugendmedizin Zentrum für Frauen- und Kindermedizin Liebigstraße 20a, Haus 6
Dear Editor,
We read with great interest the article “Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial” by Milési et al published in Arch Dis Child Fetal Neonatal Ed 2018; 103: F221-F226.1 We complement the authors for this well conducted randomized trial on a very important subject of sedation while neonatal intubation. Having gone through the article, we would like to add the following.
The intubations done were all non-emergent, with the mean gestational age being 27.6 (24-34) and 28.3 (24-36) weeks in both the groups respectively. It will be interesting to know what percentage of infants underwent Intubation, Surfactant administration, Extubation (INSURE)2 and placed back on nasal CPAP. As good respiratory drive is an essential prerequisite for nasal CPAP, there are concerns for sedation while attempting INSURE.
The other concern is about the safety of both the drugs used in neonatal particularly in preterm population. There are reports of paradoxical stimulation of central nervous system including myoclonic movements associated with administration of midazolam.3 There is also evidence to suggest midazolam administration leading to increased NICU stay and adverse neurological events.4 The oscillometric blood pressure measurement recorded intermittently as in this study might not capture continuous invasive blood pressure changes.
Finally, as the article very succinctly explained that the dosage of keta...
Dear Editor,
We read with great interest the article “Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial” by Milési et al published in Arch Dis Child Fetal Neonatal Ed 2018; 103: F221-F226.1 We complement the authors for this well conducted randomized trial on a very important subject of sedation while neonatal intubation. Having gone through the article, we would like to add the following.
The intubations done were all non-emergent, with the mean gestational age being 27.6 (24-34) and 28.3 (24-36) weeks in both the groups respectively. It will be interesting to know what percentage of infants underwent Intubation, Surfactant administration, Extubation (INSURE)2 and placed back on nasal CPAP. As good respiratory drive is an essential prerequisite for nasal CPAP, there are concerns for sedation while attempting INSURE.
The other concern is about the safety of both the drugs used in neonatal particularly in preterm population. There are reports of paradoxical stimulation of central nervous system including myoclonic movements associated with administration of midazolam.3 There is also evidence to suggest midazolam administration leading to increased NICU stay and adverse neurological events.4 The oscillometric blood pressure measurement recorded intermittently as in this study might not capture continuous invasive blood pressure changes.
Finally, as the article very succinctly explained that the dosage of ketamine used was in all probability inadequate to cause sedation, we feel that a larger trial should be conducted to establish the best pre-intubation medication in the delivery room, keeping both efficacy and safety in mind.
1. Milési C, Baleine J, Mura T, et al. Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial. Archives of Disease in Childhood - Fetal and Neonatal Edition 2018; 103: F221-F226.
2. Carlo Dani, Iuri Corsini, Giovanna Bertini, Giulia Fontanelli, Simone Pratesi & Firmino F. Rubaltelli (2010) The INSURE method in preterm infants of less than 30 weeks' gestation, The Journal of Maternal-Fetal & Neonatal Medicine, 23:9, 1024-1029, DOI: 10.3109/14767050903572174
3. Gupta MK, Mondkar JA, Hegde D. Paradoxical reaction to midazolam in preterm neonates: a case series. Indian J Crit Care Med 2018; 22: 300-2
4. Ng E, Taddio A, Ohlsson A. Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD002052. DOI: 10.1002/14651858.CD002052.pub3.
Dilini I Imbulana and coworkers have published a good systematic review of nasal injuries in preterm infants receiving non-invasive respiratory support1. They included the early work by Robertson et al.2 but not the criticism from us3 or from the company selling the device4. At that time (1996), we had experiences of treatment of about 750 newborns with early versions of Infant Flow, including extremely preterm infants. We had not a single case of significant nasal injury. Imbulana et al. rightly write that it is important to chose correct size of nasal prongs (not too small). It is also crucial to avoid a hard pressure of the CPAP device on the nose. Moderate air leaks are acceptable. Several of the lesions published by Robertson and others are probable caused by attempts to avoid air leaks by a too tight connection between the CPAP device and the nose.
Neonatal nurses from various hospitals and countries should meet face-to-face or via Skype to discuss and compare how they adapt CPAP devices to preterm newborns.
Infant Flow was invented by the anaesthetists Drs Gunnar Moa and Kjell Nilsson at our hospital. We were the first paediatrician and neonatologist to use Infant Flow but we haven’t received any fees or other benefit for that.
References
1. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Archives of Disease in Childhood - Fetal and Neonatal...
Dilini I Imbulana and coworkers have published a good systematic review of nasal injuries in preterm infants receiving non-invasive respiratory support1. They included the early work by Robertson et al.2 but not the criticism from us3 or from the company selling the device4. At that time (1996), we had experiences of treatment of about 750 newborns with early versions of Infant Flow, including extremely preterm infants. We had not a single case of significant nasal injury. Imbulana et al. rightly write that it is important to chose correct size of nasal prongs (not too small). It is also crucial to avoid a hard pressure of the CPAP device on the nose. Moderate air leaks are acceptable. Several of the lesions published by Robertson and others are probable caused by attempts to avoid air leaks by a too tight connection between the CPAP device and the nose.
Neonatal nurses from various hospitals and countries should meet face-to-face or via Skype to discuss and compare how they adapt CPAP devices to preterm newborns.
Infant Flow was invented by the anaesthetists Drs Gunnar Moa and Kjell Nilsson at our hospital. We were the first paediatrician and neonatologist to use Infant Flow but we haven’t received any fees or other benefit for that.
References
1. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Archives of Disease in Childhood - Fetal and Neonatal Edition 2018;103(1):F29-F35.
2. Robertson NJ, McCarthy LS, Hamilton PA, et al. Nasal deformities resulting from flow driver continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 1996;75:F209–12.
3. Smedsaas-Löfvenberg A, Faxelius G, Axelsson I, Lagercrantz H. Nasal deformities at a UK hospital. Archives of Disease in Childhood - Fetal and Neonatal Edition 1998;78:F156.
4. Foster SJ. Nasal deformities arising from flow driver continuous positive airway pressure. Archives of Disease in Childhood - Fetal and Neonatal Edition 1998;78:F156.
We read with interest the follow up study by Thome and colleagues assessing neurodevelopmental outcomes of the extremely low birth weight (ELBW) infants from the Permissive Hypercapnia in Extremely Low Birthweight Infants (PHELBI) trial1.
This study makes an important contribution to the evidence-base on the strategy of permissive hypercapnia for ELBW infants. It is a well-powered, multicentre trial and we commend the authors for the ambitious decision to include only intubated ELBW infants and also the use of a clinician-guided treatment protocol. While the methodology allows some systematic bias, there is strong external validity with a patient population representative of ‘real-life’ clinical practice.
We question the choice to combine the subgroups with moderate and severe bronchopulmonary dysplasia (BPD) for statistical analysis. In Table 2, we note the non-significant p-value for the combined outcome of moderate/severe BPD of 0.30 and no reported p-values for the individual subgroups moderate BPD and severe BPD. Using the raw data provided in Table 2, we calculate a p-value for severe BPD as significant at 0.01, suggesting an increase.
There is considerable clinical difference between patients with moderate BPD (requiring FiO2 <30% at 36 weeks or discharge) and those with severe BPD (requiring FiO2 ≥30% and/or positive pressure ventilation)2. Other than increased risk of mortality and respiratory disease, severity of BPD correlates with incr...
We read with interest the follow up study by Thome and colleagues assessing neurodevelopmental outcomes of the extremely low birth weight (ELBW) infants from the Permissive Hypercapnia in Extremely Low Birthweight Infants (PHELBI) trial1.
This study makes an important contribution to the evidence-base on the strategy of permissive hypercapnia for ELBW infants. It is a well-powered, multicentre trial and we commend the authors for the ambitious decision to include only intubated ELBW infants and also the use of a clinician-guided treatment protocol. While the methodology allows some systematic bias, there is strong external validity with a patient population representative of ‘real-life’ clinical practice.
We question the choice to combine the subgroups with moderate and severe bronchopulmonary dysplasia (BPD) for statistical analysis. In Table 2, we note the non-significant p-value for the combined outcome of moderate/severe BPD of 0.30 and no reported p-values for the individual subgroups moderate BPD and severe BPD. Using the raw data provided in Table 2, we calculate a p-value for severe BPD as significant at 0.01, suggesting an increase.
There is considerable clinical difference between patients with moderate BPD (requiring FiO2 <30% at 36 weeks or discharge) and those with severe BPD (requiring FiO2 ≥30% and/or positive pressure ventilation)2. Other than increased risk of mortality and respiratory disease, severity of BPD correlates with increased risk and severity of neurodevelopmental impairment (NDI)3. Analysis of all three subgroups of BPD severity might alter the findings and influence the conclusions drawn.
Conflicting results were yielded from the regression analyses, which may reflect the choice to cluster moderate and severe BPD together. The authors identified moderate/severe BPD as a risk factor for milder NDI, but did not find a significant association with severe NDI. Further, we question the choice to quantify risk using logistic regression to generate odds ratios, as opposed to other statistical models to calculate relative risk. This strategy has been shown to overestimate the measure of association in RCTs and lead to misinterpretation of results4.
Permissive hypercapnia is increasingly used as a ventilation strategy. The limited evidence to date does not, however, suggest that this improves outcomes for ELBW infants and there have been trends toward worse neurodevelopmental outcomes. While it is commendable to publish a ‘no difference’ result, we would be interested to know if the data were analysed stratifying for all three subgroups whether the findings might suggest permissive hypercapnia in EBLW confers higher risk of severe BPD and thereby poorer long-term outcomes.
Dr Eden C Andrew MBBS
Dr James Holberton MBBS, FRACP
Dr Gillian Opie MBBS, FRACP
Dr Andrew Watkins MBBS, FRACP
1. Thome UH, Genzel-Boroviczeny O, Bohnhorst B et al. Neurodevelopmental outcomes of extremely low birthweight infants randomised to different PCO2 targets: the PHELBI follow-up study. Arch Dis Child Fetal Neonatal Ed. 2017;102(5):F376-82
2. Ehrenkranz RA, Walsh MC, Vohr BR et al. Validation of the National Institutes of Health Consensus Definition of Bronchopulmonary Dysplasia. Pediatrics. 2005;116:1353-60.
3. Walsh MC, Morris BH, Wrage LA et al. Extremely Low Birthweight Neonates with Protracted Ventilation: Mortality and 18-Month Neurodevelopmental Outcomes. J Ped. 2005;146(6):798-804.
4. Knol MJ, Duijnhoven RG, Grobbee DE et al. Potential Misinterpretation of Treatment Effects Due to Use of Odds Ratios and Logistic Regression in Randomized Controlled Trials. PLoS One. 2011;6(6):e21248.
We agree that neurodevelopmental outcome may be an important outcome to measure following any neonatal surgery and would certainly welcome any study that reported this outcome in infants with gastroschisis. However following a rigorous consensus process as we have described, neurodevelopmental outcome was not selected as part of the core outcome set. We emphasise that the outcomes within the core outcome set are not the only outcomes that should be measured in future research but are the minimum recommended. Additional outcomes such as neurodevelopmental outcomes may of course be reported.
Response to comment from Drs Golumbek and Guidici
Drs Golumbek and Guidici are quite correct that characteristics of infants with gastroschisis, such as complexity of the condition at birth, may affect their prognosis. We are quite clear that this core outcome set should be used for observational studies which follow-up a cohort of infants based on these characteristics, as well as trials or observational studies which follow-up infants who have been managed using different surgical approaches. We agree that some of these outcomes are not specific to gastroschisis, but our aim was not to produce a core outcome set that had only gastroschisis specific outcomes within it, but one that contained the most important outcomes for infants with gastroschisis – some of which may apply equally to other infants. Growth at birth is not...
We agree that neurodevelopmental outcome may be an important outcome to measure following any neonatal surgery and would certainly welcome any study that reported this outcome in infants with gastroschisis. However following a rigorous consensus process as we have described, neurodevelopmental outcome was not selected as part of the core outcome set. We emphasise that the outcomes within the core outcome set are not the only outcomes that should be measured in future research but are the minimum recommended. Additional outcomes such as neurodevelopmental outcomes may of course be reported.
Response to comment from Drs Golumbek and Guidici
Drs Golumbek and Guidici are quite correct that characteristics of infants with gastroschisis, such as complexity of the condition at birth, may affect their prognosis. We are quite clear that this core outcome set should be used for observational studies which follow-up a cohort of infants based on these characteristics, as well as trials or observational studies which follow-up infants who have been managed using different surgical approaches. We agree that some of these outcomes are not specific to gastroschisis, but our aim was not to produce a core outcome set that had only gastroschisis specific outcomes within it, but one that contained the most important outcomes for infants with gastroschisis – some of which may apply equally to other infants. Growth at birth is not an outcome of postnatal treatment, therefore IUGR in this instance is not relevant, postnatal growth is clearly important whether or not an infants is small for gestational age at birth. We emphasise that the outcomes within the core outcome set are not the only outcomes that should be measured in future research but are the minimum recommended.
Dear Nick Brown
Editor in chief, Arch Dis Child Fetal Neonatal
We read with interest the study titled “Development of a gastroschisis core outcome set” by Benjamin Saul Raywood Allin et al1, and we have several questions and comments.
The aim of the authors is to design a core outcome set to be used in research in order to reduce outcome reporting heterogeneity and to help improve the clinical relevance of the research. The authors state that “Many gastroschisis studies investigate outcomes that are not relevant to patients or clinical practice”. However, they don´t clarify how they arrived to this hypothesis.
This study has developed a gastroschisis core outcome set consisting of eight outcomes that are important to parents, people born with gastroschisis and clinicians.
The eight outcomes are death, sepsis, growth, number of operations, time on parenteral nutrition, liver disease, number of severe gastrointestinal complications and quality of life. Regarding growth, it should be noticed that children born with gastroschisis are frequently intrauterine growth restricted, and therefore, this issue should be clarified - it is not always an outcome; gastrointestinal complications are also (up to 25% of gastroschisis population in some reports) a frequent component of the malformation itself, so this should be clarified when speaking of “complications”.
In high income countries, adverse outcomes are related to the presence of complex gast...
Dear Nick Brown
Editor in chief, Arch Dis Child Fetal Neonatal
We read with interest the study titled “Development of a gastroschisis core outcome set” by Benjamin Saul Raywood Allin et al1, and we have several questions and comments.
The aim of the authors is to design a core outcome set to be used in research in order to reduce outcome reporting heterogeneity and to help improve the clinical relevance of the research. The authors state that “Many gastroschisis studies investigate outcomes that are not relevant to patients or clinical practice”. However, they don´t clarify how they arrived to this hypothesis.
This study has developed a gastroschisis core outcome set consisting of eight outcomes that are important to parents, people born with gastroschisis and clinicians.
The eight outcomes are death, sepsis, growth, number of operations, time on parenteral nutrition, liver disease, number of severe gastrointestinal complications and quality of life. Regarding growth, it should be noticed that children born with gastroschisis are frequently intrauterine growth restricted, and therefore, this issue should be clarified - it is not always an outcome; gastrointestinal complications are also (up to 25% of gastroschisis population in some reports) a frequent component of the malformation itself, so this should be clarified when speaking of “complications”.
In high income countries, adverse outcomes are related to the presence of complex gastroschisis, which is not mentioned in this publication, and there are also several features associated with neonatal mortality (i.e., liver contained in the defect) that should be mentioned. We don’t believe that length of stay is a gastroschisis-specific variable associated with adverse outcomes; it is known that longer stays predict adverse outcomes in infants undergoing NICU admission.
The type of surgical approach is still being debated (as the authors stated) 2, 3, but the long-term outcomes are probably not related to this but, rather, to the type and size of the defect, the presence of complex gastroschisis, and the access to early intervention programs.
Twenty two parents completed all three phases of the Delphi process, most of them (64%) with children under five years of age at the time of the study. Recent publications alert about the association between gastroschisis and poorer verbal intelligence, an increased risk for poor performance on several aspects of attention, response inhibition and fine motor skills at school age 4, 5; therefore, it seems very important to have a larger sample of parents of school-aged children before considering that some aspects of their outcomes are not relevant.
We consider that high-quality observational studies and randomised controlled trials are required to assess the outcomes of gastroschisis patients, but those should definitively include more gastroschisis-specific variables, neurodevelopmental outcomes, and social behavior.
Respectfully,
Lidia B. Giúdici, MD
Pediatrician- Neonatologist
High Risk Newborn Follow Up Program Pedro de Elizalde Children's Hospital, Buenos Aires-Argentina
Postgraduate Neurodevelopment Specialization Director- Buenos Aires Medical College
Member of SEGUISIBEN- SIBEN (Iberoamerican Society of Neonatology)
Sergio G. Golombek, MD, MPH, FAAP
Professor of Pediatrics and Clinical Public Health
New York Medical College
Attending Neonatologist
Regional Neonatal Center-Maria Fareri Children's Hospital
Westchester Medical Center-Valhalla, NY 10595
President, SIBEN (Iberoamerican Society of Neonatology)
Ph # (914) 493-8488<tel:(914)%20493-8488>
FAX +1-914- 493-1005 Tel +1-914-493-8488
References
1- Allin BSR, Hall NJ, Ross AR, et al. Arch Dis Child Fetal Neonatal Ed Epub ahead of print: doi:10.1136/ archdischild-2017-314560
2- Charlesworth P, Ibiyinka A, Hammerton Ch et al. Preformed silos versus traditional abdominal wall closure in gastroschisis: 163 infants at a single institution. Eur J Pediatr Surg 2014; 24: 88-93.
3- Weil BR, Leysa CM, Rescorla FJ. The jury is still out: changes in gastroschisis management over the last decade are associated with both benefits and shortcomings. J Pediatr Surg 2012; 47: 119-124.
4- Giúdici L, Bokser V, Maricic M A, Golombek SG, Ferrario C., Babies born with gastroschisis and followed up to the age of six years faced long-term morbidity and impairments. Acta Paediatr. 2016; 105(6): 275-280.
5- Lap et al. Functional outcome at school age of children born with gastroschisis. Early Human Development 106–107 (2017) 47–52
Any surgery as a neonate carries increased risk of adverse neurodevelopmental outcomes and any neonatal study should include them. They are different from overall quality of life.
Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.
Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.
Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).
References
1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001
2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and many of our research participants – also think moral distress may not always be avoidable nor negative.
Disproportionate or aggressive medical treatments considered not in a patient’s best interests are commonly cited as key causes of moral distress(Prentice, Janvier et al. 2016). This may occur when there is disagreement between the treating team and the family, due to differently held beliefs and values. Though principles of harm draw some guidance around the role of parents in decision-making, many of these cases still fall within the broad ‘zone of parental discretion’(Gillam 2016, McDougall, Gillam et al. 2016). If we accept that parents have a significant role in decision-making and are ethically permitted to choose options for their child that are not (in our opinion) ideal, then a degree of moral distress is ‘inevitable’. This inevitability stems from differences in subjective beliefs and values and does not necessarily reflect an organisational failing as Epstein suggests(Epstein and Hurst 2017). The experience of moral distress in these situations – in accordance with standard definitions– can be traumatic and we do not mean to downplay this in any way. Yet as Dudinski notes “[m]oral intuitions should not be ignored, nor are they definitive. They must bear the weight of ethical scrutiny”(Dudzinski 2016). If we do not accept that moral distress can lead to constructive discussions, patient advocacy and a mechanism for progressive thought then we are left with moral distress acting as a vehicle for blame(Dudzinski 2016), often inferring that the clinical lead either is failing to listen to the concerns of others or lacks the moral courage to change the current management plan(Prentice 2017). Both of these may be unfair assumptions amidst the complex end-of-life considerations and decision-making dynamics. More worrisome is that the net effect may be to place undue pressure on the family to acquiesce to a particular treatment plan to resolve the net moral distress of the treating team – what we have elsewhere referred to as ‘moral transference’(Prentice, Gillam et al. 2017). The moral distress experienced by families is too often neglected in such conversations.
Moral distress is a burden, but it can also be something from which we can grow and learn, and our patients can benefit from. Should we not therefore be willing to accept some of its positive attributes along with all the bad? Is it fair for our patients’ families to bear the burden if we cannot?
Dudzinski, D. M. (2016). "Navigating moral distress using the moral distress map." Journal of Medical Ethics 42(5): 321-324.
Epstein, E. and A. Hurst (2017). "Looking at the Positive Side of Moral Distress: Why It's a Problem." Journal of Clinical Ethics 28(1): 37-41.
Gillam, L. (2016). "The zone of parental discretion: An ethical tool for dealing with disagreement between parents and doctors about medical treatment for a child." Clinical Ethics 11(1): 1-8.
McDougall, R., L. Gillam and H. Gold (2016). The zone of parental discretion. When Doctors and Parents Disagree. R. McDougall, C. Delany and L. Gillam, The Federation Press: 17.
Prentice, T. (2017). Accepting the Good with the Bad when Living with Moral Distress. AAP Section on Bioethics, American Academy of Pediatrics.
Prentice, T., A. Janvier, L. Gillam and P. G. Davis (2016). "Moral distress within neonatal and paediatric intensive care units: a systematic review." Archives of Disease in Childhood 101(8): 701-708.
Prentice, T. M., L. Gillam, P. G. Davis and A. Janvier (2017). "The use and misuse of moral distress in neonatology." Seminars in Fetal and Neonatal Medicine.
We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...
We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dramatically over the last 10 years, from the use of static levels of pure oxygen without SpO2 monitoring to blending oxygen to meet SpO2 values derived from full-term, healthy infants (3). Much more information is required before we can be confident that any SpO2 or FiO2 recommendations are in the best interest of the infant, especially one that is as physiologically complex as the extremely preterm infant.
In conclusion, we agree with Dr Hewson that the practice of SpO2 targeting and FiO2 titration for preterm infant resuscitation deserves further (and urgent) study. Until such data are available, we advise caution when using oxygen during preterm infant resuscitation and that clinicians should remember to tailor their resuscitation practice to meet the needs of each infant.
1. Wilson A, Vento M, Shah PS et al. A review of international clinical practice guidelines for the use of oxygen in the delivery room resuscitation of preterm infants. Acta Paediatr. 2018;107(1):20-27.
2. Dawson JA, Kamlin CO, Vento M et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics. 2010;125(6):e1340-7.
3. No authors listed. Co-publishing of the Pediatric and Neonatal Portions of the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2015;136 Suppl 2:S83-7.
We thank the letter authors for commending most of our protocol decisions. A multicenter trial is always associated with a number of compromises, e.g. between standardization and freedom of therapy, between insufficient and overzealous data collection, and between too few and too many exploratory statistical tests.
For detecting BPD, we used criteria that included all cases with requirement of supplemental oxygen or mechanical support at a postmenstrual age of 36 weeks. This definition was the same as moderate or severe BPD in the more recently formulated consensus definition, and has been used in many other previous trials, testing ventilation modes, high-frequency ventilation, steroid use, permissive hypercapnia, and many others. This made our results comparable to previously published data.
...Show MoreDear Editor,
Show MoreWe read with great interest the article “Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial” by Milési et al published in Arch Dis Child Fetal Neonatal Ed 2018; 103: F221-F226.1 We complement the authors for this well conducted randomized trial on a very important subject of sedation while neonatal intubation. Having gone through the article, we would like to add the following.
The intubations done were all non-emergent, with the mean gestational age being 27.6 (24-34) and 28.3 (24-36) weeks in both the groups respectively. It will be interesting to know what percentage of infants underwent Intubation, Surfactant administration, Extubation (INSURE)2 and placed back on nasal CPAP. As good respiratory drive is an essential prerequisite for nasal CPAP, there are concerns for sedation while attempting INSURE.
The other concern is about the safety of both the drugs used in neonatal particularly in preterm population. There are reports of paradoxical stimulation of central nervous system including myoclonic movements associated with administration of midazolam.3 There is also evidence to suggest midazolam administration leading to increased NICU stay and adverse neurological events.4 The oscillometric blood pressure measurement recorded intermittently as in this study might not capture continuous invasive blood pressure changes.
Finally, as the article very succinctly explained that the dosage of keta...
Dilini I Imbulana and coworkers have published a good systematic review of nasal injuries in preterm infants receiving non-invasive respiratory support1. They included the early work by Robertson et al.2 but not the criticism from us3 or from the company selling the device4. At that time (1996), we had experiences of treatment of about 750 newborns with early versions of Infant Flow, including extremely preterm infants. We had not a single case of significant nasal injury. Imbulana et al. rightly write that it is important to chose correct size of nasal prongs (not too small). It is also crucial to avoid a hard pressure of the CPAP device on the nose. Moderate air leaks are acceptable. Several of the lesions published by Robertson and others are probable caused by attempts to avoid air leaks by a too tight connection between the CPAP device and the nose.
Show MoreNeonatal nurses from various hospitals and countries should meet face-to-face or via Skype to discuss and compare how they adapt CPAP devices to preterm newborns.
Infant Flow was invented by the anaesthetists Drs Gunnar Moa and Kjell Nilsson at our hospital. We were the first paediatrician and neonatologist to use Infant Flow but we haven’t received any fees or other benefit for that.
References
1. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Archives of Disease in Childhood - Fetal and Neonatal...
We read with interest the follow up study by Thome and colleagues assessing neurodevelopmental outcomes of the extremely low birth weight (ELBW) infants from the Permissive Hypercapnia in Extremely Low Birthweight Infants (PHELBI) trial1.
This study makes an important contribution to the evidence-base on the strategy of permissive hypercapnia for ELBW infants. It is a well-powered, multicentre trial and we commend the authors for the ambitious decision to include only intubated ELBW infants and also the use of a clinician-guided treatment protocol. While the methodology allows some systematic bias, there is strong external validity with a patient population representative of ‘real-life’ clinical practice.
We question the choice to combine the subgroups with moderate and severe bronchopulmonary dysplasia (BPD) for statistical analysis. In Table 2, we note the non-significant p-value for the combined outcome of moderate/severe BPD of 0.30 and no reported p-values for the individual subgroups moderate BPD and severe BPD. Using the raw data provided in Table 2, we calculate a p-value for severe BPD as significant at 0.01, suggesting an increase.
There is considerable clinical difference between patients with moderate BPD (requiring FiO2 <30% at 36 weeks or discharge) and those with severe BPD (requiring FiO2 ≥30% and/or positive pressure ventilation)2. Other than increased risk of mortality and respiratory disease, severity of BPD correlates with incr...
Show MoreResponse to comment from Dr Mark W Davies:
We agree that neurodevelopmental outcome may be an important outcome to measure following any neonatal surgery and would certainly welcome any study that reported this outcome in infants with gastroschisis. However following a rigorous consensus process as we have described, neurodevelopmental outcome was not selected as part of the core outcome set. We emphasise that the outcomes within the core outcome set are not the only outcomes that should be measured in future research but are the minimum recommended. Additional outcomes such as neurodevelopmental outcomes may of course be reported.
Response to comment from Drs Golumbek and Guidici
Drs Golumbek and Guidici are quite correct that characteristics of infants with gastroschisis, such as complexity of the condition at birth, may affect their prognosis. We are quite clear that this core outcome set should be used for observational studies which follow-up a cohort of infants based on these characteristics, as well as trials or observational studies which follow-up infants who have been managed using different surgical approaches. We agree that some of these outcomes are not specific to gastroschisis, but our aim was not to produce a core outcome set that had only gastroschisis specific outcomes within it, but one that contained the most important outcomes for infants with gastroschisis – some of which may apply equally to other infants. Growth at birth is not...
Show MoreDear Nick Brown
Editor in chief, Arch Dis Child Fetal Neonatal
We read with interest the study titled “Development of a gastroschisis core outcome set” by Benjamin Saul Raywood Allin et al1, and we have several questions and comments.
Show MoreThe aim of the authors is to design a core outcome set to be used in research in order to reduce outcome reporting heterogeneity and to help improve the clinical relevance of the research. The authors state that “Many gastroschisis studies investigate outcomes that are not relevant to patients or clinical practice”. However, they don´t clarify how they arrived to this hypothesis.
This study has developed a gastroschisis core outcome set consisting of eight outcomes that are important to parents, people born with gastroschisis and clinicians.
The eight outcomes are death, sepsis, growth, number of operations, time on parenteral nutrition, liver disease, number of severe gastrointestinal complications and quality of life. Regarding growth, it should be noticed that children born with gastroschisis are frequently intrauterine growth restricted, and therefore, this issue should be clarified - it is not always an outcome; gastrointestinal complications are also (up to 25% of gastroschisis population in some reports) a frequent component of the malformation itself, so this should be clarified when speaking of “complications”.
In high income countries, adverse outcomes are related to the presence of complex gast...
Any surgery as a neonate carries increased risk of adverse neurodevelopmental outcomes and any neonatal study should include them. They are different from overall quality of life.
Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.
Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.
Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).
References
1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001
2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...
Show MoreWe thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...
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