Thank you for your interest in our study and your comment. When you read the 6th paragraph of the discussion of the article, you will find that we completely agree that Oxytocin could have influenced the observations. This was an observational study and moment of oxytocin was given to the discretion of the midwife. Nevertheless, we still observed umbilical circulation much longer than previously described. This study was performed in 2015, but our local guideline has recently been changed to administering oxytocin after cord clamping. A new study is currently undertaken using the same methodology.
We thank dr. Kumar and dr. Yadav for their interest in our study. We hope that by stating ‘delayed cord clamping may not be advisable in second-born MC twins after vaginal birth’, we expressed that gynecologists could consider to deviate from the international guidelines in some cases. It is possible that not all babies will benefit from placental transfusion in a similar way. However, we certainly agree with dr. Kumar and dr. Yadav that the optimal timing of umbilical cord clamping in twins warrants further investigation.
Thank you for this interesting and highly needed piece of knowledge on physiological umbilical bllod flow. Just one remark: uterotonics were given to all women directly after birth. Oxytocin may alter umbilical blood flow due to modifications in timing and strength of contractions, and influence timing of placental disattachment. Possibly, true physiological blood flow may be still different (and continue for even longer), if medication were administered after clamping (quite possibly with no significant disadvantage for the parturient).
Dear Editor
We genuinely appreciate the readers keen interest in our paper and critical comments.1 Here are our clarifications regarding their comments.
1. The readers have perhaps misunderstood the concept of “intention to treat analysis” and “per protocol analysis”.2 Infants were analysed as they were randomized in their respective groups (intention to treat analysis). Per protocol analysis excludes the patients who deviate from the protocol. In our study, we needed to exclude the infants who were lost to follow-up and therefore their outcomes were not known. We did not exclude them because there was a protocol deviation or violation.
2. Blood dextrose levels were monitored as per unit protocol and once stable on full enteral feeds they were done once a week along with weekly routine blood evaluations up to discharge. No additional testing for blood sugars was done for the study.
3. We believe that propranolol at lower doses of 0.5mg/kg/dose 12 hourly is unlikely to affect the normal vascularization in other organs. This drug has been previously used in newborns including preterm newborns for different indications. Till date there have been no reports of deranged neuro-developmental outcome attributed to propranolol. However, we agree with the readers thoughts that long term neuro-developmental outcome would have been useful but this was beyond the scope of this study.
4. In our study, for babies born at 31-32 weeks post menstrual age the...
Dear Editor
We genuinely appreciate the readers keen interest in our paper and critical comments.1 Here are our clarifications regarding their comments.
1. The readers have perhaps misunderstood the concept of “intention to treat analysis” and “per protocol analysis”.2 Infants were analysed as they were randomized in their respective groups (intention to treat analysis). Per protocol analysis excludes the patients who deviate from the protocol. In our study, we needed to exclude the infants who were lost to follow-up and therefore their outcomes were not known. We did not exclude them because there was a protocol deviation or violation.
2. Blood dextrose levels were monitored as per unit protocol and once stable on full enteral feeds they were done once a week along with weekly routine blood evaluations up to discharge. No additional testing for blood sugars was done for the study.
3. We believe that propranolol at lower doses of 0.5mg/kg/dose 12 hourly is unlikely to affect the normal vascularization in other organs. This drug has been previously used in newborns including preterm newborns for different indications. Till date there have been no reports of deranged neuro-developmental outcome attributed to propranolol. However, we agree with the readers thoughts that long term neuro-developmental outcome would have been useful but this was beyond the scope of this study.
4. In our study, for babies born at 31-32 weeks post menstrual age the first evaluation was done by 34 weeks corrected gestational age. This is our unit protocol based on our experience (as we have seen ROP even at earlier gestation in our country). This protocol also ensures a ROP evaluation before discharge in babies who get discharged early. It does not matter whether ROP screening starts (for infants born at 31 to 32 weeks of post menstrual age) at 2 weeks or 4 weeks, as long as there is a regular periodical follow up until full vascularization of retina.
We hope that this clarifies all the concerns raised by readers.
REFERENCES:
1. Sanghvi KP, Kabra NS, Padhi P, Singh U, Dash SK, Avasthi BS. Prophylactic propranolol for prevention of ROP and visual outcome at 1 year (PreROP trial). Arch Dis Child Fetal Neonatal Ed. 2017 Jan 13. pii: fetalneonatal-2016-311548. doi: 10.1136/archdischild-2016-311548. [Epub ahead of print]
2. Intention to treat analysis and per protocol analysis: complementary information. Prescrire Int. 2012 Dec; 21(133):304-6.
We read Hsieh et al's paper with much interest. In an experimental study of ethanol introduction in an empty isolette, they conclude that neonates in isolettes are at risk of of inadvertent exposure to ethanol from hands cleaned with ethanol-based hand sanitiser.
We would like to share with the readers of Arch Dis Child Fetal Neonatal, the results of a similar study conducted in 2011. Measurements of isopropanol/ethanol exposure were conducted for 9 neonates nursed in incubators1. We found very variable exposure profiles with peak isopropanol/ethanol value of 1982, respectively 906 ppm. A wide range of possible exposure situations were also investigated using a one-box dispersion model2. Both our clinical and experimental papers offered different approaches to reduce the potential isopropanol/ethanol exposure for neonates nursed in isolettes.
We were delighted to read that the results from Hsieh et al. were concordant with our findings. We believe that this new publication gives further evidence and emphasis on the, unfortunately often underestimated, issue of neonatal exposure to gaseous pollutants.
1 Paccaud et al. Hand-disinfectant alcoholic vapors in incubators. JNPM 4(1):15-19, 2011
2 Vernez et al. Solvent vapours in incubators: a source of exposure among neonates? Gefahrstoffe -Reinhaltung der Luft 71 (5):209-214, 2011
We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
Despite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis an...
We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
Despite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis and with good follow up to look for differences in need of blood transfusion in postnatal age and neurodevelopmental outcome.
Competing interests: None
Source of funding: None
References:
1. Verbeek L, Zhao DP, Middeldorp JM, et al. Haemoglobin discordances in twins: due to differences in timing of cord clamping? Arch Dis Child Fetal Neonatal Ed. 2017;102: F324–8.
2. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132: S543-560.
3. Verbeek L, Zhao DP, Te Pas AB, et al. Hemoglobin Differences in Uncomplicated Monochorionic Twins in Relation to Birth Order and Mode of Delivery. Twin Res Hum Genet Off J Int Soc Twin Stud. 2016;19:241–5.
4. Lopriore E, Sueters M, Middeldorp JM, et al. Haemoglobin differences at birth in monochorionic twins without chronic twin-to-twin transfusion syndrome. Prenat Diagn. 2005;25:844–50.
We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
Even though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of...
We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
Even though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of feeds. Most of the units practice cue based feeding initiation and hiking. There is enough evidence to suggest that non-nutritive sucking reduces the time infants need to transition from tube to full oral feeding,[2] here it is worth to mention about this practice in the study population.
A prospective cohort study by Shetty et al,[3] is inappropriately mentioned as case series at multiple places in the article.
Overall this trial succeeds in giving a clear message on feasibility and safety of oral feeding while on nasal CPAP or high flow nasal cannula.
Competing interests: None
Source of funding: None
References:
1. Glackin SJ, O’Sullivan A, George S, et al. High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2017;102:F329–32.
2. Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2016 Oct 4;10:CD001071.
3. Shetty S, Hunt K, Douthwaite A, et al. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 2016;101:F408-411.
We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.
Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]
We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.
Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]
Reference List
1. McDonald SJ, Middleton P, Dowswell T, Morris PS: Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2013;CD004074.
2. Westgate JA, Wibbens B, Bennet L, Wassink G, Parer JT, Gunn AJ: The intrapartum deceleration in center stage: a physiologic approach to the interpretation of fetal heart rate changes in labor. Am J Obstet Gynecol 2007;197:236-11.
3. Hooper SB, Binder-Heschl C, Polglase GR, Gill AW, Kluckow M, Wallace EM, Blank D, Te Pas AB: The timing of umbilical cord clamping at birth: physiological considerations. Matern Health Neonatol Perinatol 2016;2:4.
We read with great interest the article by Van Zanten HA et al., published in this journal and found the results impressive.[1] However, we have certain observations about the conduct of the study
Even though the authors state that this report was part of a quality improvement initiative in their NICU, the authors have neither reported the results in the format suitable for a quality improvement study nor have clearly stated the design; at the end of introduction they seem to mention that this was a retrospective data analysis; whereas, in the first line of the methods they state the design as a prospective observational study. Even though the automatic oxygen controller group would not have been affected much by any one of the design, the impact would have been in the manual group, keeping especially the training of the NICU staff in mind. It’s also worth emphasizing here that the authors mention about the local guidelines practiced for manual titration of supplemental oxygen based on the saturations, for the sake of external validity.[2]
Minute wise data points used in this study may have significantly underestimated the hypoxemic episodes and thereby the proportion of times an infant remained in the ‘below target range’ saturations. In a logical sense, manual titration would have happened sooner than expected for a hypoxemic event and hence would not have been captured if more frequent data points are not considered. Using the same technology and a lesser in...
We read with great interest the article by Van Zanten HA et al., published in this journal and found the results impressive.[1] However, we have certain observations about the conduct of the study
Even though the authors state that this report was part of a quality improvement initiative in their NICU, the authors have neither reported the results in the format suitable for a quality improvement study nor have clearly stated the design; at the end of introduction they seem to mention that this was a retrospective data analysis; whereas, in the first line of the methods they state the design as a prospective observational study. Even though the automatic oxygen controller group would not have been affected much by any one of the design, the impact would have been in the manual group, keeping especially the training of the NICU staff in mind. It’s also worth emphasizing here that the authors mention about the local guidelines practiced for manual titration of supplemental oxygen based on the saturations, for the sake of external validity.[2]
Minute wise data points used in this study may have significantly underestimated the hypoxemic episodes and thereby the proportion of times an infant remained in the ‘below target range’ saturations. In a logical sense, manual titration would have happened sooner than expected for a hypoxemic event and hence would not have been captured if more frequent data points are not considered. Using the same technology and a lesser interval (5 seconds) Van Kaam et al had shown aptly that automated control reduced hypoxemia.[2]
Comparative data on the clinical morbidities such as pulmonary artery hypertension and patent ductus arteriosus would be important as these morbidities if differentially distributed in the comparison groups, would have affected the hypoxemic episodes and proportion of time below the target range.
While concluding, the authors seem to have conveniently avoided describing the significant time spent below the target range in the automated control group. Even though this could have been due to the inherent human behavioral pattern of responding faster to lower saturations, an inbuilt error in the closed loop algorithm with a differential sensitivity towards lower saturations could have also played a role in such phenomenon.[3] For a reader, a strong message would be that even though the control is automated, a close look into the algorithm of the manufacturer is immediately required to avoid spending more time below the target range, especially when one does not know the impact of such ‘below target range’ saturations on long-term neurodevelopmental and pulmonary outcomes.
Competing interests: None
Source of funding: None
References:
1 Van Zanten H, Kuypers K, Stenson B et al. The effect of implementing an automated oxygen control on oxygen saturation in preterm infants. Archives of Disease in Childhood - Fetal and Neonatal Edition 2017fetalneonatal-2016-312172. doi:10.1136/archdischild-2016-312172
2 van Kaam A, Hummler H, Wilinska M et al. Automated versus Manual Oxygen Control with Different Saturation Targets and Modes of Respiratory Support in Preterm Infants. The Journal of Pediatrics 2015;167:545-550.e2. doi:10.1016/j.jpeds.2015.06.012
3 Bancalari E, Claure N. Control of Oxygenation During Mechanical Ventilation in the Premature Infant. Clinics in Perinatology 2012;39:563-572. doi:10.1016/j.clp.2012.06.013
I read with interest your article on spontaneous ping pong parietal fracture in newborns with impressive color images .The word 'fracture' can be quite traumatic to the parents and should avaoided if there is no radiological evidence of break in the cortex 1. It should then just be labelled as depression of skull bone without a fracture rather than labelling as DCF( depressed calvarial fracture) as mentioned in your article .You have also clearly demonstrated in your 3D CT image also that there was no break but only invagination of parietal bone .The management would also not change whether the depression is with or without fracture .
References -
Tayeh,et al.BMJCase Rep2016.doi:1136/bcr-2016-215437
Thank you for your interest in our study and your comment. When you read the 6th paragraph of the discussion of the article, you will find that we completely agree that Oxytocin could have influenced the observations. This was an observational study and moment of oxytocin was given to the discretion of the midwife. Nevertheless, we still observed umbilical circulation much longer than previously described. This study was performed in 2015, but our local guideline has recently been changed to administering oxytocin after cord clamping. A new study is currently undertaken using the same methodology.
We thank dr. Kumar and dr. Yadav for their interest in our study. We hope that by stating ‘delayed cord clamping may not be advisable in second-born MC twins after vaginal birth’, we expressed that gynecologists could consider to deviate from the international guidelines in some cases. It is possible that not all babies will benefit from placental transfusion in a similar way. However, we certainly agree with dr. Kumar and dr. Yadav that the optimal timing of umbilical cord clamping in twins warrants further investigation.
Thank you for this interesting and highly needed piece of knowledge on physiological umbilical bllod flow. Just one remark: uterotonics were given to all women directly after birth. Oxytocin may alter umbilical blood flow due to modifications in timing and strength of contractions, and influence timing of placental disattachment. Possibly, true physiological blood flow may be still different (and continue for even longer), if medication were administered after clamping (quite possibly with no significant disadvantage for the parturient).
Dear Editor
Show MoreWe genuinely appreciate the readers keen interest in our paper and critical comments.1 Here are our clarifications regarding their comments.
1. The readers have perhaps misunderstood the concept of “intention to treat analysis” and “per protocol analysis”.2 Infants were analysed as they were randomized in their respective groups (intention to treat analysis). Per protocol analysis excludes the patients who deviate from the protocol. In our study, we needed to exclude the infants who were lost to follow-up and therefore their outcomes were not known. We did not exclude them because there was a protocol deviation or violation.
2. Blood dextrose levels were monitored as per unit protocol and once stable on full enteral feeds they were done once a week along with weekly routine blood evaluations up to discharge. No additional testing for blood sugars was done for the study.
3. We believe that propranolol at lower doses of 0.5mg/kg/dose 12 hourly is unlikely to affect the normal vascularization in other organs. This drug has been previously used in newborns including preterm newborns for different indications. Till date there have been no reports of deranged neuro-developmental outcome attributed to propranolol. However, we agree with the readers thoughts that long term neuro-developmental outcome would have been useful but this was beyond the scope of this study.
4. In our study, for babies born at 31-32 weeks post menstrual age the...
Sir,
We read Hsieh et al's paper with much interest. In an experimental study of ethanol introduction in an empty isolette, they conclude that neonates in isolettes are at risk of of inadvertent exposure to ethanol from hands cleaned with ethanol-based hand sanitiser.
We would like to share with the readers of Arch Dis Child Fetal Neonatal, the results of a similar study conducted in 2011. Measurements of isopropanol/ethanol exposure were conducted for 9 neonates nursed in incubators1. We found very variable exposure profiles with peak isopropanol/ethanol value of 1982, respectively 906 ppm. A wide range of possible exposure situations were also investigated using a one-box dispersion model2. Both our clinical and experimental papers offered different approaches to reduce the potential isopropanol/ethanol exposure for neonates nursed in isolettes.
We were delighted to read that the results from Hsieh et al. were concordant with our findings. We believe that this new publication gives further evidence and emphasis on the, unfortunately often underestimated, issue of neonatal exposure to gaseous pollutants.
1 Paccaud et al. Hand-disinfectant alcoholic vapors in incubators. JNPM 4(1):15-19, 2011
2 Vernez et al. Solvent vapours in incubators: a source of exposure among neonates? Gefahrstoffe -Reinhaltung der Luft 71 (5):209-214, 2011
We read with great interest the article by Lianne Verbeek et al, published in this journal and found the results impressive however we didn’t agree with the conclusion drawn by the author.[1] In present study authors concluded that delayed cord clamping may not be advisable in second-born monochorionic twins after vaginal birth due to polycythemia and associated complications. We don’t agree with the authors in this regard. In this study there was no difference in symptomatic polycythemia, need for the partial exchange or mortality. There is no mention about hypoglycemia and jaundice in the study population. American heart association guidelines for neonatal resuscitation[2] recommends delayed cord clamping (DCC) for all preterms who didn’t require resuscitation in view of their potential benefits (decreased mortality, higher blood pressure and blood volume, less need for postnatal blood transfusion, less intraventricular hemorrhages and less risk of necrotizing enterocolitis) which outweighs minor possible complications (increased risks of polycythemia and jaundice). We suggest that till there is enough evidence to change practice we should follow DCC for first as well as second order twin in preterm as well as term babies.
Show MoreDespite so many studies[1,3,4] on this issue, we are still at the stage of hypothesis only. For better understanding, there is need of large prospective study which keeps a record of the timing of cord clamping to accept/ refute the hypothesis an...
We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
Show MoreEven though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of...
We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.
Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]
Reference List
1. McDonald SJ, Middleton P, Dowswell T, Morris PS: Eff...
Show MoreWe read with great interest the article by Van Zanten HA et al., published in this journal and found the results impressive.[1] However, we have certain observations about the conduct of the study
Show MoreEven though the authors state that this report was part of a quality improvement initiative in their NICU, the authors have neither reported the results in the format suitable for a quality improvement study nor have clearly stated the design; at the end of introduction they seem to mention that this was a retrospective data analysis; whereas, in the first line of the methods they state the design as a prospective observational study. Even though the automatic oxygen controller group would not have been affected much by any one of the design, the impact would have been in the manual group, keeping especially the training of the NICU staff in mind. It’s also worth emphasizing here that the authors mention about the local guidelines practiced for manual titration of supplemental oxygen based on the saturations, for the sake of external validity.[2]
Minute wise data points used in this study may have significantly underestimated the hypoxemic episodes and thereby the proportion of times an infant remained in the ‘below target range’ saturations. In a logical sense, manual titration would have happened sooner than expected for a hypoxemic event and hence would not have been captured if more frequent data points are not considered. Using the same technology and a lesser in...
I read with interest your article on spontaneous ping pong parietal fracture in newborns with impressive color images .The word 'fracture' can be quite traumatic to the parents and should avaoided if there is no radiological evidence of break in the cortex 1. It should then just be labelled as depression of skull bone without a fracture rather than labelling as DCF( depressed calvarial fracture) as mentioned in your article .You have also clearly demonstrated in your 3D CT image also that there was no break but only invagination of parietal bone .The management would also not change whether the depression is with or without fracture .
References -
Tayeh,et al.BMJCase Rep2016.doi:1136/bcr-2016-215437
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