We are grateful to our colleagues Haines and Davis from the UK for
their comments confirming many of our findings in their British population
-based cohort. We agree that differences in findings (e.g., different
rates of syndromal anomalies associated with congenital chylothorax) may
simply be due to small numbers. It is nice to see that this rare but
serious condition is receiving more scientific attention
We are grateful to our colleagues Haines and Davis from the UK for
their comments confirming many of our findings in their British population
-based cohort. We agree that differences in findings (e.g., different
rates of syndromal anomalies associated with congenital chylothorax) may
simply be due to small numbers. It is nice to see that this rare but
serious condition is receiving more scientific attention
I read this Randomised controlled trial with great interest. I
applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside
round is appropriate is of limited value and so deeper qualitative
discourse is needed. This can consider more meaningful questions such as
'how', 'why' and 'when' such parental presence impacts the neonatal
j...
I read this Randomised controlled trial with great interest. I
applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside
round is appropriate is of limited value and so deeper qualitative
discourse is needed. This can consider more meaningful questions such as
'how', 'why' and 'when' such parental presence impacts the neonatal
journey.
This is where I feel the authors do not fulfil the full potential of
this work. Whilst some limited analysis is made, it appears that a huge
volume of rich qualitative data has either not been analysed or analysed
in a manner that does not synthesise useful outcomes.
By not employing appropriate qualitative synthesis I feel we are left
with a piece that only tantalisingly points to the questions that will
help us to understand the value of parental presence during this aspect of
neonatal care.
I appeal to the authors to complete and publish such analysis of the
data from their focus group discussions.
We appreciate the feedback and clarity provided by the letter in
response to our review article. We agree in principle with the authors
that beta-blockers have rapidly become the standard of care for infantile
haemangiomas (IHs), and for this reason listed it first in our short
review of treatment options. Indeed, a recent meta-analysis of 35 studies
(representing 572 paediatric patients with IHs) strongly supported the...
We appreciate the feedback and clarity provided by the letter in
response to our review article. We agree in principle with the authors
that beta-blockers have rapidly become the standard of care for infantile
haemangiomas (IHs), and for this reason listed it first in our short
review of treatment options. Indeed, a recent meta-analysis of 35 studies
(representing 572 paediatric patients with IHs) strongly supported the
superior efficacy of propranolol in comparison to alternative therapeutic
options including steroids, vincristine, and laser treatment.(1) Patients
with periorbital IHs should be urgently referred to both paediatric
ophthalmology and dermatology in order to initiate treatment with
propranolol when clinically indicated.
Although propranolol is generally well tolerated by infants, systemic
beta-blockers are not without potential risks and side effects. A number
of serious adverse effects have been reported with propranolol use in
children, including bradycardia, hypotension, hypoglycaemia, bronchospasm,
and hyperkalemia.(2) A consensus conference was held in 2011 to develop
guidelines for the use of propranolol in children and the following
relative contraindications were suggested: cardiogenic shock, sinus
bradycardia, hypotension, heart failure, bronchial asthma, and
hypersensitivity to propranolol.(2) Therefore, for cases in which
propranolol is either ineffective or contraindicated, it remains important
to be aware of alternative therapeutic options for IHs.
References
1. Lou Y, Peng W-J, Cao Y, Cao D-S, Xie J, Li H-H. The effectiveness
of propranolol
in treating infantile haemangiomas: a meta-analysis including 35
studies. Br J
Clin Pharmacol. 2014 Jul 1;78(1):44-57.
2. Drolet BA, Frommelt PC, Chamlin SL, Haggstrom A, Bauman NM, Chiu
YE, et al.
Initiation and use of propranolol for infantile hemangioma: report of
a
We read with interest the review by AR Bedford Russell and F
Kumar[1] about challenges in diagnosing EONS.
The authors state to await a 100% sensitive and 100% specific test. In
theory, this gold standard is obtained by observing infants while
withholding antibiotics, which obviously is unacceptable. Instead
combinations of laboratory and clinical signs are used to exclude EONS.
Understandably, these tests must have hi...
We read with interest the review by AR Bedford Russell and F
Kumar[1] about challenges in diagnosing EONS.
The authors state to await a 100% sensitive and 100% specific test. In
theory, this gold standard is obtained by observing infants while
withholding antibiotics, which obviously is unacceptable. Instead
combinations of laboratory and clinical signs are used to exclude EONS.
Understandably, these tests must have high sensitivity. High sensitivity
in a test with poor test characteristics means by definition poor
specificity, resulting in overtreatment and all its associated drawbacks,
as described in the review.
We are thus waiting for new tests with equal sensitivity but higher
specificity. However, problems arise when developing this test. First of
all, since the sensitivity of the new test must be close to 100%, and the
non-inferiority margin must be small to prove non-inferiority an enormous
sample size is needed. Secondly, the sample size needed cannot be
calculated due to the lack of a gold standard. The same holds true for the
numbers needed to treat (NNT), sensitivity and specificity. For these
numbers, the incidence or prevalence of EONS in the population is needed.
Finally, it is unclear to what extent shortening of the course of
antibiotics would be of benefit, and thus the advantage of a more specific
test would be unclear.
In the context of all these considerations it is remarkable that in the
past neonatal antibiotic treatment has been shortened without scientific
sound underpinning. So it seems that the only way to move forward is to
just shorten treatment and monitor closely, and accept that strong
scientific foundation for optimizing EONS treatment will never be obtained
before changing the policy.
Reference list
1 A R Bedford Russell, R Kumar. Early onset neonatal sepsis: diagnostic
dilemmas and practical management. Arch Dis Child Fetal Neonatal Ed
2015;100:F350-F354.
Dear Sir,
First let me congratulate you for the phenomenal work that you have done
at Safdarjung Hospital.
On reading your paper, I found discrepancies in numbers in the flow
chart (Fig 1) and Table 2: viz. out of 1599 abnormal babies on pulse
oximetry, Echo confirmed 18 major and 15 critical CHDs. However, further
in the text and in table 2, the corresponding numbers are cited as 39
major and 22 critical CHDs...
Dear Sir,
First let me congratulate you for the phenomenal work that you have done
at Safdarjung Hospital.
On reading your paper, I found discrepancies in numbers in the flow
chart (Fig 1) and Table 2: viz. out of 1599 abnormal babies on pulse
oximetry, Echo confirmed 18 major and 15 critical CHDs. However, further
in the text and in table 2, the corresponding numbers are cited as 39
major and 22 critical CHDs. Consequently, the sensitivity, specificity and
other calculations are also confusing.
Sensitivity of pulse-oximetry for detecting any CHD according to your
study is 47.2%, whereas my calculations beg to differ, with the
sensitivity as 18.2% ie (29/159 x 100). This is of course, based on the
numbers given in the flow chart.
Kindly clarify the discrepancies in this otherwise well-written
paper.
We read with interest the article by O'Shea et al., recently
published in the Archives of Disease in Childhood Fetal and Neonatal
Edition.1
Faces of preterm infants were photographed and analyzed by using a
software; they then were compared with the size of the most commonly
available face masks (Laerdal 0/0 and Fisher & Paykel Infant
Resuscitation Masks "small" and "extra small"). Authors concluded that the
smallest...
We read with interest the article by O'Shea et al., recently
published in the Archives of Disease in Childhood Fetal and Neonatal
Edition.1
Faces of preterm infants were photographed and analyzed by using a
software; they then were compared with the size of the most commonly
available face masks (Laerdal 0/0 and Fisher & Paykel Infant
Resuscitation Masks "small" and "extra small"). Authors concluded that the
smallest size of some brands of mask is too large for many preterm infants
and that masks of 35 mm external diameter are suitable for extremely low
birth weigh infants (ELBWI).
These results are of great interest, because a face mask is the most used
interface to support respiratory function in preterm infants at birth.
The seal between the newborn's face and the mask is an important
determinant of the success of the procedure. Previous studies documented a
significant leak around the mask, when ventilating or providing CPAP to
preterm infants. 2-3-4
It is therefore necessary to identify the devices able to minimize the
leak.
The smallest mask considered by O'Shea et al. was the round face mask
Fisher & Paykel Infant Resuscitation Mask "extra small" (external
diameter 35 mm).
In our centre, we routinely use the anatomically shaped mask Ge Healthcare
Preemie Face Mask size 0 (external measures 55x50 mm, internal measures
34x25 mm) in ELBWI. It warrants a good adherence to the face, covering the
nose and the mouth and avoiding overlapping the eyes and the chin in the
most of ELBWI. This is in agreement with measurements reported by O'Shea
et al. for infants weighing <1000 g.1
We think these device could be an effective alternative to the round face
mask assessed by O'Shea et al., since an anatomically shaped mask could
warrant a better seal in some newborn.
References:
1. Measurements from preterm infants to guide face mask size. O'Shea
JE, Thio M, Owen LS, Wong C, Dawson JA, Davis PG. Arch Dis Child Fetal
Neonatal Ed. 2015 Apr 10.
2. Schm?lzer GM, Kamlin COF, O'Donnell CPF, et al. Assessment of
tidal volume and gas leak during mask ventilation of preterm infants in
the delivery room. Arch Dis Child Fetal Neonatal Ed 2010;95:F393-7.
3. Kaufman J, Schm?lzer GM, Kamlin COF, et al. Mask ventilation of
preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed
2013;98:F405-10.
4. Schilleman K, Van der Pot CJM, Hooper SB, et al. Evaluating manual
inflations and breathing during mask ventilation in preterm infants at
birth. J Pediatr 2013;162:457-63.
We were pleased that our findings [2] and those of Tunell's group [3]
have been confirmed in the recent paper by van Vonderen et al [1], that is
the inspiratory efforts of prematurely born infants coinciding with
inflations during resuscitation at birth are critical in increasing the
expired carbon dioxide levels. In addition, we have previously published
the relationship between expired tidal volume and expired carbon dio...
We were pleased that our findings [2] and those of Tunell's group [3]
have been confirmed in the recent paper by van Vonderen et al [1], that is
the inspiratory efforts of prematurely born infants coinciding with
inflations during resuscitation at birth are critical in increasing the
expired carbon dioxide levels. In addition, we have previously published
the relationship between expired tidal volume and expired carbon dioxide
levels during resuscitation.[2] We were, however, confused by figure one
in the recent paper.[1] The trace documented as expired tidal volume, we
believe is not the expired tidal volume but rather the airway pressure.
Furthermore, in our experience of measuring expired carbon dioxide levels
at resuscitation in over 200 preterm infants using a similar technique, we
found, as one would expect, the carbon dioxide levels during the
inspiratory phase to fall to a stable baseline as documented in figure 1
of our published paper.[2] We were, therefore, surprised by the expired
carbon dioxide trace shown [1] and wonder how the expired carbon dioxide
was calculated from such a trace.
REFERENCES
1. van Vonderen JJ, Lista G, Cavigioli F, et al. Effectivity of
ventilation by measuring expired CO2 and RIP during stabilisation of
preterm infants at birth. Arch Dis Child Fetal Neonatal Ed 2015 [pub ahead
of print].
2. Murthy V, O;Rourke-Potocki A, Dattani N, et al. End tidal carbon
dioxide levels during the resuscitation of prematurely born infants.
Early Hum Dev 2012;88:783-7.
3. Palme-Kilander C, Tunell R. Pulmonary gas exchange during facemask
ventilation immediately after birth. Arch Dis Child 1993;68:11-6.
To the editor: We read with interest the case report on the use of
polividon-iodine (PVI) to perform chemical pleurodesis in newborns and the
short literature review on further 12 cases in 5 publications by Resch et
al.[1].
We found another most recent publication from 2015 on a series of 5 young
infants with a success rate of 80%[2].
We agree with Resch et al., who conclude that "the risk-benefit assessment
of PVI pleur...
To the editor: We read with interest the case report on the use of
polividon-iodine (PVI) to perform chemical pleurodesis in newborns and the
short literature review on further 12 cases in 5 publications by Resch et
al.[1].
We found another most recent publication from 2015 on a series of 5 young
infants with a success rate of 80%[2].
We agree with Resch et al., who conclude that "the risk-benefit assessment
of PVI pleurodesis in the treatment of congenital chylothorax does not
support its routine use as it may be associated with significant harm".
However, we miss in their brief report a distinct warning of the danger of
disturbed thyroid function after administration of PVI, in particular in
newborns.
PVI is indicated for skin disinfection. At a concentration of > 5 mg/l
free iodine is microbicidal. Standard 7.5%- or 10%-PVI solutions have a
concentration of free iodine between 10 and 22 mg/l[3]; assuming total
enteral nutrition a 1.5 kg-infant gets 15 - 25mcg of iodine per day from
mother's milk or formula, but a further 50 - 110 mcg, if 5 ml PVI is
instilled in the pleura[1]. Assuming an equal or even better absorption
rate through the pleura this may result in a reduction in thyroid hormone
levels (Wolff-Chaikoff effect) in a population of newborns and preterm
infants, which is particularly vulnerable to hypothyroidism.
Contrary to what one might expect dilution of PVI solutions leads to
increase of free iodine, which is dissolved out of the molecule complex: a
50-fold dilution in saline increases the free iodine to about 1-2 g/l,
which is a 100-fold increase of the original substance[3]. At least 10 of
the 17 patients mentioned above were treated with diluted solutions.
Parravicini et al. drew attention to this issue already in 1996. They
analyzed free iodine in urine of VLBW infants exposed by the use of PVI
for vascular or lumbar puncture, or by administration of iodinated
contrast media. They observed iodine urine levels, which were up to 1.000
times higher than in control infants. One third of their patients had
hypothyroidism, and more than 20% had TSH levels above 20 microU/ml, with
SGA infants being in particular prone to hyperthyrotropenemia[4].
A literature research in PubMed with the key words "chemical pleurodesis
newborn" yields 6 hits, 5 of them dealing with PVI. This creates the
impression, that only PVI is effective for pleurodesis. However, in adults
pleurodesis can be performed with a variety of agents, and even more of
them have been studied successfully in animals: erythromycin, bleomycin,
tetracycline, a slurry of talc, silver nitrate, polidocanol, ethanol, OK-
432, and even autologous blood has been studied.
In summary it seems prudent to recommend close observation of infants and
young children treated with PVI with respect to pending hypothyroidism.
PVI solutions should never be diluted, because free iodine increases with
decreasing concentration. There is a need for controlled studies on
chemical pleurodesis in newborns with agents other than PVI.
References:
1 Resch B, Freidl T, Reiterer F. Povidone-iodine pleurodesis for
congenital chylothorax of the newborn. Arch Dis Child Fetal Neonatal Ed
Published Online First: 29 September 2015. doi:10.1136/archdischild-2015-
309184
2 Scottoni F, Fusaro F, Conforti A, et al. Pleurodesis with povidone-
iodine for refractory chylothorax in newborns: Personal experience and
literature review. J Pediatr Surg Published Online First: 28 April 2015.
doi:10.1016/j.jpedsurg.2015.03.069
3 Atemnkeng MA, Plaizier-Vercammen J, Schuermans A. Comparison of free and
bound iodine and iodide species as a function of the dilution of three
commercial povidone-iodine formulations and their microbicidal activity.
Int J Pharm 2006;317:161-6. doi:10.1016/j.ijpharm.2006.03.013
4 Parravicini E, Fontana C, Paterlini GL, et al. Iodine, thyroid function,
and very low birth weight infants. Pediatrics 1996;98:730-4.
Dear Editor,
Archives of Disease of childhood: Foetal and Neonatal edition
We read the review article by Dong et al(1) with interest. We wanted
to congratulate the authors on a very balanced and clinically relevant
review; highlighting the epidemiological, therapeutic and preventative
aspects of late onset sepsis caused by bacteria and fungi.
We believe that the review would have been even more clinically releva...
Dear Editor,
Archives of Disease of childhood: Foetal and Neonatal edition
We read the review article by Dong et al(1) with interest. We wanted
to congratulate the authors on a very balanced and clinically relevant
review; highlighting the epidemiological, therapeutic and preventative
aspects of late onset sepsis caused by bacteria and fungi.
We believe that the review would have been even more clinically relevant,
if it had included viral sepsis e.g. herpes simplex virus (HSV) infection.
In a recent UK based study(2) we demonstrated a high neonatal herpes
sepsis incidence (17.5 per 100,000 live births) highlighting the non-
specific clinical presentation and high mortality of this disease. The
majority of cases in our study presented between days 3 and 14 of life;
with non-specific symptoms, with or without a herpetic rash. The
differentiation from bacterial late onset sepsis at presentation is
extremely difficult. Extrapolation of our data implies UK mortality due to
herpes of over 1.5 times that of group B streptococcal sepsis(3).
Unless attending clinicians are vigilant and expand the differential
diagnoses of suspected late onset sepsis, there will be increased
morbidity and mortality from neonatal herpes infections. Raised Alanine
transaminase (ALT) can be an early marker for HSV infection and should be
part of the bloods for evaluation of sepsis. Intravenous acyclovir should
routinely be included in the protocols of late onset sepsis.
Dushyant Batra
Patrick Davies
Craig Smith
Nottingham University Hospitals NHS Trust,
Nottingham
UK
References:
1. Dong Y, Speer CP. Late onset sepsis: recent developments. Arch Dis
Child Fetal Neonatal Ed 2015;100:F257-F263 doi;10.1136/archdischild-2014-
306213
2. Batra D, Davies P, Manktelow BN, Smith C. The incidence and
presentation of neonatal herpes in a single UK tertiary centre, 2006-2013.
Arch Dis Child 2014;99:916-921.
3. Edmond KM, Kortsalioudaki C, Scott S, et al. Group B streptococcal
disease in infants aged younger than 3 months: systematic review and meta-
analysis. Lancet 2012;379:547-556.
Mukherjee et al. were interested by the response to their paper
indicating that not all units may have seen an increase in antibiotic use
and length of stay following introduction of NICE guidance CG149. The
important difference for our unit was the introduction of a second CRP at
18-24 hours to inform further investigations (lumbar puncture) and length
of antibiotic course. It is not surprising that units that already u...
Mukherjee et al. were interested by the response to their paper
indicating that not all units may have seen an increase in antibiotic use
and length of stay following introduction of NICE guidance CG149. The
important difference for our unit was the introduction of a second CRP at
18-24 hours to inform further investigations (lumbar puncture) and length
of antibiotic course. It is not surprising that units that already used a
second CRP did not see this effect. In our unit the second CRP was
frequently raised in asymptomatic infants.
The NICE guidance places emphasis on the clinical evaluation of baby, but
also includes in this the second CRP result. The second CRP may well lead
to differences in interpretation about possible sepsis between units,
particularly in infants, that have always been well and asymptomatic.
The guidance reads: 1.7.1.2 Consider performing a lumbar puncture to
obtain a cerebrospinal fluid sample in a baby, who did not have a lumbar
puncture at presentation, who is receiving antibiotics, if it is thought
safe to do so and if the baby:
*has a C-reactive protein concentration of 10 mg/litre or greater, or
*has a positive blood culture, or
*does not respond satisfactorily to antibiotic treatment.
In our unit the raised CRP has led to increased lumbar puncture and
greater length of antibiotic courses in asymptomatic infants. We have a
clear policy of careful clinical observation of 'at risk' infants, but
inclusion of CRP in the assessment of asymptomatic infants may be
problematic. We feel that a clearer distinction between the infants that
have been always asymptomatic needs to be made, and the justification for
a second CRP in this patient group is poorly studied. We believe that a
more explicit statement about avoiding LP in babies that have always been
asymptomatic may be helpful, or at least should be studied further in this
patient group.
We are grateful to our colleagues Haines and Davis from the UK for their comments confirming many of our findings in their British population -based cohort. We agree that differences in findings (e.g., different rates of syndromal anomalies associated with congenital chylothorax) may simply be due to small numbers. It is nice to see that this rare but serious condition is receiving more scientific attention
Confl...
I read this Randomised controlled trial with great interest. I applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside round is appropriate is of limited value and so deeper qualitative discourse is needed. This can consider more meaningful questions such as 'how', 'why' and 'when' such parental presence impacts the neonatal j...
We appreciate the feedback and clarity provided by the letter in response to our review article. We agree in principle with the authors that beta-blockers have rapidly become the standard of care for infantile haemangiomas (IHs), and for this reason listed it first in our short review of treatment options. Indeed, a recent meta-analysis of 35 studies (representing 572 paediatric patients with IHs) strongly supported the...
We read with interest the review by AR Bedford Russell and F Kumar[1] about challenges in diagnosing EONS. The authors state to await a 100% sensitive and 100% specific test. In theory, this gold standard is obtained by observing infants while withholding antibiotics, which obviously is unacceptable. Instead combinations of laboratory and clinical signs are used to exclude EONS. Understandably, these tests must have hi...
Dear Sir, First let me congratulate you for the phenomenal work that you have done at Safdarjung Hospital.
On reading your paper, I found discrepancies in numbers in the flow chart (Fig 1) and Table 2: viz. out of 1599 abnormal babies on pulse oximetry, Echo confirmed 18 major and 15 critical CHDs. However, further in the text and in table 2, the corresponding numbers are cited as 39 major and 22 critical CHDs...
We read with interest the article by O'Shea et al., recently published in the Archives of Disease in Childhood Fetal and Neonatal Edition.1 Faces of preterm infants were photographed and analyzed by using a software; they then were compared with the size of the most commonly available face masks (Laerdal 0/0 and Fisher & Paykel Infant Resuscitation Masks "small" and "extra small"). Authors concluded that the smallest...
We were pleased that our findings [2] and those of Tunell's group [3] have been confirmed in the recent paper by van Vonderen et al [1], that is the inspiratory efforts of prematurely born infants coinciding with inflations during resuscitation at birth are critical in increasing the expired carbon dioxide levels. In addition, we have previously published the relationship between expired tidal volume and expired carbon dio...
To the editor: We read with interest the case report on the use of polividon-iodine (PVI) to perform chemical pleurodesis in newborns and the short literature review on further 12 cases in 5 publications by Resch et al.[1]. We found another most recent publication from 2015 on a series of 5 young infants with a success rate of 80%[2]. We agree with Resch et al., who conclude that "the risk-benefit assessment of PVI pleur...
Dear Editor, Archives of Disease of childhood: Foetal and Neonatal edition
We read the review article by Dong et al(1) with interest. We wanted to congratulate the authors on a very balanced and clinically relevant review; highlighting the epidemiological, therapeutic and preventative aspects of late onset sepsis caused by bacteria and fungi. We believe that the review would have been even more clinically releva...
Mukherjee et al. were interested by the response to their paper indicating that not all units may have seen an increase in antibiotic use and length of stay following introduction of NICE guidance CG149. The important difference for our unit was the introduction of a second CRP at 18-24 hours to inform further investigations (lumbar puncture) and length of antibiotic course. It is not surprising that units that already u...
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