Lawson's editorial and Emond and colleagues' article exposes
potentially bad medicine: lack of knowledge of normal and variations of
normal; lack of knowledge of the natural history of a condition; a desire
to do something - Ulysses syndrome (1); medicalising the child by giving
the condition a name; and then ascribing any improvement to the
intervention, forgetting that association does not mean causation.
Lawson's editorial and Emond and colleagues' article exposes
potentially bad medicine: lack of knowledge of normal and variations of
normal; lack of knowledge of the natural history of a condition; a desire
to do something - Ulysses syndrome (1); medicalising the child by giving
the condition a name; and then ascribing any improvement to the
intervention, forgetting that association does not mean causation.
This writer did many years of community child health clinics seeing
babies with a variety of problems that never went near a hospital: a W-
shaped tongue [M-shaped from the baby's perspective] is a normal finding.
To describe it as tongue tie and to intervene are medicalising normality
in the majority of cases. As Illingworth says in The Normal Child (2)
[which should be required reading for all health professionals involved
with children] "The tongue is always short at birth but as the infant
grows the tongue becomes longer and thinner. Many mothers [and health
professionals - my insertion] ascribe their children's feeding
difficulties and lateness in speaking to tongue tie".
Unfortunately blaming tongue tie becomes self-perpetuating. The fact
that parents want subsequent children to have a frenotomy after their
first child has had one and doctors acquiesce to this or lactation experts
believe it is the cause of breastfeeding difficulties does not represent
proof nor does it justify performing the operation. Countries with
initial and sustained high breastfeeding rates such as New Zealand, where
this writer worked for several years, do not have high rates of frenotomy
to ensure that breastfeeding is successful. Rather it is good
breastfeeding support.
Recently a tongue-tie service was set up in my local area. I can
predict the outcome. In 12 months' time those who promoted and run the
service will announce how many tongue tie operations they done, how
parents are pleased and feel the baby is feeding better and how
"successful" the service is. The specious conclusion will be that tongue
tie was a significant problem for these babies which frenotomy cured. I
consider this is 21st Century charlatanism.
Signed
Dr Charles Essex
Consultant Neurodevelopmental Paediatrician
Suite 115
41 Oxford Street
Leamington Spa CV32 4RB
References
1. Essex C. Ulysses syndrome. BMJ 2005; 330: 1268.
2. Illingworth RS. The Normal Child. Churchill Livingstone, Edinburgh
1983.
The tongue remains with in the boundaries of the mandible during
suckling and so it is difficult to see the anatomical or the physiological
basis for how a frenulectomy works in reducing breast and nipple
discomfort during feeding. This randomised trial does not seem to assess
the potential, positive psychological impact of the mother being told
their child has had a frenulectomy. That is the question that...
The tongue remains with in the boundaries of the mandible during
suckling and so it is difficult to see the anatomical or the physiological
basis for how a frenulectomy works in reducing breast and nipple
discomfort during feeding. This randomised trial does not seem to assess
the potential, positive psychological impact of the mother being told
their child has had a frenulectomy. That is the question that must be
answered before a procedure performed on the most sensitive organ in the
body, with out anaesthesia is undertaken routinely.
Tongue tie is not proven to impact upon speech and if a release is
performed in a child with a small chin, with or without a cleft palate, it
can cause airway obstruction. A significant tongue tie causes social
embarrassment in later life but it has no other proven physical impact on
the child and so more concrete evidence of benefit for the procedure being
performed upon a neonate, with out anaesthesia, must be provided before
the practice is offered routinely. Every surgical procedure has
complications and surely there must be greater proof of benefit than
relieving nipple pain in the mother? When else is a procedure inflicted
on any patient, let alone a child, for the benefit of reducing discomfort
in a third party? With out this additional proof, practitioners may well
be performing unnecessary procedures on a defenceless infant.
With out a "sham" group, the psychological impact on the mother
cannot be excluded.
We thank Dr. Verd and colleagues for their comments [1] on our review
of the use of human milk for preterm infants. Our aim was certainly not to
discourage the use of donor human milk, but rather to look objectively at
the evidence base that currently exists for its use.
The authors of the letter refer to a 1984 study by Narayanan et al
[2] which appeared to show a reduction in the risk of infection in infants
fe...
We thank Dr. Verd and colleagues for their comments [1] on our review
of the use of human milk for preterm infants. Our aim was certainly not to
discourage the use of donor human milk, but rather to look objectively at
the evidence base that currently exists for its use.
The authors of the letter refer to a 1984 study by Narayanan et al
[2] which appeared to show a reduction in the risk of infection in infants
fed pasteurised human milk. This study, which looked at 226 low birth
weight infants, randomised them to receive unpasteurised human milk or
pasteurised human milk, with or without formula. Many of the anti-
infective factors in human milk are preserved after pasteurisation, and we
therefore do not dispute the potential of donor breast milk (DEBM) to
protect against infection. However, deductions from this paper about the
benefits of pasteurised DEBM have to be made with caution because (a) no
distinction was made in the analysis between mothers' own milk (MEBM) and
DEBM, (b) there is no description of anti-infective precautions in
reconstituting and feeding formula in a study carried out in a very
different setting to a modern NICU, and (c) there is no suggestion of
masking of analysis to study group. The second study referred to, the
R?nnestad study [3], is a national survey of late onset sepsis which
relates to babies who were predominantly fed unpasteurised human milk, and
thus does not have direct relevance to our practice -we are aware of only
one country in Europe (Norway) in which unpasteurised donor milk is
routinely used. A Cochrane review which we cited in our article [4] looked
at whether donor human milk might be better than formula in terms of rates
of invasive infection. They found only one study that they judged to be of
sufficient quality to include in their analysis, the final study quoted by
Verd and colleagues, that by Schanler et al [5]. This study found no
statistically significant difference in the incidence of one or more
episodes of invasive infection when donor milk, rather than formula, was
used to feed preterm infants. Babies were randomised to receive DEBM or
PTF to make up any shortfall of MEBM in preterm infants. Although there
was a (barely statistically significant) lower rate of chronic lung
disease in infants fed DEBM as opposed to PTF, the authors rightly state
that this is one of several outcomes assessed which the study was not
designed to look at, and requires more research.
We welcome an open discussion of the evidence base for the use of
DEBM. Currently, the use of DEBM varies from not at all to extensive use
in preterm infants in place of formula milk. If we over-interpret the
current data, there is the very real risk that we may discourage the
funding of research studies which have the potential to measure the cost-
effectiveness of DEBM more fully and thus the potential to benefit the
care of a larger number of infants by allowing the development of evidence
-based guidelines.
References
1. Verd S, Porta R and Ginovart G. Human milk feeding. Arch Dis Child
Fetal Neonatal Ed, 2014. 99(2): F172-3.
2. Narayanan I, Prakash K, Murthy NS, et al. Randomised controlled
trial of effect of raw and holder pasteurised human milk and of formula
supplements on incidence of neonatal infection. Lancet 1984;2:1111-13.
3. Ronnestad A, Abrahamsen TG, Medb? S, et al., Late-Onset Septicemia
in a Norwegian National Cohort of Extremely Premature Infants Receiving
Very Early Full Human Milk Feeding. Pediatrics, 2005. 115(3): p. e269-
e276.
4. Quigley MA, Henderson G, Anthony MY, et al. Formula milk versus
donor breast milk for feeding preterm or low birth weight infants.
Cochrane Database Syst Rev 2007;(4):CD002971.
5. Schanler RJ, Lau C, Hurst NM, et al. Randomized trial of donor
human milk versus preterm formula as substitutes for mothers' own milk in
the feeding of extremely premature infants. Pediatrics 2005;116:400-6.
Dr Essex and Mr Mercer highlight many of the reasons why we undertook
the Bristol Tongue Tie trial.
Ankloglossia is a spectrum condition, which overlaps with 'normal'
variation in anatomy, and milder forms do not result in feeding
impairment. There is very limited evidence of the need for frenotomy in
mild-moderate degrees of tongue tie. However, it is also true that at
the severe end of the spectrum infants can be limi...
Dr Essex and Mr Mercer highlight many of the reasons why we undertook
the Bristol Tongue Tie trial.
Ankloglossia is a spectrum condition, which overlaps with 'normal'
variation in anatomy, and milder forms do not result in feeding
impairment. There is very limited evidence of the need for frenotomy in
mild-moderate degrees of tongue tie. However, it is also true that at
the severe end of the spectrum infants can be limited in their ability to
breastfeed efficiently because they are not able to latch effectively.
We agree that it is easy to blame a visible tongue tie for breast
feeding difficulties which may be due to other factors, and entirely
support the view that good breastfeeding support is essential in helping
mothers with feeding difficulties.
The inequity in the use of frenotomy worldwide and within the UK is
exactly why well conducted trials are needed, to clarify which babies
should be offered frenotomy and when. The widespread use of social media,
and campaigning by some pressure groups, has resulted in an increase in
demand for the procedure. Good quality evidence from randomised trials is
needed to inform evidence- based clinical practice and the rational
commissioning of services.
We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a docum...
We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a document on the bioethical questions regarding the resuscitation of extremely preterm infants 1. Briefly, the document states the following recommendations: 1. The resuscitation of extremely preterm infants must be made without considering the gestational age, using criteria similar to that adopted for children and adults; 2. The sole high probability of severe disabilities does not justify a decision not to resuscitate an infant in the delivery room; 3. Neonatologists can discontinue the assistance (starting palliative care) when it appears futile and inappropriate; 4.Parental opinion is central, but when it is in contrast with that of Neonatologists, this late must prevail. The Italian Society on Neonatology, the most important Italian association of Neonatologists, substantially agree this document. Thus, in the majority of Italian Hospitals extremely preterm infants are resuscitated in the delivery room on the basis of their viability and not merely evaluating their gestational age.
Prof. Carlo Dani,
Division of Neonatology, Careggi University Hospital of Florence, Italy.
Prof. Costantino Romagnoli,
Division of Neonatology, Sacred Heart Catholic University of Rome, Italy.
President of Italian Society of Neonatology
Prof. Giovanni Corsello,
Department of Sciences for Health Promotion and Mother and Child Care,
University of Palermo
President of Italian Society of Pediatrics.
In the UK speciality training through the grid scheme has been in
existence for about a decade with a well-defined syllabus of knowledge and
skills deemed necessary for the qualified neonatologist. Although much
emphasis is laid on various aspects of neonatal care and the acquisition
of procedural skills including cranial ultrasound, cardiac assessment
using echocardiography is still considered to be an optional skill (1)...
In the UK speciality training through the grid scheme has been in
existence for about a decade with a well-defined syllabus of knowledge and
skills deemed necessary for the qualified neonatologist. Although much
emphasis is laid on various aspects of neonatal care and the acquisition
of procedural skills including cranial ultrasound, cardiac assessment
using echocardiography is still considered to be an optional skill (1).
There are many reasons why this position should now be challenged.
Not least the greatly enhanced armentarium of the neonatologist when
considering therapy, coupled to the relative ease of access to the
equipment necessary to undertake such an evaluation.
Hence our question 'Should cardiac assessment using echocardiography
be considered an essential skill for the neonatologist?'
The recent article by Kluckow (2) highlights the value of clinician
performed cardiac ultrasound in neonatal practice. The ability to
undertake a timely competent functional cardiac assessment - even of
limited parameters - might help optimise therapy, reduce morbidity and
potentially mortality. Yet this ability is not yet deemed essential in the
training of those looking after the most vulnerable babies.
A syllabus in functional cardiac assessment for the neonatologist
needs to be developed as a matter of priority, with access to structured
training in order that all those aspiring to be neonatologists learn the
potential of these techniques and are able to acquire the skills during
their time as a trainee. It might be argued that it would be advantageous
for those already working in the field but who lack these abilities to do
likewise.
2. Kluckow M. Use of ultrasound in the haemodynamic assessment of the
sick neonate. Arch Dis Child Fetal Neonatal Ed. 2014 Apr 15. doi:
10.1136/archdischild-2013-30492
We congratulate the authors on this study of neonatal transitional
circulation performed so quickly after birth. The authors state that the
ductal flow ratio reported in their study reflects pulmonary and
haemodynamic transition and can be used to monitor neonatal transition in
healthy infants. The implication is that their study describes a
physiological transition in healthy term infants, but we que...
We congratulate the authors on this study of neonatal transitional
circulation performed so quickly after birth. The authors state that the
ductal flow ratio reported in their study reflects pulmonary and
haemodynamic transition and can be used to monitor neonatal transition in
healthy infants. The implication is that their study describes a
physiological transition in healthy term infants, but we question that
this is the case.
Delivery by elective caesarean section is not a physiological birth
but it does permit the neonate an atraumatic birth. We are particularly
concerned that the transition may have been disrupted by the timing of
cord clamping which was between 30 and 60 seconds. While this is
considered delayed cord clamping by some, most guidelines recommend a
minimum of 60 seconds have elapsed before the circulation is interrupted
by cord clamping. The WHO advises 3 minutes.(1) Not all of the babies in
the series had established respiration before clamping and cord clamping
before the onset of respiration has a marked effect on cardiac output.(2)
It is therefore questionable that the mean and range of results published
represents a normal transition in healthy infants.
The normal fetal circulation is well described with the two
ventricles pumping in parallel, the right ventricular output being
significantly more than the left and the flow across two shunts, right to
left in the ductus arteriousus and right to left across the foramen ovale.
The normal neonatal circulation is also well described with equal outputs
by both ventricles and closed shunts. A closer look at the results
suggest some anomalous flow not readily compatible with the end result of
the neonatal circulation. For example at ten minutes the mean right
ventricular output is 343 mls/kg/min and mean left ventricular output is
212 mls/kg/min and the DA flow is 8mls/kg/min left to right. (ratio R to
L =0.9). Where does the right ventricle get the 343 output as only 212 -
8 are reaching the systemic circulation and returning to the right atrium.
Also if the pulmonary blood flow is 343+8 = 351, the excess of 141 must
be spilling left to right across the foramen ovale. Reverse flow in the
foramen ovale is described but has not been quantified. We question that
these flows are evidence that this heart is now close to transitioning to
a parallel ventricular pattern with equal outputs. Reverse flow across the
foramen ovale of 141 is contributing to over 40% of the right ventricular
output. This blood has just been through the pulmonary circulation and is
oxygenated but is now returning to the right ventricle to be pumped
through the pulmonary circulaton once more. Such flow is completely
inefficient. Can the authors explain this anomaly in physiogical terms or
could this finding in fact be a demonstration that the early clamping at
under 60 seconds sometimes before the onset of respiration has indeed
disrupted the transitional circulation ?
Reference
1. World Health Organization (WHO), US Agency for International
Development (US AID), Maternal and Child Health Integrated Program
(MCHIP). (2013). Delayed cord clamping of the umbilical cord to reduce
infant anaemia. Updated 2013. Available from:
http://www.mchip.net/node/1562 (Accessed June 12, 2014).
2. Bhatt S, Alison BJ,Wallace EM, Crossley KJ, Gill AW, Kluckow M, et al.
Delaying cord clamping until
ventilation onset improves cardiovascular function at birth in preterm
lambs. J Physiol 2013 591(Pt
8): 2113-26.
We read with interest the recent publication by Motta and colleagues
(1). Their data pertaining to use of fresh frozen plasma (FFP) in the
neonatal intensive care unit are helpful.
The British Committee for Standards in Haematology transfusion
guidelines (2) suggest that any neonates with significant coagulopathy
[e.g. prothrombin time (PT)/activated partial thromboplastin time (APTT)
ratio >1.5] and signif...
We read with interest the recent publication by Motta and colleagues
(1). Their data pertaining to use of fresh frozen plasma (FFP) in the
neonatal intensive care unit are helpful.
The British Committee for Standards in Haematology transfusion
guidelines (2) suggest that any neonates with significant coagulopathy
[e.g. prothrombin time (PT)/activated partial thromboplastin time (APTT)
ratio >1.5] and significant risk of bleeding (e.g. preterm and/or
intubated, previous periventricular haemorrhage), FFP is indicated. We
believe that this practice may lead to over-transfusion of FFP.
We have recently published data pertaining to the extremely premature
neonatal population (n = 183) born < 27 weeks' gestation on day 1 of
life (3). In this large patient cohort, we observed similar clotting times
to those reported by Motto and co-workers(Table 3) (1) in their similar
but smaller patient population. In our cohort, median (range 25th-75th
percentile) prothrombin time (PT) and activated partial thromboplastin
time (APTT) values were 20.2 (17.8-24.1) and 67.4 (56.3-88.4) seconds,
respectively.
Unfortunately, timing of both cranial sonography and specific
laboratory assessments of haemostasis were not described by Motto et al
(1). Coagulation tests were performed pre FFP transfusion, only 42% of
which occurred in first 3 days of life, with remainder occurring at later
postnatal age. Most intraventricular haemorrhage occurs within first 72
hours of life. The timing of blood sampling may influence results of
coagulation parameters, as coagulation values change with gestational age
(4). The association/lack thereof between IVH and coagulation values is
difficult to establish given lack of clarity regarding timing of both
events.
We agree with the authors that FFP should be used cautiously given
paucity of evidence for effectiveness of these transfusions. Given that
extremely premature infants have median coagulation values > 1.5 ratio,
review of FFP transfusion guidelines is warranted, as many additional
infants may have had FFP without good indication.
(1)Department of Paediatrics, Rotunda Hospital, Dublin, Ireland
(2)Department of Haematology, Rotunda Hospital, Dublin, Ireland
References
1. Motta M, Del Vecchio A, Perrone B, Ghirardello S, Radicioni M.
Fresh frozen plasma use in the NICU: a prospective, observational,
multicentred study. Arch Dis Child Fetal Neonatal Ed. 2014 Mar 19. doi:
10.1136/archdischild-2013-304747. [Epub ahead of print]
2. Gibson BE, Todd A, Roberts I, Pamphilon D, Rodeck C, Bolton-Maggs
P, Burbin G, Duguid J, Boulton F, Cohen H, Smith N, McClelland DB, Rowley
M, Turner G; British Commitee for Standards in Haematology Transfusion
Task Force: Writing group. Transfusion guidelines for neonates and older
children. Br J Haematol. 2004 Feb;124(4):433-53.
3. Neary E, Okafor I, Al-Awaysheh F, et al. Laboratory coagulation
parameters in extremely premature infants born earlier than 27 gestational
weeks upon admission to a neonatal intensive care unit. Neonatology
2013;104:222-7.
4. Andrew M, Paes B, Milner R, et al. Development of the human
coagulation system in the healthy premature infant. Blood 1988;72:1651-7.
We read with interest the article by Rolland et al regarding a
retrospective natural history study of the PDA in a cohort of preterm
infants in a unit which conservatively managed the presence of a PDA after
24 hours(1). We have concerns about the data analysis and the conclusions
drawn. In particular we question the decision to exclude infants who died
within the first 72 hrs and the subsequent exclusion of infants who d...
We read with interest the article by Rolland et al regarding a
retrospective natural history study of the PDA in a cohort of preterm
infants in a unit which conservatively managed the presence of a PDA after
24 hours(1). We have concerns about the data analysis and the conclusions
drawn. In particular we question the decision to exclude infants who died
within the first 72 hrs and the subsequent exclusion of infants who died,
due to inability to determine the date of PDA closure. Out of the total
cohort (103 infants) 12 died and were excluded in the first 72 hrs and a
further 13 subsequently died and were excluded meaning that almost 25% of
the cohort died without having their ductal status documented. As the
authors themselves acknowledge, a significant number of these infants died
from complications that may be related to a PDA, including pulmonary
haemorrhage, intraventricular haemorrhage, unresponsive respiratory or
multisystem failure and NEC. It is misleading to exclude these from the
natural history cohort and this approach by other authors in the past has
led to a potential misrepresentation of the harm that may occur as a
result of a persisting DA. There are several published natural history
series showing significant and strong associations with morbidity and
mortality if all-cause mortality is left in the cohort for analysis
purposes(2,3). Of the total group of 103 infants in this study only 59
(57%) have certain documentation of ductal closure. The balance of 44
infants either died (26 infants) or did not have spontaneous closure
documented using the gold standard of an echocardiogram. 7 infants had a
persisting PDA at discharge which is of itself not a benign outcome with
potential for increased mortality in the first year(2) and a possible
requirement for surgical closure. If it is assumed that all of the
unaccounted for patients had a PDA, the spontaneous closure rate is
actually only 57% - 16% lower than that reported in the conclusion of this
paper of 73%.
The premise of Rolland et al is that early ductal shunting is not
important, whereas work by our group suggests that the first 24-48 hours
may be the most important time for ductal related morbidity. Lack of early
assessment of the hemodynamic effects of a PDA in the first 72 hrs of life
often results in failure to recognise the association between early PDA
and morbidity/mortality. There is clear benefit to early/prophylactic
treatment of a significant PDA including reduced pulmonary haemorrhage and
intraventricular haemorrhage(4). We have recently published a trial of
targeted early treatment vs placebo demonstrating reduction in pulmonary
haemorrhage and reduced later treatment of PDA(5). Benefits from later
treatment after 3 days are less clear and as identified by many authors
should be the subject of well performed RCT's. Performing a cohort study
and excluding infants who have uncertain ductal status and suffer an
adverse outcome is problematic. An alternative conclusion to the data
presented is that a significant number of infants in this cohort died from
potential duct related complications such as pulmonary haemorrhage and
that earlier identification and treatment may have avoided this.
Concluding from the data presented that the exposure to the risk of
therapeutic intervention to close a PDA is not warranted based on
spontaneous closure rates of a selected surviving sub-group is not
justified.
References:
1] Rolland A, Shankar-Aguilera S, Diomand? D et al. Arch Dis Child Fetal
Neonatal Ed
Published Online First: 28 August 2014 doi:10.1136/archdischild-2014-
306339
2] Noori S. McCoy M. Friedlich P et al. Failure of ductus arteriosus
closure is associated with increased mortality in preterm infants.
Pediatrics 2009;123(1):e138-44.
3] Sellmer A, Vandborg Bjerre J,T+Rahbek Schmidt M et al. Morbidity and
mortality in preterm neonates with patent ductus arteriosus on day 3. Arch
Dis Child Fetal Neonatal Ed 2013 Nov;98(6):F505-10.
4] Fowlie PW, Davis PG, McGuire W. Prophylactic intravenous indomethacin
for preventing mortality and morbidity in preterm infants.[Update of
Cochrane Database Syst Rev. 2002;(3):CD000174; PMID: 12137607]. Cochrane
Database Syst Rev 2010;CD000174.
5] Kluckow M, Jeffery M, Gill A et al. A randomised placebo-controlled
trial of early treatment of the patent ductus arteriosus. Arch Dis Child
Fetal Neonatal Ed 2014;99:F99-F104.
Dear Editor
I would like to thank Dr's Madar and Kariholu for their interest in the
recent review article on use of ultrasound to assess the haemodynamic
status of the sick neonate(1,2). They raise an important point that
highlights the current disconnect between the recognition of the
usefulness of ultrasound in general for assessment of sick neonates and
the lack of availability of suitable training courses to learn th...
Dear Editor
I would like to thank Dr's Madar and Kariholu for their interest in the
recent review article on use of ultrasound to assess the haemodynamic
status of the sick neonate(1,2). They raise an important point that
highlights the current disconnect between the recognition of the
usefulness of ultrasound in general for assessment of sick neonates and
the lack of availability of suitable training courses to learn these
skills. They further propose that ultrasound is an essential skill for the
neonatologist and thus a training syllabus in neonatal functional cardiac
assessment should be developed, and foreshadow the incorporation of this
training into neonatal training programs.
Neonatology is not alone in this realisation and there is a steady push to
incorporate ultrasound to help guide clinical care into many specialty
training programs ranging from intensive care, accident and emergency to
surgery and renal medicine(3). Separation of the use of point of care
ultrasound to guide clinical care from a high level consultational
ultrasound to exclude structural pathology is key to gaining acceptance
for the use of ultrasound in this way. In Neonatology it is important to
avoid describing a focused clinical cardiac ultrasound as an
echocardiogram, as this is a term that is usually interpreted as meaning a
high level cardiology based examination, with different expectations and
outcomes. In Australia and New Zealand we have developed a point of care
ultrasound training program for both cardiac and cranial ultrasound(4).
The course has a basic and an advanced module and is based on the
following principles:
1] A physics and safety module
2] An initial introductory theory and hands on course
3] Self directed learning, logbooking and supervision of ultrasound in a
clinical neonatal setting
4] Logbook and competency assessment
5] Reaccreditation requirements
We have found that learning neonatal ultrasound in this "apprenticeship"
setting, similar to that of learning neonatology generally, results in
clinicians who have a clear understanding of the uses and limitations of
ultrasound use in the NICU. Contrary to concerns raised by traditional
users of ultrasound in the neonatal unit, we have found that not only is
physiological management of the sick neonate made easier, but that
significant structural cardiac defects are often identified earlier in the
neonatal course than had been the case before the increased use of
ultrasound to guide clinical care. We have not as yet mandated this
training as part of the national neonatal training program, mainly because
we are unable to guarantee access to training to all trainees. This will
change as the critical mass of neonatologists using ultrasound increases.
I encourage Dr's Madar and Kariholu to engage with colleagues interested
in developing a neonatal ultrasound training program in the United Kingdom
and make it a reality.
(1).Kluckow M Use of ultrasound in the haemodynamic asessment of the
sick neonate. Arch. Dis. Child. Fetal Neonatal Ed. 2014 99:F332-F337;
doi:10.1136/archdischild-2013-304926
(2). John Madar, Ujwal Kariholu. Cardiac assessment using echocardiography
in the sick neonate - An unmet need for a training syllabus for aspiring
neonatologists.Arch. Dis. Child. Fetal Neonatal Ed. 2014
(3). Moore CL and Copel JA. Point of care ultrasonography. N Engl J Med.
2011 Feb 24;364(8):749-57
(4). http://www.asum.com.au/newsite/Education.php?p=CCPU-Neonatal
Lawson's editorial and Emond and colleagues' article exposes potentially bad medicine: lack of knowledge of normal and variations of normal; lack of knowledge of the natural history of a condition; a desire to do something - Ulysses syndrome (1); medicalising the child by giving the condition a name; and then ascribing any improvement to the intervention, forgetting that association does not mean causation.
Th...
Sirs
The tongue remains with in the boundaries of the mandible during suckling and so it is difficult to see the anatomical or the physiological basis for how a frenulectomy works in reducing breast and nipple discomfort during feeding. This randomised trial does not seem to assess the potential, positive psychological impact of the mother being told their child has had a frenulectomy. That is the question that...
We thank Dr. Verd and colleagues for their comments [1] on our review of the use of human milk for preterm infants. Our aim was certainly not to discourage the use of donor human milk, but rather to look objectively at the evidence base that currently exists for its use.
The authors of the letter refer to a 1984 study by Narayanan et al [2] which appeared to show a reduction in the risk of infection in infants fe...
Dr Essex and Mr Mercer highlight many of the reasons why we undertook the Bristol Tongue Tie trial. Ankloglossia is a spectrum condition, which overlaps with 'normal' variation in anatomy, and milder forms do not result in feeding impairment. There is very limited evidence of the need for frenotomy in mild-moderate degrees of tongue tie. However, it is also true that at the severe end of the spectrum infants can be limi...
Dear Dr. Gallagher,
We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a docum...
In the UK speciality training through the grid scheme has been in existence for about a decade with a well-defined syllabus of knowledge and skills deemed necessary for the qualified neonatologist. Although much emphasis is laid on various aspects of neonatal care and the acquisition of procedural skills including cranial ultrasound, cardiac assessment using echocardiography is still considered to be an optional skill (1)...
Dear Sir,
We congratulate the authors on this study of neonatal transitional circulation performed so quickly after birth. The authors state that the ductal flow ratio reported in their study reflects pulmonary and haemodynamic transition and can be used to monitor neonatal transition in healthy infants. The implication is that their study describes a physiological transition in healthy term infants, but we que...
We read with interest the recent publication by Motta and colleagues (1). Their data pertaining to use of fresh frozen plasma (FFP) in the neonatal intensive care unit are helpful.
The British Committee for Standards in Haematology transfusion guidelines (2) suggest that any neonates with significant coagulopathy [e.g. prothrombin time (PT)/activated partial thromboplastin time (APTT) ratio >1.5] and signif...
We read with interest the article by Rolland et al regarding a retrospective natural history study of the PDA in a cohort of preterm infants in a unit which conservatively managed the presence of a PDA after 24 hours(1). We have concerns about the data analysis and the conclusions drawn. In particular we question the decision to exclude infants who died within the first 72 hrs and the subsequent exclusion of infants who d...
Dear Editor I would like to thank Dr's Madar and Kariholu for their interest in the recent review article on use of ultrasound to assess the haemodynamic status of the sick neonate(1,2). They raise an important point that highlights the current disconnect between the recognition of the usefulness of ultrasound in general for assessment of sick neonates and the lack of availability of suitable training courses to learn th...
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