This symposium on CLD by Kotecha et al.[1] covered important aspects and
controversies in the management of CLD. We accept the authors' inability
to cover all aspects of management.
We feel that some space could have been devoted to diuretics in management
of CLD. Nearly all patients with CLD of some stage of their disease
will recieve diuretics and most of them will be on them for a long time. We...
This symposium on CLD by Kotecha et al.[1] covered important aspects and
controversies in the management of CLD. We accept the authors' inability
to cover all aspects of management.
We feel that some space could have been devoted to diuretics in management
of CLD. Nearly all patients with CLD of some stage of their disease
will recieve diuretics and most of them will be on them for a long time. We came across only one systemic review by Brion et al.[2]
in the Cochrane database. Conclusion of the authors was that there was no
beneficial effect of using distal tubular diuretics for more than 4 weeks
after initial stage. There was also no benefit in adding potassium sparing
diuretics or newer diuretics like metalozone.
Inspite of very little evidence base for diuretics in CLD, one finds
nearly all CLD patients on a diuretic cocktail. In addition to their effect
on electrolytes, they affect Ca/PO4 metabolism. This may
exacrebate osteopenia of prematurity and may have adverse effect on lung
compliance.
There is a need for more discussion or clear guidelines on this issue.
References
(1) Management issues in CLD of prematurity. S Kotecha
Arch Dis Child Fetal Neonatal Ed 2002;87:F2.
(2) Cochrane Database Systemic Review. LP Brion, RA Primhak 2002:(1):CD001453.
Professor Dunn quotes Downman's approval of Lady Mary Montagu in his
fascinating account of the Exeter physician. Her contemporaries, however,
were often less generous. This beautiful and literary lady contracted
smallpox in 1715 and probably knew of the Turkish practice of 'engrafting'
or 'variolation' against the disease from her own doctors. As Fellows of
the Royal Society they may well have heard an a...
Professor Dunn quotes Downman's approval of Lady Mary Montagu in his
fascinating account of the Exeter physician. Her contemporaries, however,
were often less generous. This beautiful and literary lady contracted
smallpox in 1715 and probably knew of the Turkish practice of 'engrafting'
or 'variolation' against the disease from her own doctors. As Fellows of
the Royal Society they may well have heard an account of it passed on from
Timonius of Constantinople.[1]
The following year she had the opportunity of travelling to Turkey with her
husband who had been appointed ambassador to the Ottoman Empire. Receptive
towards Islamic culture she was struck by the relative absence of smallpox
and learned that this was attributable to the deliberate infecting of
subjects with material from smallpox victims.
In March 1718 she summoned the nurse who was Constantinople's
'general surgeon' for inoculation. The nurse pricked the wrist of Lady
Mary's young son with a needle, laid a tiny droplet of smallpox matter on
the skin and mixed it with a drop of blood from the puncture. Some eight
days later he became febrile and developed about 100 spots on his body.
These quickly resolved without leaving scars.
Subsequently, the chequered success of variolation in the hands of
English physicians, careless of the finer details of Turkish practice
emphasised by Lady Mary, contributed to lifelong controversy. Most
cruelly, her former friend Alexander Pope implied in one of his satires
that she left people 'pox'd by her love',[2] quite deliberately a
defamatory double entendre as well as an attack on the safety of
variolation.
References
(1) Grundy I. Lady Mary Wortley Montagu. Oxford: Oxford University Press, 1999; p102.
(2) Grundy I. Lady Mary Wortley Montagu. Oxford: Oxford University Press, 1999; p334.
We wish to raise a few concerns regarding the study reported by S
Rahman and colleagues.[1]
We found it surprising that only five species of micro-organisms were
isolated in this series of over a 1000 blood cultures obtained from
neonates with sepsis. Similar studies done in other major cities of
Pakistan, with much smaller sample sizes have shown a wider spectrum of
pathogens . Anwer SK (2000)[2...
We wish to raise a few concerns regarding the study reported by S
Rahman and colleagues.[1]
We found it surprising that only five species of micro-organisms were
isolated in this series of over a 1000 blood cultures obtained from
neonates with sepsis. Similar studies done in other major cities of
Pakistan, with much smaller sample sizes have shown a wider spectrum of
pathogens . Anwer SK (2000)[2] showed 11 species types in 109 blood
cultures, Bhutta ZA (1997)[3] showed 13 species types in 38 cultures, and 11
species types in a series of 276 positive blood cultures (2001)[5]. Khan IA
(1987)[4] showed more than 8 different species types from 89 cultures. In
addition to the 5 species causing neonatal sepsis reported by Rahman et al
(Esherichia coli 36.6 %, Staphylococcus aureus 29.5 %, Pseudomonas 22.4 %,
Klebsiella 7.6 % and Proteus 3.8 %), all the other investigators have also
reported Serratia spp and Enterococcus, and most reported Streptococcus
pneumoniae, Salmonella spp and group B Streptococcus. Although the authors
do not clearly state whether they excluded hospital-acquired infections in
their series, the studies reported by Bhutta ZA5 did exclude nosocomial
infections.
The antimicrobial susceptibility data reported by Rahman et al. are
not interpretable as the number of micro-organisms on which antimicrobial
susceptibility testing was performed is not presented. In addition, the
susceptibility results are not internally consistent; 60 % of the
Staphylococcus aureus tested are reported to be ampicillin-sensitive but
only 27 % were Amoxicillin + Clavulanate (Augmentin) sensitive. This
represents a highly unusual susceptibility result with a high percentage
of S. aureus not producing beta-lactamase enzymes to inactivate penicillin
(ampicillin), but still showing resistance to a penicillin-beta-lactamase
combination such as Augmentin. We wonder if the 60 % reported sensitivity
of S. aureus to ampicillin is erroneous since the vast majority of
S.aureus even in developing countries, are now penicillin (ampicillin)-
resistant [5,6,7,8]. We also find the 73 % resistance rate of S. aureus to
amoxicillin-clavulanate (which is equivalent to methicillin-resistance for
S. aureus) surprisingly high, and question if this indicates the presence
of hospital-acquired infections in this series.
Syed A Ali Tauseef A Khan Anita KM Zaidi
Department of Paediatrics
The Aga Khan University
Karachi, Pakistansyed.ali@aku.edu
References
(1) S Rahman, A Hameed, M T Roghani, Z Ullah. Multidrug resistant
neonatal sepsis in Peshawar, Pakistan. Arch Dis Child Fetal Neonatal Ed
2002;87:F52-F54.
(2) Anwer SK, Mustafa S, Pariyani S, Ashraf S, Taufiq KM. Neonatal sepsis:
An etiological study. J Pak Med Assoc 2000; 50(3): 91-93.
(3) Bhutta ZA, Yusuf K. Early onset neonatal sepsis in Pakistan: A case
control study of risk factors in a birth cohort. Am J Perinatol 1997;
14(9): 577-581.
(4) Khan IA, Akram DS. Neonatal sepsis – Etiological study. J Pak Med Assoc
1987;37: 327-30.
(5) Bhutta ZA. Spectrum of nonnosocomial neonatal sepsis. State of the
World's newborns: Pakistan. Saving Newborn LivesOct 2001.
(6) Kuruvilla KA, Pillai S, Jesudason M, Jana AK. Bacterial profile of sepsis in a neonatal unit in South India. Indian Pediatr 1998;35: 851-8.
(7) Tallur SS, Kasturi AV, Nadgir SD, Krishna BVS. Clinico-bacteriological
study of neonatal septicemia in Hubli. Indian J Pediatr 2000;67(3):169-74.
(8) Ako-Nai AK, Adejuyigbe EA, Ajayi FM, Onipede AO. The Bacteriology of
Neonatal Septicemia in Ile-Ife, Nigeria. J Trop Pediatr 1999;45:146-51.
Shinwell et al.[1] have addressed the important issue of outcome of very
low birthweight (VLBW) triplets compared to twins and singletons.
When
counselling mothers of triplet pregnancies clinicians should be careful in
extrapolating the data from this very specific cohort to all triplet
pregnancies. Their patient population is not representative of most
triplet pregnancies, as they include on...
Shinwell et al.[1] have addressed the important issue of outcome of very
low birthweight (VLBW) triplets compared to twins and singletons.
When
counselling mothers of triplet pregnancies clinicians should be careful in
extrapolating the data from this very specific cohort to all triplet
pregnancies. Their patient population is not representative of most
triplet pregnancies, as they include only VLBW infants with a mean
gestational age at delivery of 28.5 weeks. There are few studies looking
at the outcome of all triplet pregnancies. Pons et al.[2] report a mean birth
weight of 1715.9g ( +- 465g) and a mean gestational age of delivery of
33.4 weeks.
We conducted a study[3] reviewing the outcome of 60 triplet pregnancies
to a single tertiary neonatal unit over 14 years from 1986 to 2002 In
our series there were only 14 sets (23%) where all infants were VLBW. The
mean gestational age of delivery was 31.5 weeks (range
24-36 weeks), mean birthweight was 1597g (range 562-2532g). 173 (96.6%) of
triplet fetuses were delivered alive. Intraventricular haemorrhage
occurred in 11(7%) infants. There were 17post natal deaths, including 2
infants who were not VLBW. Overall cohort survival was 90%
and reached 98.9% at 28 weeks gestation. The perinatal mortality rate was
92/1000. Of the initial 60 pregnancies 3(5%) had no survivors, 4(6.6%) had
1 survivor, 7(11%) had 2
survivors and all infants survived in 46 pregnancies (76%). Information
was available on the neurodevelopmental outcome at 12 months of age for
143 survivors, 138 infants were
reported as normal. Logistic regression showed that only gestation had a
significant effect on survival. Steroid use, birthweight, administration
of surfactant or time period of birth did not significantly affect
survival. Shiwell also comments on the possibility of diminished efficacy
of antenatal steroid treatment in multiple pregnancy. We noted no adverse
effects of multiple
doses of antenatal steroid exposure on weight or head circumference at
birth and developmental outcome at one year of age.
Care should be taken that Shinwell’s study results are not
extrapolated to triplet pregnancies as a whole as not all triplets are
VLBW. In mature triplet pregnancies with modern obstetric and neonatal
intensive care the outcome is good.
References
(1) Shinwell ES, Blickstein I, Lusky A, Reichman B in collaboration
with the Israel Neonatal Network. Excess risk of mortality in very low
birthweight triplets. Arch Dis Child Fetal Neonatal Ed 2003;88:36-41.
(2) Pons J, Charlemaine C, Dubreuil E, Papiernik E, Frydman R. Management
and outcome of triplet pregnancy. European Journal of Obstetrics and
Gynaecology and Reproductive Biology 1998;76:131-139.
(3) D’Amore A, Ahulwalia J, Kaptoge S, Prentice A, Cheema I, Kelsall W.
The effect of antenatal corticosteroids on fetal growth, survival and
neurodevelopmental outcome in triplet pregnancies. American Journal of
Perinatology (in press)
This is in response to the letter from SA Ali et al.[1]
1. The total number (1598)and the culture positive babies (1003)in
our article [1] represent cases after the patients meeting the exclusion
criteria were taken out. We did grow isolated cases of Strp sp. Salmonella
and Enterococci which happened to fall in the excluded group. In the
spectrum as a whole, these oganisms accounted for...
This is in response to the letter from SA Ali et al.[1]
1. The total number (1598)and the culture positive babies (1003)in
our article [1] represent cases after the patients meeting the exclusion
criteria were taken out. We did grow isolated cases of Strp sp. Salmonella
and Enterococci which happened to fall in the excluded group. In the
spectrum as a whole, these oganisms accounted for <_0.5 _="_" of="of" the="the" organisms.="organisms." this="this" is="is" similar="similar" to="to" study="study" done="done" by="by" maryam="maryam" w="w" i="i"/>et al[2]in a
public sector institution with population of exactly similar
socioeconomic, cultural, religious and climatic background as ours. Their
study was done in the same time period as ours but completely independent
and blinded from ours. In their series of 284 cases, they grew E. Coli 130
cases (45.77 %), Klebsiella 49 cases (17.25 %), Pseudomonas 46 cases (16.2 %),
Staph A 39 cases (13.73 %), Staph Epi 18 cases (6.34 %), Strep sp 1 case
(0.35 %) and Salmonella 1 case (0.35 %). The numbers are slightly different
among the studies from south of Pakistan. This is not surprising because
neonatal sepsis is known for the temporal and regional variation of the
spectrum of its organisms even in different hospitals within the same
city.
2. The basic message from the majority of studies from Pakistan is
the same "Gram Negative organisms are the main caues of neonatal sepsis in
Pakistan followed by Staph A". This group of organisms is responsible for
>99 % of the spectrum and unfortunately the grave situation of multidrug
resistance is emerging among these organisms. That is where one needs to
concentrate instead of the organisms responsible for <_0.5 _="_" of="of" the="the" spectrum="spectrum" i="i"/>Salmonella, Strep sp etc) which do not carry any significane for
overall neonatal mortality and morbidity.
3. Out of 296 cases of Staph A in our series, Ampicillin was tested
on 285 cases with 171 (60 %)sensitive to it while 279 were tested for
Augmentin with 75(26.88 %) sensitive to it. I agree with S Ali et al. that
this pattern of sensitivity looks unusual as for as Staph A is concerned
though this phenomenon is known to occurr with Beta lactamase producing E.
Coli. It may be due to the varying strengths of Augmentin discs available
or known biochemical instability of Clavulonic acid or difficulty of
interpretation when a combination of two antibiotics is used in one disc
using disc diffusion technique. However, I would love to listen some more
expert opinion about this. Our series did not exclude hospital acquired
infections.
4. The longitudinal analysis of our data shows an increasing
sensitivity to Penicillin and decreasing sensitivity to Cephalosporins,
particularly Cefotaxime, over the last half decade. This is consistent
with the change in antibiotic use in Pakistan since early 1990s when
Penicillin/Gentamicin was switched over to Cephalosporins/ Amikacin as the
first line antibiotic regime. Most of the Gram negative organisms in
Pakistan still maintain a very high degree of sensitivity to Amikacin
[2,3]but not to Gentamicin. I feel Penicillin/Amikacin may be a very good
choice as the first line antibiotic in the neonatal units in Pakistan.
This is a high time to review our antibiotic policies and at the same time
approach the government to rationalise the antibiotic marketing in the
country.
References
(1) Rahman S, Hameed A, RoghaniM T , and Ullah Z. Multidrug resistant neonatal sepsis in Peshawar
Pakistan. Arch Dis Child Fet Neo Ed 2002;87:F52-4
(2) Maryam W et al. Neonatal sepsis spectrum of antibiotic resistance.
Proceedings of 10th Annual National Pediatric Conference PPA. 2001; 57.
(3) Anwar SK et al. Neonatal Sepsis: an etiological study. JPMA. 2000
Mar; 50(3)91-4.
In my experience the best treatment for umbilical granulomas is the
application of non-iodized common salt. It is helpful also in most cases
of umbilical discharges, and even persistent bloody discharge from the
umbilicus after the cord has fallen off. No cultures or antibiotic therapy
for discharges is required. The method of applicatio is simple. The
umbilicus is cleaned with alcohol or any other...
In my experience the best treatment for umbilical granulomas is the
application of non-iodized common salt. It is helpful also in most cases
of umbilical discharges, and even persistent bloody discharge from the
umbilicus after the cord has fallen off. No cultures or antibiotic therapy
for discharges is required. The method of applicatio is simple. The
umbilicus is cleaned with alcohol or any other antiseptic. Stretch the
umbilicus and drop common salt on it as much as the umbilicus can hold.
In most of the cases one application is enough. Uncommonly a second or
third application may be required. Common salt application causes no
burns, is inexpensive, no special methodology is required,and anybody can
do it. Up to today I have used it in 103 infants aged two to six weeks
attending my well baby clinic over a period of seven years. 79 infants had
a granuloma, 18 had persistent bloody discharge and 6 had mild purulent
discharge. None of the infants with granulomas required silver nitrate
cauterization. 57/79 with granulomas healed with one application; 16
needed two applications and the rest needed three applications. The
decision to the number of applications was left to the mother. All the
infants with bloody discharge and purulent discharge were permitted only
one application. The bloody discharge stopped in all the eighteen. 2/4
infants with purulent discharge needed antibiotic therapy. Cultures should
a growth of S. aureus.
We read this article with interest, and it prompted us to review
our own experience with progressive ventricular dilatation (PVD)
over the past 22 years at the Maine Medical Center (MMC) in
Portland, Maine.
Since 1980, we have used a single approach to
management of PVD. As noted in previous publications, we
have considered the need for intervention to be rapid head growth
defined as an increase in OFC...
We read this article with interest, and it prompted us to review
our own experience with progressive ventricular dilatation (PVD)
over the past 22 years at the Maine Medical Center (MMC) in
Portland, Maine.
Since 1980, we have used a single approach to
management of PVD. As noted in previous publications, we
have considered the need for intervention to be rapid head growth
defined as an increase in OFC of 2 cm per week or more rather
than relying on imaging.[1,2] As this degree of head growth
suggests increased intracranial pressure,[3] we have intervened
by directly draining ventricular fluid via a 21 gauge angiocath
placed through the right coronal suture into the right lateral
ventricle. This catheter is connected to a ventriculostomy
drainage system and drainage is continued for 7 days if possible.
The catheter is then removed and the drop in head circumference
and ventricular size recorded. The infant is watched for return
of rapid head growth and an angiocath is reinserted as needed.
This procedure is repeated until the infant reaches approximately
2 kg, and if rapid head growth continues, a permanent VP shunt is
placed.[2] We do not use pharmacological treatment or repeat LP
to treat PVD.
As pointed out by the authors, PVD sufficient to
require intervention occurs almost exclusively in infants with
grade 3 or 4 IVH. As expected, the VLBW infants with high grade
IVH have a high mortality. The table below shows a comparison
between the outcomes for grade 3-4 IVH at MMC during the 1980s
and over the past 5 years (1997-2001 inclusive), and the authors'
data grouped in the same way. As noted, there is little
difference over time or between studies. Overall mortality for
grade 3-4 IVH was 33 % (26/79) for Murphy et al, 33 % (31/94) for
MMC 1980s and 31 % (9/29) for MMC 1997-2001. Until grade 3-4 IVH
can be eliminated, post-haemorraghic hydrocephalus will continue
to occur with high morbidity and mortality.
Murphy, et al [4]
MMC 1980s [2]
MMC 1997-2001
Grade 3-4 IVH
(% of all <1500g)
79 (7%)
94 (6%)
29 (6%)
Death <14 days
18/79 (23%)
29/94 (30%)**
8/29 (28%)**
PVD req.ing Rx
34/61 (56%)
24/65 (37%)
11/21 (52%)
VP shunt/late death
(% of PVD Rx)
18/8
(26/34 = 76%)
12/3
(15/24 = 63%)
6/1
(7/11 = 63%)
* Rate for all infants <_35 weeksbr="weeksbr"/>
** Rate for all deaths <_30 days="days" _="_" font="font"/>
References
(1) Allan WC, Holt PJ, Sawyer LR, et al. Ventricular
dilation after neonatal periventricular-intraventricular
hemorrhage. Natural history and therapeutic implications. American
Journal of Diseases in Children 1982;136:589-93.
(2) Marro PJ, Dransfield DA, Mott SH, et al.
Posthemorrhagic hydrocephalus: Use of an intravenous-type
catheter for cerebrospinal fluid drainage. American Journal
of Diseases in Children 1991;145:1141-6.
(3) Hill A, Volpe JJ. Normal pressure hydrocephalus in the newborn
Pediatrics 1981;68:623-9.
(4) Murphy BP, Inder TE, Rooks V, et al. Posthaemorrhagic
ventricular dilatation in the premature infant: natural history
and predictors of outcome. Arch Dis Child Fetal Neonatal Ed
2002;87:F37-F41
The Seldinger technique [1] of inserting a percutaneous central
venous catheter (PCVC) had been published 10 years ago.[2]
We have recently published a novel, simple and quick technique, “The
Townsville method,” which allows a PCVC to be inserted easily without the
need for a butterfly needle or guide wire in any baby who has an
indwelling peripheral intravenous cannula [3]: A 24-gauge c...
The Seldinger technique [1] of inserting a percutaneous central
venous catheter (PCVC) had been published 10 years ago.[2]
We have recently published a novel, simple and quick technique, “The
Townsville method,” which allows a PCVC to be inserted easily without the
need for a butterfly needle or guide wire in any baby who has an
indwelling peripheral intravenous cannula [3]: A 24-gauge cannula (BD
Insyte, Becton Dickson, Utah) is inserted into the largest vein available.
The stylet is removed and the hub of the cannula is cut off with sterile
scissors. Care must be taken not to dislodge the cannula from the skin,
or to let it slide too far into the vein. The 27-gauge silicone catheter
(Premicath, Vygon, Germany) is introduced into the cannula and inserted to
the required length. The 24-gauge cannula sleeve is then removed from the
vein and skin, and pulled back as far as possible on the silicone
catheter. The catheter and cut-off cannula are then fixed in place and
chest Xray obtained to confirm position of the tip of the central line
near the heart. The procedure is carried out using aseptic precautions
with the operator masked and gowned. (Photos of the procedure are
available).
Using our method anyone who can site a 24-gauge cannula in a baby
will be able to insert a PCVC. Use of this technique has resulted in
reduced blood loss in the babies. In comparison to previous techniques
reported in the literature [1,2] we believe that the "Townsville method" is
the simplest method of inserting a percutaneous central venous catheter in
a sick newborn baby
Yours sincerely,
Koh THHG FRCPCH Neonatologist
Aung S Registrar
Regional Neonatal Intensive Care Unit
The Townsville Hospital / James Cook University
Queensland
AUSTRALIA 4814
Acknowledgement: Method conceived whilst working with Dr Jonathan
Shaw (who described the original method of siting neonatal PCVC) in
University Colleg Hospital in 1984.
References
(1) Bayley G. Technique for insertion of percutaneous central venous
catheters in the newborn period. Archives of Disease in Childhood Fetal
and Neonatal Edition 2003;88:F256.
(2) Stephenson T, Khan J. A new technique for placement of central
venous catheters in small infants. J Parenter Enteral Nutr 1993;17(5):479-80.
(3) Gandini D, Koh TH.A novel, simple way to insert percutaneous
central venous catheters in newborn babies. J Perinatol 2003; 23(2):162-3.
I read with interest the article on Neonatal Shaken Baby
Syndrome.[1] While a fascinating account
of the sequence of events in this saga it is factually
incorrect in several respects.
As the perinatal pathologist involved in the Birmingham
series I raised the possibility that the brain damage was
due to the effects of physiotherapy prior to the publication
of our report. My co-authors felt tha...
I read with interest the article on Neonatal Shaken Baby
Syndrome.[1] While a fascinating account
of the sequence of events in this saga it is factually
incorrect in several respects.
As the perinatal pathologist involved in the Birmingham
series I raised the possibility that the brain damage was
due to the effects of physiotherapy prior to the publication
of our report. My co-authors felt that the suggestion was
too speculative to be included. It is however of note that
the physiotherapy regime was changed at this time as a
precaution and as I remember I encountered only one further
case until my retirement in 2000. At the time I presented
the pathological data at several scientific meetings both in
the UK and abroad suggesting physiotherapy was relevant and
also discovered that the method used in Birmingham appeared
to be unique in allowing free movement of the babies head
during treatment of the chest.
Some years later I received a telephone call from Dr David
Becroft the perinatal pathologist concerned with the New
Zealand cases which pathologically appeared very similar to
our own. They had no explanation for their cases at this
time and I indicated that I had always been of the opinion
that physiotherapy was responsible. As I understand it this
resulted in changes in the physiotherapy regime in New
Zealand and the disappearance of the lesion.
In retrospect I should have insisted that my hypothesis
however speculative was included in our original paper or
expressed the view in the correspondence columns at the time
since it might have prevented or at least reduced the number
of affected cases in New Zealand. Certainly today I would
not have been so reticent. In the event it is gratifying
that detailed clinical analysis of the cases confirmed my
original opinion.
As to the pathology of the condition detailed unpublished
studies of the affected brains in our series suggest the
lesion is more akin to that of hydranencephaly than
infantile shaken baby syndrome and leads me to raise the
possibility that hydranencephaly may be the result of
intra-uterine brain trauma.
D Ian Rushton MB ChB FRCPCH FRCP
Reference
(1) Williams AN, Sunderland R, Rosenbloom L and Ryan S. Neonatal shaken baby syndrome: an aetiological view from Down Under. Arch Dis Child Fetal Neonatal Ed 2002;87: F29-F30.
Drs Williams and Sunderland[1] and the accompanying commentary from
Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated
with chest physiotherapy in very preterm infants. Rosenbloom is correct
that the topic lacks topicality, but mainly because neonatal chest
physiotherapy is now used very little if at all. I disagree that there is
an abundant literature detailing appropriate treatm...
Drs Williams and Sunderland[1] and the accompanying commentary from
Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated
with chest physiotherapy in very preterm infants. Rosenbloom is correct
that the topic lacks topicality, but mainly because neonatal chest
physiotherapy is now used very little if at all. I disagree that there is
an abundant literature detailing appropriate treatment and the absence of
brain damage associated with neonatal chest physiotherapy. Older data
suggested benefit,[3-5] but more recent publications demonstrate none.[6-8]
The reported benefits were transient improvements in oxygenation and
slight increased removal of secretions. The older studies are all too
small to adequately address safety. Chest physiotherapy, by whatever
method has little or no place in neonatal intensive care.
There are several lessons to be learned from the experience of the
units who found these brain lesions. The first is that a treatment
generally recognised as being beneficial may not be so, especially with
other changes in care over the passage of time. Continued reassessment of
the usefulness of treatment is needed. The second is that side effects can
appear, even when a treatment has supposedly passed the test of time.
Ongoing audit is needed. The third is that there is a dilemma that
clinicians face in reporting complications. The first hospital to find
this lesion did not further investigate the cause or report its suspicions.[9] The second hospital did.[10] That hospital has been subject to a long
official public inquiry, law suites and had twenty medical, nursing and
physiotherapy staff investigated by registration authorities, lasting 8
years. All this happened in the supposedly non-litigious medicolegal
environment of New Zealand. There needs to be the ability to be open about
complications and side effects and have an atmosphere of learning from,
rather than blame for them.
I would like to correct one statement by Williams and Sunderland. In
our nursery there was no change in the vigour of chest physiotherapy from
the introduction of the technique in 1985 until we stopped all chest
physiotherapy at the end of 1994. The cerebral lesions appeared from 1992
to 1994. From 1985, the same physiotherapist was teaching and supervising
the technique. During those three years, babies who developed the brain
lesion had more chest physiotherapy than matched concurrent controls, but
considerably less than many infants in previous years. Why the brain
lesion began to appear remains a mystery.
References
(1) Williams AN, Sunderland R, Neonatal shaken baby syndrome: an
aetiological view from Down Under. Arch Dis Child 2002; 87: F29-30
(2) Rosenbloom L, Ryan S, Neonatal shaken baby syndrome: an
aetiological view from Down Under. Commentary. Arch Dis Child 2002; 87:
F30
(3) Finer NN, Boyd J. Chest physiotherapy in the neonate: a controlled
study. Pediatrics 1978; 61: 282-85.
(4) Etches PC, Scott B. Chest physiotherapy in the newborn: effect on
secretions removal. Pediatrics 1978; 62: 713-15.
(5) Tudehope DI, Bagley C. Techniques of physiotherapy in intubated
babies with the respiratory distress syndrome. Aust Paediatr J 1980; 16:
226-28.
(6) Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post-
extubation atelectasis. Pediatr Pulmonol 1996; 21: 227-30.
(7) Bloomfield FH, Teele RL, Voss M, Knight DB, Harding JE. The role
of neonatal chest physiotherapy in preventing postextubation atelectasis.
J Pediatr 1998; 133: 269-71.
(8) Bagley CE, Flenady VJ, Tudehope DI, Gray PH, Lamont A, Shearman A.
The role of routine prophylactic post-extubation chest physiotherapy in
neonates: a randomised controlled trial. Proc Perinatal Society of
Australia and New Zealand, Brisbane. 2000; page 73.
(9) Rushton DI. Neonatal shaken baby syndrome – historical inexactitudes. [electronic
response to Williams AN et al. Neonatal shaken baby syndrome: an aetiological view from Down Under] archdischild.com 2002 http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;87/1/F29#139
(10) Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB. Chest
physiotherapy may be associated with brain damage in extremely preterm
infants. J Pediatr 1998; 132: 440-44.
Dear Editor
This symposium on CLD by Kotecha et al.[1] covered important aspects and controversies in the management of CLD. We accept the authors' inability to cover all aspects of management. We feel that some space could have been devoted to diuretics in management of CLD. Nearly all patients with CLD of some stage of their disease will recieve diuretics and most of them will be on them for a long time. We...
Dear Editor
Professor Dunn quotes Downman's approval of Lady Mary Montagu in his fascinating account of the Exeter physician. Her contemporaries, however, were often less generous. This beautiful and literary lady contracted smallpox in 1715 and probably knew of the Turkish practice of 'engrafting' or 'variolation' against the disease from her own doctors. As Fellows of the Royal Society they may well have heard an a...
Dear Editor
We wish to raise a few concerns regarding the study reported by S Rahman and colleagues.[1]
We found it surprising that only five species of micro-organisms were isolated in this series of over a 1000 blood cultures obtained from neonates with sepsis. Similar studies done in other major cities of Pakistan, with much smaller sample sizes have shown a wider spectrum of pathogens . Anwer SK (2000)[2...
Dear Editor
Shinwell et al.[1] have addressed the important issue of outcome of very low birthweight (VLBW) triplets compared to twins and singletons.
When counselling mothers of triplet pregnancies clinicians should be careful in extrapolating the data from this very specific cohort to all triplet pregnancies. Their patient population is not representative of most triplet pregnancies, as they include on...
Dear Editor
This is in response to the letter from SA Ali et al.[1]
1. The total number (1598)and the culture positive babies (1003)in our article [1] represent cases after the patients meeting the exclusion criteria were taken out. We did grow isolated cases of Strp sp. Salmonella and Enterococci which happened to fall in the excluded group. In the spectrum as a whole, these oganisms accounted for...
Dear Editor
In my experience the best treatment for umbilical granulomas is the application of non-iodized common salt. It is helpful also in most cases of umbilical discharges, and even persistent bloody discharge from the umbilicus after the cord has fallen off. No cultures or antibiotic therapy for discharges is required. The method of applicatio is simple. The umbilicus is cleaned with alcohol or any other...
Dear Editor
We read this article with interest, and it prompted us to review our own experience with progressive ventricular dilatation (PVD) over the past 22 years at the Maine Medical Center (MMC) in Portland, Maine.
Since 1980, we have used a single approach to management of PVD. As noted in previous publications, we have considered the need for intervention to be rapid head growth defined as an increase in OFC...
Dear Editor
The Seldinger technique [1] of inserting a percutaneous central venous catheter (PCVC) had been published 10 years ago.[2]
We have recently published a novel, simple and quick technique, “The Townsville method,” which allows a PCVC to be inserted easily without the need for a butterfly needle or guide wire in any baby who has an indwelling peripheral intravenous cannula [3]: A 24-gauge c...
Dear Editor
I read with interest the article on Neonatal Shaken Baby Syndrome.[1] While a fascinating account of the sequence of events in this saga it is factually incorrect in several respects.
As the perinatal pathologist involved in the Birmingham series I raised the possibility that the brain damage was due to the effects of physiotherapy prior to the publication of our report. My co-authors felt tha...
Dear Editor
Drs Williams and Sunderland[1] and the accompanying commentary from Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated with chest physiotherapy in very preterm infants. Rosenbloom is correct that the topic lacks topicality, but mainly because neonatal chest physiotherapy is now used very little if at all. I disagree that there is an abundant literature detailing appropriate treatm...
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