I am reassured by Dr Lee et al’s response indicating that the same secondary screeners worked in both hospitals in their study. I am not so convinced that their interpretation of sensitivity is correct but this does not affect their conclusions, as there is no reason to suspect that the secondary screeners acted differently at the two hospitals. With that information I accept that they have indeed prove...
I am reassured by Dr Lee et al’s response indicating that the same secondary screeners worked in both hospitals in their study. I am not so convinced that their interpretation of sensitivity is correct but this does not affect their conclusions, as there is no reason to suspect that the secondary screeners acted differently at the two hospitals. With that information I accept that they have indeed proved their point.
The letter from Dr Mantadakis addresses the important issue of the
absence of randomised studies on the clinical effectiveness of the
interventions used to prevent the possible severe sequelae of fetal
alloimmune thrombocytopenia. Studies in small series are suggestive of
some benificial effect of the current interventions like high dose
intravenous immunoglobulin to the mother or intrauterine transfusion of
HPA compat...
The letter from Dr Mantadakis addresses the important issue of the
absence of randomised studies on the clinical effectiveness of the
interventions used to prevent the possible severe sequelae of fetal
alloimmune thrombocytopenia. Studies in small series are suggestive of
some benificial effect of the current interventions like high dose
intravenous immunoglobulin to the mother or intrauterine transfusion of
HPA compatible platelets. However, many in the field share concerns that
the quality of evidence available to the clinical community is not meeting
the standards required today. We therefore support her call for a multi-
centre study as the only way forward to achieve further improvements in
the management of this severe condition which is effecting 1 in 1000
neonates.
We read the recent article by Embleton et al with interest.[1] We accept their conclusion that foot length is an accurate predictor of
nasotracheal tube length in neonates, and is at least as accurate as the
conventional weight based estimation. We however wish to point out that
palpation of the tip of the endotracheal tube (ETT) in the suprasternal
fossa continues to provide the simplest means to ens...
We read the recent article by Embleton et al with interest.[1] We accept their conclusion that foot length is an accurate predictor of
nasotracheal tube length in neonates, and is at least as accurate as the
conventional weight based estimation. We however wish to point out that
palpation of the tip of the endotracheal tube (ETT) in the suprasternal
fossa continues to provide the simplest means to ensure its correct
placement during emergency tracheal intubation when weighing the neonate
or measuring its foot length may not be practical or appropriate.[2,3] Given
that the “safety zone” for the tracheal tube tip placement in neonates is
only ~2.5 cms, the natural tendency is for the ETT to be located too
distally.[3] The placement of the ETT tip in the suprasternal fossa helps
avoid the consequences of intubation of the right main bronchus. We have
found this method useful in achieving optimal placement of the ETT for
emergency intubation as well as for elective intubation and surfactant
instillation in high-risk neonates (e.g. birth weight £1000 grams, those
with congenital diaphragmatic hernia). We have observed that if the tip of
the tube can not be felt in the suprasternal fossa,it is too far down into
the right main bronchus. If the position of the ETT is confirmed to be in
the airway, withdrawal of the tube by a centimeter achieves its optimal
placement.Confirmation of the suprasternal location of the tip of the ETT
is facilitated by minimal forward and backward gentle movement of the tube
at the nares or the lip depending on the route of intubation.Prospective
assessment of this simple technique is warranted.
PATOLE SK, JOG SM, WHITEHALL JS
References
(1) Embleton ND, Deshpande SA, Scott D, Wright C, Milligan DWA. Foot
length, an accurate predictor of nasotracheal tube length in neonates Arch
Dis Child Fetal Neonatal Ed 2001; 85: F60-F64.
(2) Finer NN. Flexible fiber-optic bronchoscopy. In: Spitzer AR, ed.
Intensive Care of the fetus and neonate. St. Louis: Mosby, 1996: 531-7.
(3) Kuhns LR, Poznaski AK. Endotracheal tube position in the infant. Jr
Pediatr 1971; 78:991-6.
We read with interest the excellent review by Dr Ng on the fetal and neonatal hypothalamic-pituitary-adrenal axis.(1) Although the issue of antenatal administration of steroids is addressed in a separate section of the paper it is practically restricted to their antenatal use for the prevention of respiratory distress syndrome and other complications of prematurity.
We read with interest the excellent review by Dr Ng on the fetal and neonatal hypothalamic-pituitary-adrenal axis.(1) Although the issue of antenatal administration of steroids is addressed in a separate section of the paper it is practically restricted to their antenatal use for the prevention of respiratory distress syndrome and other complications of prematurity.
We would agree that this is the commonest reason for giving steroids antenatally. However albeit rare there are other indications for their administration during pregnancy for purely maternal reasons. An example is the mother who has undergone renal transplantation, where steroids may be given for prolonged periods.
Some 20 years ago we reported 5 babies (2),whose mothers being recipients of of renal transplants had received 10 mg/day of prednisone throughout pregnancy. Umbilical cord plasma cortisol levels ranged from 12.8 microgram/dl to 16.3 microgram/dl. Synachthen test yielded normal adrenal response in all but one where there was no rise of cortisol level at 30 and 60 minutes. This baby received a 10 day ACTH course following which a new Synachthen test yielded a normal resonse. We mention this experience to draw attention to other situations where adminstration of steroids may be rquired during pregnancy. We think that Dr Ng should have addressed these issues too.
References
1. Ng PC. The fetal and neonatal hypothalamic-pituitary-adrenal axis. Arch Dis Child Fetal Neonatal Ed 2000;82:F250-F254
2. Dellagrammaticas HD, Parkin JM. Maternal renal Transplantation-complications in the newborn baby. Paediatriki 1980;43:364-373
Dr HD Dellagrammaticas MD, FRCPCH
Dr Nicoletta Iacovidou MD
NICU, 2nd Department of Paediatrics University of Athens Aglaia Kyriakou Children's Hospital Athens, Greece
Lees et al report that advanced nurse practitioners (ANNPs) are
significantly more effective than trainee paediatricians in detecting
abnormalities on neonatal examination. This is an important finding but
the paper raises some methodological and clinical issues.
The authors report the sensitivity of the examinations. Given the
intrinsic trade off between sensitivity and specificity, it would...
Lees et al report that advanced nurse practitioners (ANNPs) are
significantly more effective than trainee paediatricians in detecting
abnormalities on neonatal examination. This is an important finding but
the paper raises some methodological and clinical issues.
The authors report the sensitivity of the examinations. Given the
intrinsic trade off between sensitivity and specificity, it would be
helpful if both parameters were presented, together with likelihood
ratios. The table gives the likelihood ratios for "positive" and
"negative" screening examinations for each test, based on the assumption
that all children in each hospital were screened. All 95% confidence
intervals for ANNPs and trainee paediatricians overlap.
LR +ve (95% CI)
LR -ve (95% CI)
Hips: Trainee
13.1 (9.5-16.5)
0.28 (0.14-0.47)
ANNP
10.4 (8.5-11.9)
0.04 (0.01-0.21)
Eyes: Trainee
231.0 (60.2-772.0)
0.7 (0.36-0.88)
ANNP
589.5 (224.8-1440.9)
0 (0.0-0.39)
Heart: Trainee
215.0 (75.9-577.7)
0.61 (0.39-0.8)
ANNP
1117.0 (179.9-6736.0)
0.5 (0.24-0.76)
The second issue is that 53/5027(1.05%) are classified as having
abnormal hips, approximately ten times the risk of established dislocation
in an unscreened population. The clinically appropriate definition of
"abnormal hip" used here must include many children whose hips would have
"normalised" without intervention. This may signficantly bias estimates of
test performance.
The consequences associated with both missing true cases and over-
referring normal children need to be traded against one another. Childre
referred have the potential to overload the diagnostic services and may
suffer long term effects from parental anxiety generated. In addition,
over referral from screening examinations may lead to over treatment of
normal children. "Diagnostic" assessments are themselves test that are
seldom 100% specific: the greater the number of children referred for
diagnostic assessment, the greater the number who will be unnecessarliy
treated.
Presentation only of sensitivity leads the authors to suggest that
skill mix at routine neonatal examination is more effective. However,
calculation of specificity and likelihood ratios may lead to a less clear
cut conclusion.
The article by Beardsall et al[1] once again raises awareness of this important and as yet unresolved issue for the UK. We would like to make two related points:
(1) Although the authors have discussed both early and late onset Group B Streptococcus disease, perinatal intervention is effective in
preventing only early onset Group B Streptococcus disease.
The article by Beardsall et al[1] once again raises awareness of this important and as yet unresolved issue for the UK. We would like to make two related points:
(1) Although the authors have discussed both early and late onset Group B Streptococcus disease, perinatal intervention is effective in
preventing only early onset Group B Streptococcus disease.
(2) A common related scenario is of a healthy newborn who is colonised with Group B streptococcus. Management strategies vary from no intervention to antibiotic prophylaxis (intramuscular Benzyl Penicillin
or oral Penicillin V or Amoxycillin) for 7 to 14 days. It would be useful
if the British Paediatric Surveillance Unit could gather data that would lead to evidence based guidelines
for management of these babies.
Reference
1. Beardsall K, Thompson MH, Mulla RJ. Neonatal group B
streptococcal infection in South Bedfordshire, 1993-1998. Arch Dis Child Fetal Neonatal Ed 2000;82:F205-7.
We were surprised at the results of the two studies published in your journal by Baumer[1] and Bersford et al[2]. Our experience with triggered ventilation over 10 years is shown in the table below:
We were surprised at the results of the two studies published in your journal by Baumer[1] and Bersford et al[2]. Our experience with triggered ventilation over 10 years is shown in the table below:
Complications of prematurity 1991-99
1991
1992
1993
1994
1995
1996
1997
1998
1999
<_1500 g="g" td="td"/>
n = 175
n = 190
n = 182
n = 184
n = 218
n = 169
n = 196
n = 203
n = 184
Retinopathy of prematurity Grade 3 or 4 (%)
2.2
5.2
6.5
4.8
5.5
7.1
3.2
Intraventricular haemorrhage Grade 3 or 4 (%)
13.1
2.5
16.4
12.3
12.8
11.8
7.6
9.3
3.2
Pneumothorax (%)
2.2
4.7
3.8
3.8
2.2
7
5
3.4
3.2
<_1250 g="g" td="td"/>
n = 130
n = 136
n = 133
n = 128
n = 162
n = 130
n = 154
n = 163
n = 134
Retinopathy of prematurity Grade 3 or 4 (%)
3
7.3
9
7
6.7
9.2
3.2
0.6
5.2
Intraventricular haemorrhage Grade 3 or 4 (%)
7.6
29.4
21
16.4
14.8
15.3
9.7
11.6
3.7
Pneumothorax (%)
3
4.4
5.2
4.6
3
5.3
3.5
3.6
3.7
In comparison to the outcome figures in the articles, our incidence of complications of pneumothoraces, intraventricular haemorrhage, and retinopathy of prematurity were significantly less.
As explained in our original article[3] and subsequently shown by others, pressure and flow triggered systems perform suboptimally in infants less than 1500 g. While bench testing may suggest an adequate response time, clinical practice indicates that these systems are compromised by the following:
(1) chest wall and lung compliance (2) airway resistance (3) leak around the endotracheal tube (4) endotracheal tube resistance (5) systems compliance.
The trigger delay may be aggravated by each of these factors, especially in the very low birth weight infants.
We believe that the inability of the patient to terminate the insufflation of gases at the onset of exhalation leads to increased intra thoracic pressure and even intra cranial pressure. Thus, if there is trigger delay as postulated above, the ventilator continues to force gases into the infant during the expiratory phase causing active exhalation and with consequent deleterious effects.
The system used in our unit is triggered by modified impedance technology. Peak detectors within the system detect onset of inspiration and exhalation with sensitivity and rapidly. Further, since the sensitivity depends on the rate of change of impedance, it is more sensitive when applied to very low birth weight infants or with increased rate of respiration. This may explain the marked difference in outcome, compared to the pressure triggered system, as shown by the application of the system in 1701 infants weighing less than 1500 g over 10 years. There were 1270 infants in the same group were less than 1250 g. The only problem we have encountered is that of some cardio respiratory monitors are incompatible with the triggering device. The signal processing through the monitors is crucial to the optimal performance of the respiratory analog input signal to the trigger/terminator. Prototypes of the system were used initially but since 1993 commercially available system (Sechrist SAVI) was utilized exclusively.
In large multicenter studies, derivation of consensus and consistent application of a standardized "conventional ventilation" protocol is very difficult. This may skew some of the outcome data. Perhaps the limitations of flow and pressure triggered systems need to be considered prior to abandoning triggered systems in the respiratory support of newborns. Active exhalation predisposes some of these infants to the complications cited. The incidence of ROP in our experience is less than that reported in the literature. Possibly the same mechanism described above also predisposes the infants to ROP.
Given all of the above, further studies and analysis may be prudent. Such studies of patient triggered ventilation should also incorporate the capability of patient terminated ventilation.
References
1. Baumer JH. International randomised controlled trial of patient triggered ventilation in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2000;82:F5-F10.
2. Beresford MW, Shaw NJ, Manning D. Randomised controlled trial of patient triggered and conventional fast rate ventilation in neonatal respiratory distress syndrome. Arch. Dis Child Fetal Neonatal Ed 2000;82:F14-F18.
3. Visveshwara N, Freeman B, Peck M, Caliwag W, Shook S, Rajani K B. Patient-triggered synchronized assisted ventilation of newborns; report of a preliminary study and three years' experience. J Perinatol 1991;XI:347-354.
We thank Dr Gabrielle Laing for her comments regarding our study.[1]
Specificity is indeed valuable, but due to the way we defined our infant
cohorts the denominator (total live births minus those infants with
abnormalities) could only be approximated by using the obstetric data from
each study hospital during the period of the study. The sensitivity and
positive predictive values were presented in...
We thank Dr Gabrielle Laing for her comments regarding our study.[1]
Specificity is indeed valuable, but due to the way we defined our infant
cohorts the denominator (total live births minus those infants with
abnormalities) could only be approximated by using the obstetric data from
each study hospital during the period of the study. The sensitivity and
positive predictive values were presented in our paper as this data was
collected directly. However in view of her comments the calculated
specificities in the cardiac group were 2,760/2,765 (99.82%) for
paediatric trainees, and 2,233/2,234 (99.96%) for advanced neonatal nurse
practitioners (ANNPs)(p<_0.05. in="in" the="the" eye="eye" group="group" paediatric="paediatric" trainees="trainees" displayed="displayed" a="a" calculated="calculated" specificity="specificity" of="of" _2770="_2770" _2774="_2774" _99.86="_99.86" with="with" _2234="_2234" _2238="_2238" _99.82="_99.82" for="for" annps="annps" p="p"/>0.05). In the hip group calculated
specificity was 2,600/2,756 (94.3%) for paediatric trainees and
2,012/2,218 (90.7%) for ANNPs (p<_0.05. thus="thus" it="it" would="would" appear="appear" that="that" annps="annps" are="are" more="more" specific="specific" than="than" paediatric="paediatric" trainees="trainees" when="when" detecting="detecting" cardiac="cardiac" abnormalities="abnormalities" similar="similar" eye="eye" and="and" less="less" for="for" hip="hip" abnormalities.="abnormalities." this="this" latter="latter" result="result" was="was" mainly="mainly" to="to" be="be" accounted="accounted" by="by" the="the" referring="referring" _70="_70" clicky="clicky" hips="hips" compared="compared" _40="_40" referred="referred" _-="_-" is="is" difficult="difficult" know="know" whether="whether" due="due" over-referral="over-referral" or="or" under-referral="under-referral" of="of" a="a" high-risk="high-risk" group="group" trainees.="trainees." p="p"/> We agree with Dr Laing that likelihood ratios are helpful and thank
her for the table. In view of the fact that a high likelihood ratio for a
positive test and a low value for a negative test indicates a more
effective screening test,[2] her table demonstrates a clear trend that ANNP
screening appears more effective than that performed by paediatric
trainees in five out of six likelihood ratios.
We disagree that a rate of 1.05% for hip abnormalities is ten-times
the rate seen previously. Using similar criteria other groups have quoted
rates of 1.1%[3] and 1.2%[4].
We endorse Dr Laing's statement that both over-referral and under-
referral have consequences. In this regard, our data suggests that ANNPs
are as effective as trainee paediatricians at detecting hip, eye, and
cardiac abnormalities during the neonatal examination, and may in fact be
more effective.
Tim Lee
St James's University Hospital
Ruth Skelton
The General Infirmary at Leeds
Caryl Skene
Hull and East Yorkshire Hospitals NHS Trust
References
(1) Lee TWR, Skelton RE, Skene C. Routine neonatal examination -
Effectiveness of trainee paediatrician compared to advanced neonatal nurse
practitioner. Arch Dis Child Fetal Neonatal Ed 2001; 85: F100-F104.
(2) Gilbert R, Logan S. Assessing diagnostic and screening tests. In:
Evidenced based paediatrics and child health, edited by Moyer VA, Elliot
EJ, Davis RL et al. BMJ Books 2000; P24-36.
(3) Falliner A. Hahne HJ. Hassenpflug J. Sonographic early hip screening and
early management of developmental dysplasia of the hip. Journal of
Paediatric Orthopaedics 1999. Part B. 8(2): 112-7.
(4) Committee on Quality Improvement, American Academy of Pediatrics -
Clinical Practice Guidelines: Early detection of developmental dysplasia
of the hip. Pediatrics 2000; 105: 896-905.
With great interest we read the paper by Whyte et al regarding the
practice of premedication before intubation in UK neonatal units.[1]
Their finding that only 37% of the units gave any sedation before
intubation is worrysome in view of the known physiologic responses to
awake intubation.[2-4] However, one potential bias in their study design
was not discussed.
With great interest we read the paper by Whyte et al regarding the
practice of premedication before intubation in UK neonatal units.[1]
Their finding that only 37% of the units gave any sedation before
intubation is worrysome in view of the known physiologic responses to
awake intubation.[2-4] However, one potential bias in their study design
was not discussed.
Since the information regarding this subject was
derived from telephonic interviews with the sister in charge of the unit
the results might merely reflect the policy of the unit as perceived by
this person and not the practice of the individual neonatologist
performing or supervising the intubation. Whether this would result in
underscoring or overscoring on the subject remains to be answered.
In our
experience sustantial interindividual variation exists among
neonatologists in the use of premedication before intubation of neonates.
In March of 1999 we performed a written survey among all neonatologists
and fellows working on each of the 10 neonatal intensive care units
(NICUs) in The Netherlands. The response rate was 77/87 (89%). Of the
respondents, 58 (76%) always gave some form of analgesia or sedation prior
to intubation, 13 (16%) only sometimes gave premedication, whereas 6 (8%)
never gave premedication. Of those who always gave premedication 33 (57%)
always combined the use of sedation with a muscle relaxant. Only 15 (17%)
used a written protocol for premedication.
Similar to Whyte’s results
great variation existed with regard to the choice and dose regimen of the
premedication. Morphine was the most widely used opioid, followed by
fentanyl and pethidine. Midazolam was the most popular sedative. On a few
occasions, ethomidate was mentioned as anaesthetic drug. Atropine was
sometimes used in patients with proven rapid onset of reflex bradycardia.
From these results it appears that premedication before intubation of
neonates is the rule rather than the exception in the NICU environment in
The Netherlands, although overscoring cannot be ruled out. When analysed
on a per NICU basis it was obvious that a great intra-NICU variation in
the practice of premedication exists.
Our results closely resemble those
of a recent survey among Canadian neonatologists which showed that in
approximately 75% of cases some premedication before intubation is used in
Canadian NICUs.[5] It would be interesting to see the results of a
survey among neonatologists in the UK.
The known physiological responses
to awake intubation include bradycardia, hypertension, hypoxemia,
laryngospasm and increased intracranial pressure (2-4). Moreover, awake
intubation requires more attempts, is more time-consuming and is
accompanied with more mucosal damage than premedicated intubation.[6]
Optimal prevention of these adverse effects probably requires the
combination of a vagolytic, an opioid and a muscle relaxant.[7]
Therefore, in our institution the combination of atropine (0.1 mg),
morphine (0.05-0.1 mg/kg) and vecuroniumbromide (0.05-0.1 mg/kg) is
routinely applied with great satisfaction. We fully agree with Whyte et al[1] that there is now sufficient evidence to support the routine practice
of premedication for elective intubation of neonates. Indeed, more
research is needed to investigate the optimal drug and dose regimen.
REFERENCES
1. Whyte S, Birrell G, Wyllie J: Premedication before intubation in
UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41.
2. Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL: Physiologic
changes associated with endotracheal intubation in preterm infants. Crit
Care Med 1984; 12(6):501-3.
3. Kelly MA, Finer NN: Nasotracheal intubation in the neonate: Physiologic
responses and effects of atropine and pancuronium. J of Pediatrics
1984;105:303-9.
4. Friesen RH, Honda AT, Thieme RE: Changes in anterior fontanel pressure
in preterm neonates during tracheal intubation. Anesth Analg 1987;66:874-
8.
5. Vogel S, Gibbins S, Simmons B, Shah V: Premedication for endotracheal
intubation (EI) in neonates: A Canadian Perspective. Pediatric Research
2000;47(4):438A.
6. Oei J, Hari R, Lui K: Suxamethonium, atropine and morphine as induction
for neonatal nasotracheal intubation: A randomised controlled trial.
Pediatric Research 2000;47(4):421A.
7. Barrington KJ, Byrne PJ: Premedication for neonatal intubation. Am J of
Perinatol 1998;15(4):213-6.
Harry Molendijk, MD,
Neonatologist
Anneke Jaarsma, MD,
Neonatologist
Beatrix Children’s Hospital
Department of Pediatrics, Subdivision of Neonatology
University Hospital Groningen, P.O. Box 30001
9700 RB Groningen, The Netherlands
The paper by Aubrey and Yoxall[1] concludes that Advanced Neonatal
Nurse Practitioners (ANNPs) are effective in the resuscitation of preterm
babies at birth. In the same edition, Lee et al.[2] show that ANNPs in
East Yorkshire are significantly more effective in detecting abnormalities
during the neonatal check.
Neither of these results surprise me. ANNPs are intelligent,
motivated and mos...
The paper by Aubrey and Yoxall[1] concludes that Advanced Neonatal
Nurse Practitioners (ANNPs) are effective in the resuscitation of preterm
babies at birth. In the same edition, Lee et al.[2] show that ANNPs in
East Yorkshire are significantly more effective in detecting abnormalities
during the neonatal check.
Neither of these results surprise me. ANNPs are intelligent,
motivated and most importantly, trained for these relatively self
contained tasks. Quite rightly, they can expect a structured training
programme and will have to show competence in these tasks before being
allowed to operate independently of direct supervision.
Paediatric SHOs on the other hand receive an 'ad hoc' training with
no demonstration of competence. In my experience, preparation for the
neonatal examination usually involves a half-hour lecture and a brief
demonstration by the registrar before being pointed in the direction of
the postnatal ward.
Neonatal resuscitation receives slightly more weight. Junior
paediatricians are usually accompanied to deliveries 'until they can
intubate'. They learn by a supervised apprenticeship. There is usually
middle grade cover to ensure safety, but in no way is this comparable to
the way ANNPs or anaesthetists are trained.
Changes in staffing and service delivery will undoubtedly occur as
Trusts are forced to make posts compliant with both the New Deal[3] and
the European Working Time Directive[4]. This will make it both attractive
and necessary to employ ANNPs to carry out these tasks in place of
doctors.
The implications are rather worrying. Are paediatricians to lose
their technical resuscitation skills? Similarly, are SHOs to be denied the
necessary (if at times slightly tedious) experience of the new born
examination?
These studies demonstrate that junior paediatricians suffer as a
result of their traditional 'service based training'. They need a proper,
structured education with an assessment of competence before complementing
the work of the ANNPs on both the labour and postnatal wards.
Dr Ieuan Davies
SpR Paediatrics
University Hospital of Wales
References
(1) Aubrey WR, Yoxall CW. Evaluation of the role of the neonatal nurse
practitioner in resuscitation of preterm infants at birth. Arch Dis Child
Fetal Neonat Ed 2001;85:F96-F99.
(2) Lee TWR, Skelton RE, Skene C. Routine neonatal examination:
effectiveness of trainee paediatrician compared with advanced neonatal
nurse practitioner. Arch Dis Child Fetal Ed 2001;85:F100-F104.
(3) NHS Management Executive. Junior Doctors-The New Deal. London:
Department of Health;1991.
(4) European Working Time Directive. 93/104/EEC.
Dear Editor
I am reassured by Dr Lee et al’s response indicating that the same secondary screeners worked in both hospitals in their study. I am not so convinced that their interpretation of sensitivity is correct but this does not affect their conclusions, as there is no reason to suspect that the secondary screeners acted differently at the two hospitals. With that information I accept that they have indeed prove...
The letter from Dr Mantadakis addresses the important issue of the absence of randomised studies on the clinical effectiveness of the interventions used to prevent the possible severe sequelae of fetal alloimmune thrombocytopenia. Studies in small series are suggestive of some benificial effect of the current interventions like high dose intravenous immunoglobulin to the mother or intrauterine transfusion of HPA compat...
Dear Editor,
We read the recent article by Embleton et al with interest.[1] We accept their conclusion that foot length is an accurate predictor of nasotracheal tube length in neonates, and is at least as accurate as the conventional weight based estimation. We however wish to point out that palpation of the tip of the endotracheal tube (ETT) in the suprasternal fossa continues to provide the simplest means to ens...
We read with interest the excellent review by Dr Ng on the fetal and neonatal hypothalamic-pituitary-adrenal axis.(1) Although the issue of antenatal administration of steroids is addressed in a separate section of the paper it is practically restricted to their antenatal use for the prevention of respiratory distress syndrome and other complications of prematurity.
We would agree that this is the commonest...
Dear Editor
Lees et al report that advanced nurse practitioners (ANNPs) are significantly more effective than trainee paediatricians in detecting abnormalities on neonatal examination. This is an important finding but the paper raises some methodological and clinical issues.
The authors report the sensitivity of the examinations. Given the intrinsic trade off between sensitivity and specificity, it would...
The article by Beardsall et al[1] once again raises awareness of this important and as yet unresolved issue for the UK. We would like to make two related points:
(1) Although the authors have discussed both early and late onset Group B Streptococcus disease, perinatal intervention is effective in preventing only early onset Group B Streptococcus disease.
(2) A common related scenario...
We were surprised at the results of the two studies published in your journal by Baumer[1] and Bersford et al[2]. Our experience with triggered ventilation over 10 years is shown in the table below:
Complications of prematurity 1991-99
Dear Editor,
We thank Dr Gabrielle Laing for her comments regarding our study.[1] Specificity is indeed valuable, but due to the way we defined our infant cohorts the denominator (total live births minus those infants with abnormalities) could only be approximated by using the obstetric data from each study hospital during the period of the study. The sensitivity and positive predictive values were presented in...
Dear Editor
With great interest we read the paper by Whyte et al regarding the practice of premedication before intubation in UK neonatal units.[1] Their finding that only 37% of the units gave any sedation before intubation is worrysome in view of the known physiologic responses to awake intubation.[2-4] However, one potential bias in their study design was not discussed.
Since the information regarding...
Dear Editor,
The paper by Aubrey and Yoxall[1] concludes that Advanced Neonatal Nurse Practitioners (ANNPs) are effective in the resuscitation of preterm babies at birth. In the same edition, Lee et al.[2] show that ANNPs in East Yorkshire are significantly more effective in detecting abnormalities during the neonatal check.
Neither of these results surprise me. ANNPs are intelligent, motivated and mos...
Pages