we read with interest the paper by C J Bossley et al (1) in which the
authors performed fitness-to-fly tests to understand if preterm infants
with broncopulmonary dysplasia might require supplemental oxygen during
high-altitude flight. In the opening sentence of abstract it is stated
that "during air flight cabin pressurisation produces an effective
fraction of inspired oxygen of 15%", but this sent...
we read with interest the paper by C J Bossley et al (1) in which the
authors performed fitness-to-fly tests to understand if preterm infants
with broncopulmonary dysplasia might require supplemental oxygen during
high-altitude flight. In the opening sentence of abstract it is stated
that "during air flight cabin pressurisation produces an effective
fraction of inspired oxygen of 15%", but this sentence, in our opinion,
may be misleading or, at least, needs to be explained in more details.
For this reason we would like just to point out the difference between
fraction of inspired oxygen and partial pressure of oxygen.
The fraction of inspired O2, or FiO2, also known as ambient O2
concentration, indicates the proportion of O2 in the inspired air. In
standard air condition FiO2 is 21%. This parameter is not directly related
to the absolute number of O2 molecules per gas volume, but specifies the
proportion of oxygen in the air mixture. The effective number of O2
particles depends rather on the specific air thermodynamic state (its
temperature and pressure).
The partial pressure of O2 in alveolar gas, or PAO2, instead is directly
proportional to the amount of O2 present in the gas mixture (at a specific
temperature) and therefore O2 exchange at the alveoli level is degraded as
the air pressure is reduced. In other words PAO2 relates directly to the
actual number of O2 molecules and consequently to the alveolar oxygen
tension which in turn affects the diffusion into the pulmonary capillary
blood.
The alveolar O2 exchange can be improved by increasing both the FiO2
(changing the air mixture proportions) and the air thermodynamic pressure
(augmenting the PAO2).
The PAO2 is dependent on barometric pressure which at sea level is
considered equal to 760 mmHg (with 15?C temperature). Therefore at sea
level PAO2 is approximately 150 mmHg. Considering that barometric pressure
varies with altitude, PAO2 consequently decreases while FiO2 remains
constant at 21%.
Because aircrafts use to fly at high altitudes, the common practice is
then to pressurise the cabin thus maintaining an adequate PAO2. The
pressure value into the cabin is fixed to a minimum of 75.3 kPa, or 564
mmHg, corresponding to an altitude of 8000 ft, or 2438 m, the so-called
physiological zone.
However, at 2438 m (8000 ft) the PAO2 is less than at sea level and thus
the O2 exchange is degraded. Specifically such condition is equivalent of
breathing an air mixture with 15% oxygen at sea level. Consequently, to
simulate the situation of being at 2438m, the fitness-to-fly test is
performed, following the British Thoracic Society Recommendations (2),
with the oxygen level inside the box reduced to 15% by adding nitrogen
into the chamber.
We suggest, in order to avoid confusion among not specialized readers, to
specifically remark that during high-altitude flights the FiO2 in the
cabin remains 21%, while the PAO2 changes. The value of PAO2 in
pressurised cabin is actually equivalent to the value detectable at sea
level when the FiO2 is artificially decreased to 15%.
References
1. Bossley CJ, Cramer D, Mason B, Hayward A, Smyth J, McKee A,
Biddulph R, Ogundipe E, Jaff? A, Balfour-Lynn IM. Fitness to fly testing
in term and ex-preterm babies without bronchopulmonary dysplasia. Arch Dis
Child Fetal Neonatal Ed. 2011 Sep 13.
2. www.brit-
thoracic.org.uk/Portals/0/Clinical%20Information/Air%20Travel/Guidelines/FlightRevision04.pdf
Brithish Thoracic Society Standards of care Committee.Managing Passengers
with Respiratory Disease Planning and Air Travel. (accessed 13 Jul 2011).
Leow et al (1) report the incidence of sudden, unexpected and
unexplained early neonatal death in a retrospective population-based study
as 0.35/10,000 live births. The authors conclude that such deaths occur
more rarely than previously appreciated and as such 'extra intrusive
supervision' following birth is not justified.
Although SUNC and related-death is rare, it is important to highlight
aspects which may co...
Leow et al (1) report the incidence of sudden, unexpected and
unexplained early neonatal death in a retrospective population-based study
as 0.35/10,000 live births. The authors conclude that such deaths occur
more rarely than previously appreciated and as such 'extra intrusive
supervision' following birth is not justified.
Although SUNC and related-death is rare, it is important to highlight
aspects which may contribute to under-recognition. The natural history of
SUNC is that infants who are in a state of extremis are subsequently
successfully resuscitated before dying from hypoxic-ischaemic sequelae.
Traditionally the cause of death is certified according to the subsequent
manifestations despite the cause of collapse being unexplained.
Retrospective data collection fails to identify these infants and will
underestimate the incidence of such deaths. The recently published UK and
German surveillance studies of sudden unexpected neonatal collapse (SUNC)
within 12-24 hours of birth, reported mortality as 0.11-0.14/10,000 (2)
(3) and CEMACH data confirms a rate of 0.66/10,000 for neonatal deaths in
the first week where the cause was certified 'unknown' or secondary to
SIDS (4).
Secondly it is increasingly recognised that many infants collapse in
circumstances suggestive of accidental asphyxiation, and therefore
although their deterioration is sudden and unexpected, there is a
postulated explanation. Such infants accounted for around half of all
those in the UK surveillance study and their contribution to unexpected
deaths should not be discounted despite there being a putative clinical
cause.
In addition to the mortality from SUNC, many survivors suffer
longterm neurological disability. Moreover, around a third of newborns who
collapse unexpectedly do so because of an underlying condition, the
outcome of which may be modified by earlier identification. A growing body
of literature describes a high incidence of risk factors which are common
to conventional SIDS. These include prone positioning, maternal sedation
and co-sleeping (2,3). For newborn infants receiving postnatal care under
the responsibility of the NHS, the authors deem that 'extra intrusive
supervision' is unjustified, but have not considered that sensible
recommendations about easily modifiable risk factors could be applied
universally to newborns however rare SUNC appears to be.
(1) Leow JY, Ward Platt MP. Sudden, unexpected and unexplained early
neonatal deaths in the North of England Arch Dis Child Fetal Neonatal Ed
2011;96:F440-F442
(2) Becher JC, Bhushan SS, Lyon AJ. Unexpected collapse in apparently
healthy newborns - a prospective national study of a missing cohort of
neonatal deaths and near-death events.
Arch Dis Child Fetal Neonatal Ed. 2011 Jun 28. [Epub ahead of print]
(3) Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent
life-threatening events in term infants within 24 hours of birth.
Pediatrics. 2011;127:e869-73.
(4) Dominic Acolet, CEMACH, personal communication, 2007
We read with interest the paper by Vasudevan et al. on foetal and
perinatal consequences of maternal obesity.(1) The authors highlight the
increased risk of perinatal mortality, neural tube and structural cardiac
defects in the offspring. They also report an increased risk of birth
injuries, perinatal asphyxia, respiratory distress and metabolic
instability that are related to the associated foetal...
We read with interest the paper by Vasudevan et al. on foetal and
perinatal consequences of maternal obesity.(1) The authors highlight the
increased risk of perinatal mortality, neural tube and structural cardiac
defects in the offspring. They also report an increased risk of birth
injuries, perinatal asphyxia, respiratory distress and metabolic
instability that are related to the associated foetal macrosomia.
In a recent study of 6125 pregnant women (25% of whom were overweight,
12.1% moderately and 7% severely obese), to differentiate between the
direct effects of maternal obesity on neonatal outcomes and those caused
by confounding factors, such as foetal macrosomia, we used a logistic
multivariate analysis.(2) Although the crude unadjusted prevalence of
several adverse neonatal outcomes was higher in their offspring, the only
two outcomes significantly directly associated with maternal obesity were
neonatal macrosomia (adjusted odds ratios aOR 1.4, p < 0.001) and
meconium aspiration syndrome (aOR 1.6, p = 0.05). All other neonatal
outcomes, such as birth injuries, metabolic disturbances were confounded
by the associated foetal macrosomia. In addition we found no significant
association with congenital anomalies. This validates the results of a
meta-analysis which also showed no significant relationship between
maternal obesity and the incidence of neonatal asphyxia, hypoglycaemia or
the need for mechanical ventilation.(3) Furthermore, such an association,
if it exists, may not necessarily be causal.
Therefore, while we agree that prevention of maternal obesity would very
likely decrease adverse health risks on the mother, we believe that any
resulting decrease in foetal and neonatal complications would be mainly
due to decreasing the prevalence of foetal macrosomia, although a causal
relationship still needs to be established. There is currently no evidence
to support the idea that prevention of maternal obesity has the potential
to decrease neonatal complications not directly related to foetal
macrosomia. Further research is needed to clarify these issues before any
recommendations can be made.
References
1. Vasudevan C, Renfrew M, McGuire W. Fetal and perinatal
consequences of maternal obesity. Arch Dis Child Fetal Neonatal Ed
2011;96:F378-82
2. Narchi H, Skinner A. Overweight and obesity in pregnancy do not
adversely affect neonatal outcomes: new evidence. J Obstet Gynaecol
2010;30:679-86
3. Heslehurst N, Simpson H, Ells LJ, et al. The impact of maternal
BMI status on pregnancy outcomes with immediate short-term obstetric
resource implications: a meta-analysis. ObesRev 2008;9:635-83
Dear Editor,
We read with interest the paper by Rovamo et al in which the authors
assessed the resuscitation skills of physicians on a manikin using a
standard simulation scenario of birth asphyxia.(1) They used a30-item
checklist to score the technical skills of each participant. The cut-off
point for passing or failing each of the 30 items was determined by
experts using the Angoff method for absolute standards setting...
Dear Editor,
We read with interest the paper by Rovamo et al in which the authors
assessed the resuscitation skills of physicians on a manikin using a
standard simulation scenario of birth asphyxia.(1) They used a30-item
checklist to score the technical skills of each participant. The cut-off
point for passing or failing each of the 30 items was determined by
experts using the Angoff method for absolute standards setting, as stated
by the authors.(2) The results they obtained showed a high prevalence of
inadequate skills in neonatal resuscitation.
The Angoff method is based on the estimated percentage of borderline
candidates who will adequately perform each assessment item, as judged by
a large panel of experts in that field. The scores (or percentages) for
all the items defining the whole assessment are summed up then averaged
and that obtained average constitutes the final passing score.(2) It is
widely used and recommended for standard setting of objective structured
clinical examinations (OSCE) even when used in simulation on a manikin
such in this study.(3)
We have concerns regarding the way in which this method was used by the
authors. It seems that the same score of 0.662 (or 66% of borderline
participants) was estimated for each of the 30 items of neonatal
resuscitation and the total passing mark was calculated accordingly. We
feel that this methodology is intrinsically flawed and likely to have
influenced the obtained results. This is because it is extremely unlikely
and indeed implausible that exactly the same percentage of participants
(66%) would be expected to adequately perform each of the separate 30
skills encompassing an extremely wide range of complexity, for example
something as simple as drying the baby or as technically demanding as
performing endotracheal intubation. Without adopting the proper standard
setting methodology, the stated results cannot be taken at face value.
There could be, worryingly, even far more physicians with inadequate
resuscitation skills than stated by the authors, or, reassuringly, many
more who can perform adequate neonatal resuscitation. The resulting
implications for corrective strategies for neonatal resuscitation training
are too important.
References
1. Rovamo L, Mattila MM, Andersson S, et al. Assessment of newborn
resuscitation skills of physicians with a simulator manikin. Archives of
disease in childhood Fetal and neonatal edition 2011;96:F383-9.
2. Angoff WH. Scales, Norms and Equivalent Scores. Educational
Measurement. Washington, DC: American Council on Education, 1971:508-600.
3. Pell G, Fuller R, Homer M, et al. How to measure the quality of
the OSCE: A review of metrics - AMEE guide no. 49. Medical teacher
2010;32:802-11
To the editor,
We were most interested to read the review by Sie et al.1 The authors
reviewed the literature on the effects of SRI use in pregnancy for mothers
and their offspring, and formulated guidelines. However, although their
review could have been more comprehensive, our main concern is with their
"practical recommendations". Several guidelines produced by psychiatric
governing bodies have been published regarding...
To the editor,
We were most interested to read the review by Sie et al.1 The authors
reviewed the literature on the effects of SRI use in pregnancy for mothers
and their offspring, and formulated guidelines. However, although their
review could have been more comprehensive, our main concern is with their
"practical recommendations". Several guidelines produced by psychiatric
governing bodies have been published regarding this subject, which were
formulated using evidence-based information with a multidisciplinary
approach.2 Therefore, we feel that some of Sie et al recommendations are
not only redundant but may not be in the best interests of either the
mother or baby.
There were several recommendations that we found troubling: 1) there is no
such thing as a "safe" antidepressant to use in pregnancy. The danger is
that a woman will switch and her depression will not be treated
effectively, increasing the risk of depression. 2) Tapering of
antidepressants doses is not useful, since there is no linear dose-
response curve, and therefore effects of changes in dose are very hard to
predict.3 3) Regarding breastfeeding, because the pharmacodynamics of
these drugs are individual, discouraging continuation of use of an
antidepressant (fluoxetine) solely based on an M/P ratio of maximally 11
percent is arbitrary. In addition, none of the antidepressants (including
fluoxetine) are excreted in breast milk in large enough amounts to
disallow breastfeeding, and there are very few reports of adverse effects
in the infant.4 4) The Finnegan score (as the authors acknowledge) was not
designed for SRI-related symptoms in neonates, but for fetal exposure to
opioids. Therefore, clinical decision making when suspecting poor neonatal
adaptation syndrome, should not be based solely on a Finnegan score, and
finally, 5) we are not aware of any evidence suggesting an anticonvulsant
such as phenobarbital for treatment of symptoms.2
Geert.W. 't Jong MD PhD
Clinical Fellow in Clinical Pharmacology Division of Clinical Pharmacology
& Toxicology and The Motherisk Program, The Hospital for Sick
Children, University of Toronto, Toronto ON, Canada
Adrienne Einarson RN
Consultant, The Motherisk Program, The Hospital for Sick Children,
University of Toronto, Toronto ON, Canada
References
1. Sie SD, Wennink JMB, van Driel JJ, et al. Maternal use of SSRIs, SNRIs
and NaSSAs: practical recommendations during pregnancy and lactation. Arch
Dis Child Fetal Neonatal Ed. 2011. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21798871. Accessed August 4, 2011.
2. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression
during pregnancy: a report from the American Psychiatric Association and
the American College of Obstetricians and Gynecologists. Gen Hosp
Psychiatry. 2009;31(5):403-413.
3. Burke MJ, Harvey AT, Preskorn SH. Pharmacokinetics of the newer
antidepressants. Am. J. Med. 1996;100(1):119-121.
4 Kendall-Tackett K, Hale TW The use of antidepressants in pregnant and
breastfeeding women: a review of recent studies. J Hum Lact. 2010
May;26(2):187-95. Review.
To the Editor:
I read the article by Prendergast et al with great interest (1). The
results of this study are in contrast to our traditional belief. In this
regard, I would like to point out few issues that needs urgent explanation
before the study results can be accepted.
First, the part of the hypothesis stating poor lung function in preterm
infants exposed to chorioamnionitis is not fully correct as in various
animal m...
To the Editor:
I read the article by Prendergast et al with great interest (1). The
results of this study are in contrast to our traditional belief. In this
regard, I would like to point out few issues that needs urgent explanation
before the study results can be accepted.
First, the part of the hypothesis stating poor lung function in preterm
infants exposed to chorioamnionitis is not fully correct as in various
animal models antenatal inflammation has been found to increase the
surfactant production and enhances lung maturation (2). Moreover in many
human studies chorioamnionitis is associated with decreased incidence of
RDS (3).
Second, the distribution of the number of patients requiring any
resuscitation after birth in each group is missing. Any positive pressure
ventilation given during resuscitation will have influence on the lung
functions.
Third, the distribution of the infants in each group from the previous two
studies is important to know because the various practices of
resuscitation like use of air and oxygen mixture instead of 100% oxygen,
use of PEEP, prolonged initial inflation time and introduction of early
CPAP have changed over last few years, though the authors claim that there
is no change in routine policies like antenatal steroid, surfactant etc.
All this will affect the lung function and possibly BPD also (4, 5).
Fourth, the first lung function measurement should have been done at the
earliest after the initial stabilization rather than on D2 of life. The
various interventions like amount of fluid received, presence of PDA,
initiation of ventilation (invasive/non-invasive), will alter the lung
function and the true influence of chorioamnionitis will get nullified.
Fifth, more infants in the chorioamnionitis group were exposed to
antenatal steroids (p=0.04) which could have partly influenced the lung
function.
Sixth, the surfactant has been given to symptomatic infants (rescue
therapy). It is not the prophylactic use of surfactant as has been
highlighted.
Despite these limitations, I would like to appreciate the authors for
their work, which has opened up the Pandora's Box.
References
1.Prendergast M, May C, Broughton S, Pollina E, Milner AD, Rafferty GF et
al. Chorioamnionitis, lung function and bronchopulmonary dysplasia in
prematurely born infants. Arch Dis Child Fetal Neonatal Ed 2011;96:270-74.
2.Kramer BW, Kallapur S, Newnham J, Jobe AH. Prenatal inflamemation and
lung development. Semin Fetal Neonatal Med 2009;14:2-7.
3.Andrews WW, Goldenberg RL, Faye Petersen O, Cliver S, Goepfert AR, Hauth
JC. The Alabama Preterm Birth Study: polymorphonuclear and mononuclear
cell placental infiltrations, other markers of inflammation, and outcomes
in 23 to 32 week preterm newborn infants. Am J Obstet Gynecol 2006;195:803
-8.
4.Siew ML, Te Pas AB, Wallace MJ, Kitchen MJ, Lewis RA, Fouras A et al.
Positive end expiratory pressure enhances development of a functional
residual capacity in preterm rabbits ventilated from birth. J Appl
Physiol. 2009;106:1487-93.
5.Te Pas AB, Siew M, Wallace MJ, Kitchen MJ, Fouras A, Lewis RA et al.
Establishing functional residual capacity at birth: the effect of
sustained inflation and positive end-expiratory pressure in a preterm
rabbit model. Pediatr Res. 2009;65:537-41.
To The Editor:
I read the article by Tracy et al with great interest (1). However I would
like to point out few issues that need explanation before the study
results can be accepted.
First, despite of more leak with one person method, the tidal volumes
being delivered are not statistically different in both the groups. Hence,
the superiority of this technique in decreasing the need of endotracheal
intubation and chest com...
To The Editor:
I read the article by Tracy et al with great interest (1). However I would
like to point out few issues that need explanation before the study
results can be accepted.
First, despite of more leak with one person method, the tidal volumes
being delivered are not statistically different in both the groups. Hence,
the superiority of this technique in decreasing the need of endotracheal
intubation and chest compression by improving ventilation is doubtful and
should be first tested in clinical studies before its widespread
implementation.
Second, surprisingly the tidal volumes generated in both the techniques
are much above the desired tidal volume of 4-5ml/kg. Animal studies have
clearly shown that ventilation even for 15 minutes at high tidal volumes
(15ml/kg) initiates' lung injury which in turn cause decreased lung
compliance and impaired gas exchange.
Third, the current Neonatal Resuscitation Programme guidelines recommend
the presence of one person at every delivery and two persons in high risk
deliveries (2). This new technique will require one extra resuscitator.
The burden of one more resuscitator will be a big challenge for developing
countries where 98% of total neonatal deaths occur worldwide (3).
Fourth, the sample size calculation has not been elaborated by the
authors.
Despite these limitations, I appreciate the authors for their work which
opens up new arenas of research in mask ventilation and neonatal
resuscitation.
References
1.Tracy MB, Klimek J, Coughtrey H, Shingde V, Ponnampalam G, M Hinder M et
al. Mask leak in one-person mask ventilation compared to two-person in
newborn infant manikin study. Arch Dis Child Fetal Neonatal Ed 2011;96:195
-200.
2.Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J
et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation 2010;122;909-919.
3.Carlo Wa, Goudar SS, Jehan I, Chomba E, Tshefu A, Garces A et al.
Newborn-Care Training and Perinatal Mortality in Developing Countries. N
Engl J Med 2010;362:614-23.
Phillips et.al (1) demonstrated the Neonatal Illness Prognosis
Indicator (NIPI) to be a good predictor of mortality in very low birth
weight neonates. We carried out a study replicating the design of the
original research to evaluate the use of this newly developed scoring
system in a different setting.
The study was based in Glan Clwyd District General Hospital,
Boddelwyddan, which has...
Phillips et.al (1) demonstrated the Neonatal Illness Prognosis
Indicator (NIPI) to be a good predictor of mortality in very low birth
weight neonates. We carried out a study replicating the design of the
original research to evaluate the use of this newly developed scoring
system in a different setting.
The study was based in Glan Clwyd District General Hospital,
Boddelwyddan, which has approximately 2500 deliveries a year and provides
Level 3 neonatal intensive care. Retrospective data on highest blood
lactate concentration, gestation and life threatening malformations was
collated to create an NIPI score for neonates weighing <1501 grams born
in the hospital between October 2008 and January 2011. The primary outcome
of death before discharge and secondary outcome of adverse event (using
the same criteria used in Phillips et.al's study) were used to assess the
NIPI's predictive ability. Local ethical and research approval was
granted for the study.
97 eligible babies were inborn during this time period of which 12
were excluded due to still being an inpatient at the time of the study or
transfer out to other hospitals. This left 85 babies which were included
in the study cohort. Predictive ability was determined from area under the
receiver operator curve (AUC). AUC for death before discharge was 0.932
(95 % confidence interval of 0.873 - 0.991) showing similar excellent
predictive value as the original validation cohort. AUC for adverse
outcome was calculated at 0.743 (95% confidence interval of 0.629 - 0.856)
and therefore did not show a clinically significant predictive ability.
This small study provides evidence that the NIPI score retains its
predictive ability for mortality when used in a different setting to that
which it was originally validated in. Larger studies in other varied
settings would be encouraged in order to fully assess its potential
clinical application.
1. Phillips, L. A., C. J. Dewhurst, Yoxall,C.W. The Prognostic Value
of Initial Blood Lactate Concentration Measurements in Very Low
Birthweight Infants and their use in Development of a new Disease Severity
Scoring System. Archives of disease in childhood. Fetal and neonatal
edition; 2011;96(4): F275-F280
Dear Editor,
We read with great interest the article by Fumagalli et al.,1 who reported
subcutaneous fat necrosis (SFN) in an infant suffering perinatal hypoxic
injury and treated with total body cooling, which complicated by
hypercalcaemia. In their report,1 it is suggested that total body cooling
likely increase the risk of SFN and renal complications. Recently, we
report a case of SFN, which complicated by hypercalcaem...
Dear Editor,
We read with great interest the article by Fumagalli et al.,1 who reported
subcutaneous fat necrosis (SFN) in an infant suffering perinatal hypoxic
injury and treated with total body cooling, which complicated by
hypercalcaemia. In their report,1 it is suggested that total body cooling
likely increase the risk of SFN and renal complications. Recently, we
report a case of SFN, which complicated by hypercalcaemia, due to
perinatal hypoxic injury.2 Unlike case of Fumagalli et al.,1 our patient
did not undergo to hypothermia therapy. Hence, we would like to make some
comments on their report.
Firstly, it is reported that as if SFN is mainly caused by therapeutic
hypothermia in newborns. Although the hypothermia can cause to SFN,3 it
usually occurs secondary to some perinatal conditions about by postnatal
day five to seven.2 However, cold panniculitis appears 48 to 72 hours
after exposure to cold.4 Therefore, in case of Fumagalli et al.,1 SFN at
35 hour of life suggests the facilitating effect of cold stress.
Nevertheless, it should be emphasized that neonatal SFN is primarily
caused by perinatal asphyxia,1,2 but therapeutic hypothermia may
facilitate this process.
Secondly, marked nephrocalcinosis present in this case may suggest
prolonged severe hypercalcaemia. We wonder if the patient's kidneys
previously evaluated by ultrasound for any reason? As hypercalcaemia is an
expectant metabolic complication of SFN of newborn,1,2 these patients
should be closely monitored for development of hypercalcaemia, as reported
in present case. Nephrocalcinosis present in this case is due to
hypercalcaemia as a complication SFN, but not being hypothermia therapy.
However, although the hypothermia may cause renal damage,5 hypoxic-
ischemic injury itself is the main cause of renal injury in these cases.
Therefore, title of the article in which "Total body cooling: skin and
renal complications" is not consistent with the reported case.
In conclusion, SFN of the newborn is a disorder of the adipose tissue,
mostly affecting full-term or post-term infants who experience perinatal
distress. Nevertheless, though perinatal hypoxic-ischemic event is the
main cause of SFN, hypothermia may facilitate its development. In
addition, the patients with SFN should be closely monitored for developing
metabolic problems like hypercalcaemia.
REFERENCES
1. Fumagalli M, Ramenghi LA, Pisoni S, Borzani I, Mosca F. Total body
cooling: skin and renal complications. Arch Dis Child Fetal Neonatal Ed
2011;DOI: 10.1136/adc.2010.207886
2. Hakan N, Aydin M, Zenciroglu A, et al. Alendronate for the treatment of
hypercalcaemia due to neonatal subcutaneous fat necrosis. Eur J Pediatr
2011;DOI: 10.1007/s00431-011-1468-8
3. Markus JR, de Carvalho VO, Abagge KT, et al. Ice age: a case of cold
panniculitis. Arch Dis Child Fetal Neonatal Ed 2011;96:F200.
4. Torrelo A, Hern?ndez A. Panniculitis in children. Dermatol Clin
2008;26:491-500, vii.
5. Ura H, Asai Y, Mori K, Nara S, Yoshida M, Itoh Y. Total necrosis of the
pancreas and renal cortex secondary to hypothermia therapy. J Trauma
2002;52:987-9.
Dear Editor:
The recent article of retrospective comparison of two methods, colour
Doppler ductal diameter and pulsed Doppler flow pattern, as
echocardiographic indicator for patent ductus arteriosus (PDA) treatment
in preterm infants by Condo' et al was well-designed and interesting.[1]
We agree the conclusions of that both methods are significantly
associated, and may use as a cross check to assist in the management o...
Dear Editor:
The recent article of retrospective comparison of two methods, colour
Doppler ductal diameter and pulsed Doppler flow pattern, as
echocardiographic indicator for patent ductus arteriosus (PDA) treatment
in preterm infants by Condo' et al was well-designed and interesting.[1]
We agree the conclusions of that both methods are significantly
associated, and may use as a cross check to assist in the management of
preterm infants with a PDA.
However, the following statement in the Discussion caused a little
concern: "If, instead, treatment is indicated by a pulsatile or growing
pattern, as was done in another RCT, a substantial proportion of infants
may be treated despite having a ductal diameter <2.0 mm". The reference
given here is our RCT.[2] Although, as found in their study, 40 of the 83
echocardiographic traces classified as growing or pulsatile had a diameter
<2.0 mm, their flow patterns did reveal a significant left to right
shunting and did reflect the realistically hemodynamic status of the PDA
that deserved treatment.
The authors described that 82.4% of the PH pattern group having ductal
diameter values >2.0 mm. However, there was no data showing the
percentage of transition from PH pattern to closing or closed pattern.
According to our previous reports,[3,4] about 50% of PH patterns remained
to be non-significant PDA and changed to closing or closed patterns. And
if a ductal diameter >2.0 mm is used as the indicator of treatment as
suggested by the authors, 41.2% infants with PDA of PH pattern may be
treated unnecessarily despite remaining non-significant and finally closed
spontaneously.
The authors indicated that a significant portion (28/197, 14.2%) of
echocardiographic studies had a flow pattern could not be clearly
classified. These traces appeared intermediate between the pulsatile and
closing patterns. We would like to remind that the classification of PDA
flow pattern depends on the profile of the pulsed Doppler wave form as
well as the flow velocity, the pulsatile pattern has a left to right
shunting with a pulsatile notched contour of peak flow velocity about 1.5
m/second, and closing pattern has a characteristic continuous profile with
a peak flow velocity of about 2 m/second.[3,4]
Finally, we would like to highlight the importance of the sequential
echocardiographic assessment of the hemodynamic status of PDA rather than
to depend only on a spot time measurement. What is most important is
whether the echocardiographically derived index can detect prospectively
the development of clinically significant PDA.
REFERENCES
1. Condo' M, Evans N, Bellu' R, Kluckow M. Echocardiographic assessment of
ductal significance: retrospective comparison of two methods. Arch Dis
Child Fetal Neonatal Ed on line first, published on May 5, 2011.
2. Su BH, Lin HC, Chiu HY, Hsieh HY, Chen HH, Tsai YC. Comparison of
ibuprofen and indometacin for early-targeted treatment of patent ductus
arteriosus in extremely premature infants: a randomised controlled trial.
Arch Dis Child Fetal Neonatal Ed 2008;93:F94-F99
3. Su BH, Watanabe T, Shimitzu M, et al. Echocardiographic assessment of
ductus
arteriosus shunt flow pattern in premature infants. Arch Dis Child Fetal
Neonatal Ed 1997;77: F36-40.
4. Su BH, Peng CT, Tsai Ch. Echocardiographic flow patterns of patent
ductus arteriosus: A guide to indomethacin treatment in premature infants.
Arch Dis Child Fetal Neonatal Ed 1999;81:F197-20.
Dear Editor,
we read with interest the paper by C J Bossley et al (1) in which the authors performed fitness-to-fly tests to understand if preterm infants with broncopulmonary dysplasia might require supplemental oxygen during high-altitude flight. In the opening sentence of abstract it is stated that "during air flight cabin pressurisation produces an effective fraction of inspired oxygen of 15%", but this sent...
Leow et al (1) report the incidence of sudden, unexpected and unexplained early neonatal death in a retrospective population-based study as 0.35/10,000 live births. The authors conclude that such deaths occur more rarely than previously appreciated and as such 'extra intrusive supervision' following birth is not justified.
Although SUNC and related-death is rare, it is important to highlight aspects which may co...
Dear Editor,
We read with interest the paper by Vasudevan et al. on foetal and perinatal consequences of maternal obesity.(1) The authors highlight the increased risk of perinatal mortality, neural tube and structural cardiac defects in the offspring. They also report an increased risk of birth injuries, perinatal asphyxia, respiratory distress and metabolic instability that are related to the associated foetal...
Dear Editor, We read with interest the paper by Rovamo et al in which the authors assessed the resuscitation skills of physicians on a manikin using a standard simulation scenario of birth asphyxia.(1) They used a30-item checklist to score the technical skills of each participant. The cut-off point for passing or failing each of the 30 items was determined by experts using the Angoff method for absolute standards setting...
To the editor, We were most interested to read the review by Sie et al.1 The authors reviewed the literature on the effects of SRI use in pregnancy for mothers and their offspring, and formulated guidelines. However, although their review could have been more comprehensive, our main concern is with their "practical recommendations". Several guidelines produced by psychiatric governing bodies have been published regarding...
To the Editor: I read the article by Prendergast et al with great interest (1). The results of this study are in contrast to our traditional belief. In this regard, I would like to point out few issues that needs urgent explanation before the study results can be accepted. First, the part of the hypothesis stating poor lung function in preterm infants exposed to chorioamnionitis is not fully correct as in various animal m...
To The Editor: I read the article by Tracy et al with great interest (1). However I would like to point out few issues that need explanation before the study results can be accepted. First, despite of more leak with one person method, the tidal volumes being delivered are not statistically different in both the groups. Hence, the superiority of this technique in decreasing the need of endotracheal intubation and chest com...
Dear Editor,
Phillips et.al (1) demonstrated the Neonatal Illness Prognosis Indicator (NIPI) to be a good predictor of mortality in very low birth weight neonates. We carried out a study replicating the design of the original research to evaluate the use of this newly developed scoring system in a different setting.
The study was based in Glan Clwyd District General Hospital, Boddelwyddan, which has...
Dear Editor, We read with great interest the article by Fumagalli et al.,1 who reported subcutaneous fat necrosis (SFN) in an infant suffering perinatal hypoxic injury and treated with total body cooling, which complicated by hypercalcaemia. In their report,1 it is suggested that total body cooling likely increase the risk of SFN and renal complications. Recently, we report a case of SFN, which complicated by hypercalcaem...
Dear Editor: The recent article of retrospective comparison of two methods, colour Doppler ductal diameter and pulsed Doppler flow pattern, as echocardiographic indicator for patent ductus arteriosus (PDA) treatment in preterm infants by Condo' et al was well-designed and interesting.[1] We agree the conclusions of that both methods are significantly associated, and may use as a cross check to assist in the management o...
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