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.
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
Neonatal health-care providers have the duty to fully inform parents
about the prognosis of their sick, extremely preterm infant.
Prognostication is however difficult since survival and long-term outcome
are multifactorially influenced, and the quality of prognosis research is
often poor. [1] By reporting "Determinants of developmental outcomes in a
very preterm Canadian cohort" [2], Synnes et al. extend the previous wor...
Neonatal health-care providers have the duty to fully inform parents
about the prognosis of their sick, extremely preterm infant.
Prognostication is however difficult since survival and long-term outcome
are multifactorially influenced, and the quality of prognosis research is
often poor. [1] By reporting "Determinants of developmental outcomes in a
very preterm Canadian cohort" [2], Synnes et al. extend the previous work
of the Canadian Neonatal Network [3], thereby refining the possibility of
long-term prognostication. Forward stepwise logistic regression analyses
were performed for neurodevelopmental impairment (NDI), severe NDI (sNDI)
and "sNDI or death". Unfortunately, the paper does not include the
logistic regression equations. I kindly request the authors to further
document their findings by sharing the following data: for each of the
studied outcomes, the full logistic regression equation of Step 4 (with
standard errors of the regression coefficients) and the variance or
covariance matrix (enabling to calculate the confidence interval for the
risk estimates). It would be regrettable if this useful information would
remain concealed from the reader.
References
1. Hemingway H, Riley RD, Altman DG. Ten steps towards improving prognosis
research. BMJ 2009;339:b4184 doi: 10.1136/bmj.b4184[published Online
First: Epub Date]|.
2. Synnes A, Luu TM, Moddemann D, et al. Determinants of developmental
outcomes in a very preterm Canadian cohort. Arch Dis Child Fetal Neonatal
Ed 2016 doi: 10.1136/archdischild-2016-311228[published Online First: Epub
Date]|.
3. Ge WJ, Mirea L, Yang J, et al. Prediction of neonatal outcomes in
extremely preterm neonates. Pediatrics 2013;132(4):e876-85 doi:
10.1542/peds.2013-0702[published Online First: Epub Date]|.
We read this article with considerable interest as it confirms that
Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate
within seconds of birth, much earlier than is possible with oximetry and
much more reliably than with auscultation. As the authors state "Handheld
Doppler use for measuring newborn HR has been described in the literature"
(by Goenka et al and by Hutchon) "but needs further investigat...
We read this article with considerable interest as it confirms that
Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate
within seconds of birth, much earlier than is possible with oximetry and
much more reliably than with auscultation. As the authors state "Handheld
Doppler use for measuring newborn HR has been described in the literature"
(by Goenka et al and by Hutchon) "but needs further investigation before
being used clinically.". Dyson et al chose to use a Hadeco Smartdop 45
(Hadeco--2-7-11 Arima, Miyamae-ku, Kawasaki, 216-0003, Japan), which is a
bidirectional handheld Doppler usually used for measuring arterial and
venous blood flow in the extremities although it can also detect a fetal
HR. In 2014 we demonstrated the use of a readily available and low cost
dedicated fetal doppler machine and found the 2mHz probe readily detected
the neonatal heart rate when placed on the chest(1). We reported on the
Contec Sonoline C2 Pocket Fetal Doppler which also provides a digital
display of heart rate and records the signal for subsequent computer
download, and documentation and review.
We have also shown that if the transducer is separated from the hand
held probe of the machine and connected with light flexible wiring, the
lightweight transducer can sit on the neonate's chest held in place simply
by the surface tension of the ultrasound gel. This allows hands-free use
and avoids the risk of excessive pressure by a handheld probe on the
neonate's chest. The position of the transducer on the chest is not
critical and can easily be adjusted. By aligning with the skin the
transducer automatically scans at 90 degrees.
https://www.youtube.com/watch?v=ut0vpZxkidI
Precordial Doppler Ultrasound (PDU) can be readily adapted to provide
a measurement of the neonatal heart rate at caesarean section without
compromising the sterile surgical field. The Doppler machine is connected
to a bluetooth transmitter and placed inside a sterile polythene bag
ensuring that transducer is coated in ultrasound gel and in contact with
the wall of the bag. The transducer can then be handled by a member of the
scrubbed team and applied to the neonatal chest through a further
application of ultrasound gel. The signal is received by a matching
bluetooth receiver outside the sterile field. This can be used to provide
an audible signal to the neonatologist and team and recorded for
documentation and audit.
For the preterm neonate at risk of hypothermia it is important to
avoid exposure of the skin and PDU can be carried out through the
recommended polythene wrap without the exposure of the neonatal skin
required by ECG or oximetry.
Although we reported on the Contec Sonoline C2 Pocket Fetal Doppler,
other machines without a recording facility have been shown to be as
effective. After a few minutes when oximetry is functional the PDU becomes
redundant.
References
Goenka S, Khan M, Koppel RI, Heiman HS. Precordial Doppler Ultrasound
Achieves Earlier and More Accurate Newborn Heart Rates in the Delivery
Room. Pediatric Academic Societies and Asian Society for Pediatric
Research
2014; 590p.
Hutchon DJR. Technological Developments in Neonatal Care at Birth. J
Nurs Care 2014; 3: 218.
We thank Dr Hutchon for his interest in our article and acknowledge
his contribution to developing this technique of measuring heart rate
rapidly and efficiently in newborns. We were particularly interested to
hear of his experience with a Doppler that displays an averaged heart
rate. We can see that having a displayed rather than counted Doppler
heart rate would be highly practical in the delivery room providing that...
We thank Dr Hutchon for his interest in our article and acknowledge
his contribution to developing this technique of measuring heart rate
rapidly and efficiently in newborns. We were particularly interested to
hear of his experience with a Doppler that displays an averaged heart
rate. We can see that having a displayed rather than counted Doppler
heart rate would be highly practical in the delivery room providing that
it is accurate, able to detect heart rates of <60bpm and has a suitably
short averaging time. During our study we found that counting the audible
Doppler sound was considerably more accurate than using the displayed
heart rate provided by our Doppler machine Hadeco Smartdop 45(Hadeco--2-7-
11 Arima, Miyamae-ku, Kawasaki, 216-0003, Japan) (1) and cannot find other
published data to the contrary. We also agree that there are clearly
practical and ergonomic advantages to having a hands free transducer as
has been described by Dr Hutchon, particularly if this can be used with a
Doppler that is used for fetal heart rate monitoring and therefore already
present in the delivery room.
We think that the focal depth of the probe is likely to have an
impact on the accuracy of the device given the variation in size of the
neonatal population and found that our 8MHz probe was more accurate in
smaller babies <1.5kg (1). We found that while it has been shown that
the using a 2MHz probe is effective in detecting the heart rate in
newborns over 35 weeks gestation in the delivery room (2), we wonder if
the focal depth of 10cm of a 2MHz probe might make it difficult to obtain
accurate measurements in smaller preterm newborns and feel that this
should be a direction of further research.
1. Dyson A, Jeffrey M, Kluckow M, Measurement of Newborn Heart Rate
Using Handheld Doppler ultrasound, Arch Dis Child Fetal Neonatal Ed
doi:10.1136/archdischild-2016-310669
2. Goenka S, Khan M, Koppel RI, Heiman HS. Precordial Doppler
Ultrasound Achieves Earlier and More Accurate Newborn Heart Rates in the
Delivery Room. Pediatric Academic Societies and Asian Society for
Pediatric Research 2014; 590p.
This paper highlights some limitations in the use of infant car-seat
challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior
to hospital discharge[1]. Current practice is non-standardised and
unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks
gestation or birth-weight <2500g should have a period of observation in
a car-seat prior t...
This paper highlights some limitations in the use of infant car-seat
challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior
to hospital discharge[1]. Current practice is non-standardised and
unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks
gestation or birth-weight <2500g should have a period of observation in
a car-seat prior to hospital discharge[2]. This is based on reports of
preterm infants experiencing cardiorespiratory compromise in car-seats.
There is no national UK guidance.
We evaluated current practice in England and Wales by conducting a
postal survey of the 179 level I-III Neonatal Units between December 2013
- January 2014.
The response rate was 62.6% (n=112). Our results showed that 27.7% of
respondents regularly tested infants in car-seats pre-discharge; compared
to 10% of 200 UK units contacted in 2005[3] and 30% of 30 units in
2006[4].
In our survey, 51.6% of units had no gestational age or weight
criteria for performing the ICSC. 25.8% had no formal failure criteria.
Parameters tested and duration of monitoring varied widely.
Arya reported the static ICSC does not reflect the angle or motion of
a moving vehicle. Infants, in a more upright seat (40 degrees) with
vibration experienced in a car, showed significantly increased heart rate,
respiratory rate and decreased oxygen saturations[1]. Of note, 83.8% of
units in our survey placed the car-seat on the floor (~30 degrees) rather
than more upright in a seat.
The 2006 Cochrane review of ICSCs found no eligible randomised
controlled trials and concluded that further studies were required to
determine if ICSCs accurately predict risk of clinically significant
adverse events[5].
Schutzman compared an ICSC and polysomnogram (PSG). The ICSC negative
predictive value was 0.45 when compared with PSG. They concluded that
although less time consuming, the ICSC is not a reliable substitute[6].
However, current ICSCs are time consuming. In a previous study we
performed 181 ICSCs over 18 months[7]. Each ICSC observation period was
120 minutes, which totaled 362 hours (30.2 working days) of nursing time.
Thus, implementing a national policy that advocates ICSC would impact on
nursing staff and may have a significant financial impact on neonatal
units.
This is an important problem. Car-seats are vital and 71% effective
in reducing infant fatality in road traffic accidents[2]. However, car-
seats are frequently observed to be used inappropriately; Callahan
reported infants spending a mean of 5.7+/- 3.5 hours per day in a car-seat
or similar sitting device[8]. Bamber identified 14 car-seat associated
deaths; 70% occurred whilst the seat was being used inappropriately or
outside the car[9]. In a recent review, Davis discusses observations of
infants in the semi-upright position and the continued unanswered
questions regarding ICSCs[10].
Our survey highlights that significant nursing time is being spent on
performing ICSCs in UK units in disparate ways. At present there is not
enough evidence regarding testing or how to interpret results. Therefore,
education of parents about appropriate use of car-seats must remain
paramount whilst further research establishes the appropriate use of ICSCs
in UK hospitals.
References:
1. Arya R, Williams G, Kilonback A et al. Is the infant car sear
challenge useful? A pilot study in a simulated moving vehicle. Arch. Dis.
Child. Fetal Neonatal Ed. 2016.doi:10.1136/archdischild-2016-310730.
2. Bull M, Agran P, Laraque D et al. American Academy of Pediatrics,
Committee on Injury and Poison Prevention. Safe transportation of newborns
at hospital discharge. Pediatrics. 1999;104:986-987.
3. N Joffe, J Hall (2006) Limiting the risks of apnoea and
bradycardia in low birth weight infants using car seats.. Journal of
Neonatal Nursing 12, 91-96.
4. Bhojani S., Desai P., Skeoch C. Car seat challenge - the current
practice. Infant 2008; 4(6): 211-13.
5. Pilley E, McGuire W. Pre-discharge "car seat challenge" for
preventing morbidity and mortality in [preterm infants. The Cochrane
Library 2008 Issue 3.
6. Schutzman DL, Salvador A, Janeeczko M et al. A comparison of the
infant car seat challenge and the polysomnogram at the time of hospital
discharge. Arch Dis Child Fetal Neonatal Ed 2013; 98: F411-F415.
7. Towler R, Eastwood R, Ballentyne B, Arya R. The car seat challenge
- 18 months experience in a district general hospital. Arch Dis Child
Fetal Neonatal Ed 2013; 98: F411-F415
8. Callahan CW, Sisler C. Use of seating devices in infants too young
to sit. Arch Pediatr Adolesc Med. 1997 Mar;151(3):233-5.
9. Bamber AR, Pryce J, Ashworth MT et al. Sudden unexpected infant
deaths associated with car seats. Forensic Sci Med Pathol. 2014
Jun;10(2):187-92.
10. Davis NL Screening for cardiopulmonary events in neonates: a
review of the infant car seat challenge. Journal of Perinatology (2015)
35, 235-240.
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence...
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence were likely underestimated due to underreporting, particularly the low incidence of neonate antibiotic exposure for suspected sepsis... which [was] substantially lower than estimates described in the literature at academic institutions". However, despite likely overall underreporting, antibiotic treatment for sepsis would be reported non-differentially between epidural and non-epidural groups. Therefore, we believe the comparisons between groups and associations identified to be valid and an important step in describing the issue of neonatal sepsis evaluation. The issue the writer raises highlights the need to improve administrative data collection tools, such as the birth certificate database, in order to provide more precise estimates, but does not impact the validity of the conclusions of this study.
Dear editor,
We read with interest the report by Arun Babu and colleagues1 and have
concern with the diagnosis of "congenital intraoral Fordyce spots" that
was rendered in this case. Fordyce spots/granules in the oral cavity are
considered ectopic holocrine glands, and they differ considerably from
those shown in the mentioned article. Fordyce spots usually appear as
asymptomatic, multiple yellowish raised papules with...
Dear editor,
We read with interest the report by Arun Babu and colleagues1 and have
concern with the diagnosis of "congenital intraoral Fordyce spots" that
was rendered in this case. Fordyce spots/granules in the oral cavity are
considered ectopic holocrine glands, and they differ considerably from
those shown in the mentioned article. Fordyce spots usually appear as
asymptomatic, multiple yellowish raised papules with well-defined borders
as we demonstrate in Figure 1. In our experience Fordyce granules are
permanent, variable in size depending on the state of cytoplasmic
engorgement, and considered as a normal variant of the oral cavity. We
believe that the lesions in the case report appear as multiple areas of
"ductal ectasia" with mucous retention, which should resolve with
appropriate hydration. On close observation you can notice a central
ductal opening in each lesion, which is inconsistent with the clinical
presentation of Fordyce granules. Clinicians involved with the case
reported should also be aware of the possibility of cystic fibrosis due to
the presence of mucous plugs. Another less likely possibility would be
lymphectasia. Finally, the two references2,3 cited do not support the
diagnosis made by the original authors.
References.
1. Arun Babu T, Vijayadevagaran V, Carounanidy U. Congenital intraoral
Fordyce spots. Arch Dis Child Fetal Neonatal Ed. 2016 May;101(3):F252.
2. Flinck A. Oral findings in a group of newborn Swedish children. Int J
Paediatr Dent. 1994 Jun;4(2):67-73.
3. Cutaneous disorders of the newborn. In: Paller AS, Mancini AJ, eds.
Hurwitz's clinical pediatric dermatology: a textbook of skin disorders of
childhood and adolescence. 4th ed. Philadelphia, PA: Elsevier Saunders,
2011:10-36.
Respectively,
Thamer M. Musbah, B.D.S.
Assistant Professor
Division of Oral Diagnosis, Oral Medicine and Oral Radiology
University of Kentucky College of Dentistry
Craig S. Miller D.M.D., M.S.
Professor of Oral Medicine
Chief, Division of Oral Diagnosis, Oral Medicine and Oral Radiology
University of Kentucky College of Dentistry
Douglas D. Damm, D.D.S.
Professor of Oral Pathology
Chief, Division of Oral and Maxillofacial Pathology
University of Kentucky College of Dentistry
We read with interest the article by Zanardo et al (1).
The authors found a lower pre-ductal SpO2, a higher hearth rate (HR) and
hematocrit in term infants born by cesarean delivery (CD) compared to
those born by vaginal delivery (VD), similarly to the findings by Dawson
et al (2) but not confirmed by others (3).
The authors did not mentioned if a different management of cord clamping
was performed between vaginal and ce...
We read with interest the article by Zanardo et al (1).
The authors found a lower pre-ductal SpO2, a higher hearth rate (HR) and
hematocrit in term infants born by cesarean delivery (CD) compared to
those born by vaginal delivery (VD), similarly to the findings by Dawson
et al (2) but not confirmed by others (3).
The authors did not mentioned if a different management of cord clamping
was performed between vaginal and cesarean delivered newborns, as the
higher hematocrit at birth found in the VD group suggests. In fact,
hematocrit at birth, in term newborns, seems not to be significantly
influenced by the mode of delivery (4). In this study, a delay in cord
clamping (DCC) in VD newborns comapred to CD could have determined a
better neonatal adaptation in the formers and explain the differences in
HR, SpO2 and neonatal hematocrit described by the Authors.
In animal models, cord clamping before the onset of spontaneous breathing
resulted in lower right and left ventricular output, slower reduction in
pulmonary vascular resistance, a longer period of right-to-left shunt
through the ductus arteriosus and higher HR in the minutes after delivery.
Smit et al (5) demonstrated that healthy VD newborns with DCC have higher
SpO2 and lower HR in the first minutes of life compared to current
reference ranges (2). We believe that the influence of delayed cord
clamping, a standard practice when resuscitation in not required, should
be further investigated in term and preterm newborns delivered by elective
cesarean section.
1. Zanardo V, Cengio V, Parotto M, et al. Elective caesarean delivery
adversely affects preductal oxygen saturation during birth transition.
Arch Dis Child Fetal Neonatal Ed. 2016 Jul;101(4):F339-43.
2. Dawson JA, Kamlin CO, Vento M, et al. Defining the reference range for
oxygen saturation for infants after birth. Pediatrics 2010; 125: e1340-7.
3. Ying-Chun Lu, Chih-Chien Wanga, Chuen-Ming Leed, et al. Reevaluating
Reference Ranges of Oxygen Saturation for Healthy Full-term Neonates Using
Pulse Oximetry. Pediatr Neonatol 2014; 55:459-65.
4. Glasser L, Sutton N, Schmeling M, et al. A comprehensive study of
umbilical cord blood cell developmental changes and reference ranges by
gestation, gender and mode of delivery. J Perinatol 2015; 35: 469-475
5. Smit m, Dawson JA, Ganzeboom A, et al.Pulse oximetry in newborns with
delayed cord clamping and immediate skin-to-skin contact. Arch Dis Child
Fet Neonat Ed 2014; 99:F309-F314.
Dear Sirs,
We read with interest the recent work by Dr Tracy and colleagues: "The
effectiveness of Ambu neonatal self-inflating bag to provide consistent
positive end-expiratory pressure", doi:10.1136/ archdischild-2015-308649
ADC FN&N Ed. 2016.
We would like to comment on the statement and findings by Tracy et
al.
Firstly, a strong point of the paper is that the authors have
systematically investigated t...
Dear Sirs,
We read with interest the recent work by Dr Tracy and colleagues: "The
effectiveness of Ambu neonatal self-inflating bag to provide consistent
positive end-expiratory pressure", doi:10.1136/ archdischild-2015-308649
ADC FN&N Ed. 2016.
We would like to comment on the statement and findings by Tracy et
al.
Firstly, a strong point of the paper is that the authors have
systematically investigated the reliability of single and multiple use
SIBs and valves. Also, the observation that PEEP provision varies within
differently compliant systems is particularly noteworthy, especially when
using SIBs on newborn infants who are known to portray rapidly changing
lung mechanics. For instance, the well-known work by Bjoerklund et al. and
Dreyfuss et al. highlighted the importance of tight PIP control when
ventilating newborn lungs (Bjoerklund 1996; Dreyfuss 1997). We further
read with interest that Tracy et al. found the strongest correlation
between inflations per minute (IPM) and accuracy of PEEP provision when
IPM was 60min-1. Authors thereby replicated previous results by Morley et
al. and Kelm et al. and others (Morley 2010, Kelm 2009).
Conversely, we are surprised to read that Tracy and co-authors
suggest that a) the Ambu SIB/PEEP-valve combination, used together with
the Ambu manometer, has not been previously studied. This is not correct;
several investigators have researched the reliability of manual
ventilation devices, incl. SIB/ PEEP-valve combinations. And b) we believe
that the author's concluding strong statement on the safety of the Ambu
SIB/PEEP-valve combination needs to be revisited in the light of findings
by other authors, as outlined below.
The Ambu SIB/PEEP-valve combination, with or without the attachable
manometer, has been studied in detail by several groups of investigators
(Hartung et al. 2012, 2013, 2014 & 2016; Thio et al. 2010 & 2014;
Kelm et al. 2012). As an example, Hartung and colleagues recently
investigated the reliability of the delivered end-expiratory pressures
from the Ambu SIB, together with Ambu 10-PEEP-valves, both with single use
and multiple use PEEP-valves (Hartung 2013 & Hartung 2014 &
Hartung 2016). However, much different to Tracy and colleagues' findings,
these studies showed significant variation in their PEEP provision, even
when factory new Ambu-10-PEEP-valves were tested on a new Ambu Mark IV SIB
(Ambu Ballerup, Denmark) under highly standardized conditions: PEEPs
ranged from 2.0 cmH2O to 5.15 cmH2O when set at 5 cmH2O, and 5.0 to 9.08
when set at 10cmH2O, respectively. Hartung et al. further found that
repeated thermo sterilization continued to decrease the reliability of the
tested Ambu multi-use PEEP-valves (Hartung 2013).
It is common to most in vitro-studies on the provision of PIP/ PEEP
that these, for obvious advantages such as repeatability of the tests
etc., are conducted under controlled circumstances, including the use of
leak free models. However, as shown by both Wood et al. and Schilleman et
al., large mask leaks constantly occur during manual ventilation of
babies, which impact significantly on the efficiency of manual ventilation
(Wood 2008, Schilleman 2010). Accordingly, previous work by Hartung et al.
investigated how leak affected the provision of PIP/ PEEP when using the
SIB. The findings were that increased leak correlated with decreased PIP
and PEEP provision when using a SIB/PEEP-valve combination, whereas the
tested T-piece resuscitator (Neopuff, Fisher and Paykel Healthcare,
Auckland, NZ), a continuous flow device, steadily compensated for leaks up
to 85% (Hartung 2012). But, we believe that recommendations for real life,
clinical scenarios, even when based on convincing laboratory data, need to
be made with considerably caution, when the results stem from highly
controlled laboratory studies.
Lastly, Tracy et al. studied a lung model which was ventilated by a
human operator, whereas the aforementioned studies by Hartung et al. were
performed using a standardized plunger-driver to exclude variations in
pressures as seen in manually delivered inflations (Hartung 2012 &
2013 & 2016). Therefore, we would like to strongly caution against
Tracy et al.'s statement, which, based on their findings from only three
investigators, confidently states that it would be possible to
consistently deliver a required PIP by hand when using an Ambu SIB/PEEP-
valve combination with manometer. The concept of the "educated hand" has
long been refuted, for instance in studies by Bennett et al. (Bennett
2005), Hartung et al. (Hartung 2014), van Vonderen et al. (van Vonderen
2014) or Roehr and colleagues (Roehr 2012). They, as well as other
authors, proved the highly significant variation in the delivery of
positive pressure ventilation by human operators when using SIB/ PEEP-
valve combinations. Reassuringly, and not dissimilar to Tracy's
observations, Kelm et al. were able to show that specific training in
target PIP delivery improved PIP provision in neonatal practitioners (Kelm
2010) and Hartung et al. showed that use of the Ambu pressure manometer
helped with adherence to target PIPs, when compared to no manometer use
(Hartung 2014). However, worryingly we read the very recent reports from
Japan, in which an increased incidence of pneumothoraces in resuscitated
term born infants (by use of SIB) has been lamented since the 2010 change
in neonatal resuscitation guidelines, as featured in ADC F&N, together
with an accompanying editorial by Ruediger and Poets (Hishikawa 2015;
Ruediger 2015).
To conclude, our current understanding of the limited body of
literature on SIB use in neonates suggests that the safest means to
provide safe and effective manual ventilation for preterm infants
requiring resuscitation still remains to be established. Given the
discrepancy between the available in-vitro and in-vivo studies, and in
keeping with Tracy's final conclusion, we strongly caution that before
sound conclusions about the reliability and safety of any SIB device are
made, further research is needed. More efforts need to be made to
establish in order to determine the safest and most effective way of in
delivering manual ventilation to babies during neonatal resuscitation.
Charles C Roehr, Gerd Schmalisch, Julia C Hartung
March 2nd 2016
References:
Tracy M, Shah D, Priyadarshi A, Hinder M. The effectiveness of Ambu
neonatal self-inflating bag to provide consistent positive end-expiratory
pressure. Arch Dis Child Fetal Neonatal Ed. 2016 Jan 19. pii:
fetalneonatal-2015-308649. doi: 10.1136/archdischild-2015-308649. [Epub
ahead of print]
Bjoerklund LJ, Vilstrup CT, Larsson A, Svenningsen NW, Werner O.
Changes in lung volume and static expiratory pressure-volume diagram after
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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 MoreI 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
Neonatal health-care providers have the duty to fully inform parents about the prognosis of their sick, extremely preterm infant. Prognostication is however difficult since survival and long-term outcome are multifactorially influenced, and the quality of prognosis research is often poor. [1] By reporting "Determinants of developmental outcomes in a very preterm Canadian cohort" [2], Synnes et al. extend the previous wor...
We read this article with considerable interest as it confirms that Precordial Doppler Ultrasound (PDU) can detect the neonatal heart rate within seconds of birth, much earlier than is possible with oximetry and much more reliably than with auscultation. As the authors state "Handheld Doppler use for measuring newborn HR has been described in the literature" (by Goenka et al and by Hutchon) "but needs further investigat...
We thank Dr Hutchon for his interest in our article and acknowledge his contribution to developing this technique of measuring heart rate rapidly and efficiently in newborns. We were particularly interested to hear of his experience with a Doppler that displays an averaged heart rate. We can see that having a displayed rather than counted Doppler heart rate would be highly practical in the delivery room providing that...
This paper highlights some limitations in the use of infant car-seat challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior to hospital discharge[1]. Current practice is non-standardised and unlikely to replicate actual infant experience.
In the USA it is recommended that all infants born <37 weeks gestation or birth-weight <2500g should have a period of observation in a car-seat prior t...
We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence...
Dear editor, We read with interest the report by Arun Babu and colleagues1 and have concern with the diagnosis of "congenital intraoral Fordyce spots" that was rendered in this case. Fordyce spots/granules in the oral cavity are considered ectopic holocrine glands, and they differ considerably from those shown in the mentioned article. Fordyce spots usually appear as asymptomatic, multiple yellowish raised papules with...
We read with interest the article by Zanardo et al (1). The authors found a lower pre-ductal SpO2, a higher hearth rate (HR) and hematocrit in term infants born by cesarean delivery (CD) compared to those born by vaginal delivery (VD), similarly to the findings by Dawson et al (2) but not confirmed by others (3). The authors did not mentioned if a different management of cord clamping was performed between vaginal and ce...
Dear Sirs, We read with interest the recent work by Dr Tracy and colleagues: "The effectiveness of Ambu neonatal self-inflating bag to provide consistent positive end-expiratory pressure", doi:10.1136/ archdischild-2015-308649 ADC FN&N Ed. 2016.
We would like to comment on the statement and findings by Tracy et al. Firstly, a strong point of the paper is that the authors have systematically investigated t...
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