Many procedural interventions remain a burden as they result in pain
or discomfort in neonates. Adequate management of pain necessitates an
integrated approach. Such an approach should also include the use of the
most effective methods to perform a given procedure. [1] We therefore
appreciate the paper on the randomized comparison between binocular
indirect ophthalmoscopy (BIO) and wide-field digit...
Many procedural interventions remain a burden as they result in pain
or discomfort in neonates. Adequate management of pain necessitates an
integrated approach. Such an approach should also include the use of the
most effective methods to perform a given procedure. [1] We therefore
appreciate the paper on the randomized comparison between binocular
indirect ophthalmoscopy (BIO) and wide-field digital retinal imaging
(WFDRI) recently published by Dhaliwal et al. in this journal. [2] Based
on observations collected in 76 infants, the authors concluded that both
techniques resulted in a similar pain response and speculated that the
pain during screening for retinopathy of prematurity was mainly due to the
introduction of the speculum.
We recently also reported on the clinical pain response during BIO and
compared these observations with the outcome variables as described by
Belda et al. [3,4] However, instead of the classic scleral indentation
technique as used by Belda et al. and by Dhaliwal et al., the eyelid was
kept open with a 20 diopter lens (Fabrilens). [5] A blunted clinical
stress response was observed with a faster return to baseline in neonates
in whom the Fabrilens was used since CRIES score returned to pre-
intervention values within 5 minutes while changes in cardiovascular
indicators were less prominent. We therefore confirm the hypothesis
formulated by Dhaliwal et al. that indeed the introduction of the eyelid
speculum results in the pain response.
In addition to the prospective validation of various (non)pharmacological
interventions for procedural pain relief, there is extensive field of
prospective evaluation of various procedural techniques waiting for
neonatal caregivers, nurses and doctors, to generate the data urgently
needed reduce the pain and stress associated with the medical and nursing
care in neonates.
References
1.Allegaert K, Veyckemans F, Tibboel D. Clinical practice: analgesia in
neonates. Eur J Pediatr 2009;168:765-770.
2.Dhaliwal CA, Wright E, McIntosh N, Dhalial K, Fleck BW. Pain in neonates
during screening for retinopathy of prematurity using binocular indirect
ophthalmoscopy and wide-filed digital retinal imaging: a randomised
comparison. Arch Dis Child Fetal Neonatal Ed 2009 (online available)
DOI:10.1136/adc.2009.168971
3.Belda S, Pallas CR, De la Cruz J, Tejada P. Screening for retinopathy of
prematurity: is it painful? Biol Neonate 2004;86:195-200.
4.Allegaert K, Tibboel D. Shouldn’t we reconsider procedural techniques to
prevent neonatal pain? Eur J Pain 2007;11:910-912.
5.Missotten L, Afschrift L. Contact lenses for ophthalmoscopy in children
and premature. Bull Soc Belge Ophthalmol 1975;172:802-804.
Azzopardi et al (1) report the experience of introducing total body
cooling as a standard form of therapy for infants with moderate or severe
perinatal asphyxia. It is notable that this publication includes only one
level 2 neonatal intensive care unit of the 25 units providing data for
the TOBY register (Royal Cornwall Hospital, Truro). The Royal Devon and
Exeter Hospital (also a level 2 unit) has since joined the TOBY...
Azzopardi et al (1) report the experience of introducing total body
cooling as a standard form of therapy for infants with moderate or severe
perinatal asphyxia. It is notable that this publication includes only one
level 2 neonatal intensive care unit of the 25 units providing data for
the TOBY register (Royal Cornwall Hospital, Truro). The Royal Devon and
Exeter Hospital (also a level 2 unit) has since joined the TOBY register
having participated in the TOBY trial. Part of the success in
recruitment to the TOBY trial was due to the trial being rolled out to
many more units in the second phase of the trial (2). The Peninsula
Neonatal Network level 3 unit at Derriford Hospital in Plymouth
participated in this trial as did the two level 2 units in Exeter and
Truro. All the units were very well supported by training days set up at
the units by the TOBY trial investigators.
In the Peninsula Neonatal Network this system of care has continued
and total body cooling is provided at the three units that participated in
the TOBY trial. Since the trial 6 babies have been cooled in Exeter and 9
babies in Truro. The two level 2 units inform the level 3 unit of infants
that are being cooled. We believe that there are significant advantages
providing total body cooling on a locality basis when the skills are there
and the training is continually updated as long as the infant is stable
without evidence of multi-system problems. There is close liaison on these
issues with the level 3 centre. Early treatment is important and this is
best done as soon as possible in the unit in which the infant is born.
There are real benefits to not transferring the infant out to another unit
particularly when the delivery has been traumatic and there may be a
number of questions from parents and vital issues of communication about
obstetric management. These can be addressed quickly and locally in these
high risk situations. Providing thermal control for infants is part of
the everyday management of neonatal units and the level 2 units have had
no difficulty in the technical aspects of providing body cooling. This is
likely to be made easier with the advent of servo controlled cooling. We
all contribute to the TOBY register which provides feedback on our
temperature control and all those providing cooling in the units have
attended and presented at regional and national meetings on total body
cooling.
We believe that there is a strong case to be made for level 2 units
who have experience of cooling to continue to provide this. It is
important to remember that one of the central tenets of the NHS is to
provide appropriate care as close to home as possible for the family. The
case for cooling to be provided in level 2 units rests on the support
structures and a rigorous approach to case review and quality
control/audit both through the TOBY register and by local oversight. The
network approach establishes this by ensuring treatment is supported as a
network provision, not as a unit provision.
Yours sincerely
Dr Michael Quinn
Consultant Neonatal
Paediatrician,
Neonatal Unit,
Royal Devon and Exeter Hospital,
Barrack Rd,
Exeter EX2 5DW
Dr Paul Munyard
Consultant Neonatal
Paediatrician,
Neonatal Unit,
Royal Cornwall Hospital,
Treliske,
Truro TR1 3LJ.
Correspondence to Dr Michael Quinn.
Competing Interests: None
REFERENCES
1. Azzopardi D, Strohm B, Edwards AD, Halliday H, Juszczak E, Levene
M, Thoresen M, Whitelaw A, Brocklehurst P on behalf of the Steering Group
and TOBY Cooling Register participants. Treatment of asphyxiated newborns
with moderate hypothermia in routine clinical practice: how cooling is
managed in the UK outside a clinical trial. Arch Dis Child (Fetal and
Neonatal Edition) 2009; 94 (4):F260-F264
2. Azzopardi D, Strohm B, Edwards AD, Dyet L, Halliday H, Juszczak E,
Kapellou O, Levene M, Marlow N, Porter E, Thoresen M, Whitelaw A,
Brocklehurst P for the TOBY Study Group. Moderate hypothermia to treat
perinatal asphyxial encephalopathy. N Eng J Med 2009; 361 (14): 1349-1358
Dear editor, the article by Keren et al 'Visual assessment of
jaundice in term and late preterm infants' justifies the limitations of
visual assessment of jaundice in newborns. The authors have advised to do
serum bilirubin levels in case of visible jaundice. The problem with total
serum bilirubin level is that it is dependent on the serum albumin level.
Therefore a healthy newborn with a good serum albumin will bind bili...
Dear editor, the article by Keren et al 'Visual assessment of
jaundice in term and late preterm infants' justifies the limitations of
visual assessment of jaundice in newborns. The authors have advised to do
serum bilirubin levels in case of visible jaundice. The problem with total
serum bilirubin level is that it is dependent on the serum albumin level.
Therefore a healthy newborn with a good serum albumin will bind bilirubin
which will appear in the circulation showing a high serum bilirubin level
despite having low levels in the tissues as compared to a preterm or sick
neonate with low albumin levels where despite low serum bilirubin level
due to poor binding to albumin and more tissue bound bilirubin, there is
an increased risk of damage to the tissues including the brain. Also, the
laboratory estimations of bilirubin are quite variable. Till free
bilirubin measurements are available we are forced to use these surrogate
markers of bilirubin which are far from being perfect in predicting the
brain damage.
Dear Sir,
Dr Hawkes is right, if a gas flow meter that will deliver
very high flows when turned
up to its maximum flow, which may be over 80 L/min, is used
with the Neopuff then if
the flow is increased about the set level dangerously high
levels of PIP and PEEP
will be delivered.
What is not commonly known is that some flow meters that are
marked to deliver a
flow from 0 to 15 L/min can deliver these very high flows
whi...
Dear Sir,
Dr Hawkes is right, if a gas flow meter that will deliver
very high flows when turned
up to its maximum flow, which may be over 80 L/min, is used
with the Neopuff then if
the flow is increased about the set level dangerously high
levels of PIP and PEEP
will be delivered.
What is not commonly known is that some flow meters that are
marked to deliver a
flow from 0 to 15 L/min can deliver these very high flows
which will overwhelm the
pressure control valves in the Neopuff. A flow meter should
never be used with the
Neopuff that can deliver a maximum gas flow above 15 L/min.
The practical message for all who use the Neopuff is that it
should be used
according to the manufacturer’s instructions.
• The recommended operating gas flow range is 5 to 15 L/min.
It specifically
says, “Do not attempt to use a flow higher than 15 L/min".
• Adjust the gas supply to the desired flow rate between 5
and 15 L/min then
set the PIP and PEEP.
• If the flow rate increases from 5 to 15L/min, peak
pressure typically increases
approximately 8 cm H2O/mbar.
• The Neopuff should only be used on a baby after checking
that correct
pressures will be delivered to the baby.
If the Neopuff PIP and PEEP are set with a flow of 5 L/min
then if the flow is
increased to 10 L/min the PEEP will rise to about 15 cm H2O
and the PIP will be
similar to, or just above the set PIP even when max PIP is
set very high. If the flow is
increased to 15 L/min the PEEP rises to about 24 cm H2O and
PIP is similar to, or
just above the set PIP even when max PIP is set very high.
The effect of increasing
the flow to 15 L/min will be much less if the PIP and PEEP
were set at a flow of 10
l/min at the start.
The practical clinical messages are simple
1) Pick a flow you are going to use, we suggest 8 L/min
should be more than
adequate, set the PEEP and PIP and then don’t alter the
flow.
2) If the PEEP and PIP are not being delivered this is due
to a large leak
between the mask and face and that should be remedied by
altering mask
position and hold and not by increasing the flow.
Yours sincerely,
Colin Morley, Georg Schmoelzer, Peter Davis
We read with interest Laing’s article on controlling an outbreak of
MRSA in a neonatal unit. We have also learnt from outbreaks on our
neonatal unit. Laing et al talk about cohort nursing for those babies
found to be colonised. In our experience it is important to isolate/cohort
not just those babies that are MRSA colonised, but also to cohort those
babies whom are known contacts, with MRSA swabs repeated weekly. It is
i...
We read with interest Laing’s article on controlling an outbreak of
MRSA in a neonatal unit. We have also learnt from outbreaks on our
neonatal unit. Laing et al talk about cohort nursing for those babies
found to be colonised. In our experience it is important to isolate/cohort
not just those babies that are MRSA colonised, but also to cohort those
babies whom are known contacts, with MRSA swabs repeated weekly. It is
important that both staff and parents realise that a single negative MRSA
screen does not outrule low level colonisation in the baby. For this
reason, we continue to isolate or cohort nurse both MRSA positive babies
and their contacts until discharge from the neonatal unit. We ask that all
staff; including pharmacists and radiographers visit these rooms last when
visiting the neonatal unit. We ensure people maintain scrupulous hand
hygiene practices.
We acknowledge that the treatment of staff is contentious. Laing et
al mention anonymised staff screening. We have used a screen and treat
approach i.e, all staff are screened and immediately started on a
decolonisation protocol. The advantage of this approach is that positive
individuals do not usually have to be subsequently removed from duty.
Good communication is vital during such an outbreak. Regular meetings
briefing neonatal staff and also key individuals in affiliated departments
(e.g. obstetrics and midwifery), supported by circulated minutes ensure
that everyone is receiving the same information. We keep daily cot
position maps detailing where each baby is, so as to see how spread might
have occurred. If the neonatal unit closes, it is important to notify all
other hospitals within the perinatal network to ensure that they know that
they may be receiving a higher workload and will not be able to repatriate
babies back to the affected unit.
Dr Geraldine Ng, Consultant Neonatologist, St Mary’s Hospital,
Imperial College Healthcare NHS Trust, London
Dr Marianne Nolan, Consultant Microbiologist, St Mary’s Hospital,
Imperial College Healthcare NHS Trust, London
References
1. Laing IA, Gibb AP, McCallum A. Controlling an outbreak of MRSA in
the neonatal unit: a steep learning curve. Arch Dis Child 2009;94:F307-310
2. Deurenberg RH, Stobberingh EE. The molecular evolution of hospital
- and community-associated methicillin-resistant Staphylococcus aureus.
Curr Mol Med. 2009;9(2):100-15
We read with interest the article by K Ganesan et al 1 about using
prophylactic oral Nystatin to prevent fungal colonisation and invasive
fungaemia. We strongly support this practice especially in preterm babies
who are on broad spectrum antibiotics.
It is interesting to know if the authors discovered any other
bacterial organisms apart from candida in there routine surveillance
swabs. We in our unit in Royal O...
We read with interest the article by K Ganesan et al 1 about using
prophylactic oral Nystatin to prevent fungal colonisation and invasive
fungaemia. We strongly support this practice especially in preterm babies
who are on broad spectrum antibiotics.
It is interesting to know if the authors discovered any other
bacterial organisms apart from candida in there routine surveillance
swabs. We in our unit in Royal Oldham hospital (large District Hospital 16
neonatal level 2 Cots) not only swab babies but also there
microenvironment, toys and religious items left in incubators and cots. In
a recent random safety study we found 16 items in 10 cots, surveillance
swabs taken form them revealed scanty growth of skin organisms in 7,
scanty to moderate growth of coliforms in 3 and scanty growth of
staphylococci in 1. It is interesting to note that none of these
environmental swabs demonstrated any fungal colonisation. In view of the
above study findings we follow a ‘No soft toys or religious items in
cots/incubators policy’ along with the enforcement of strict hand washing
policy.
Prophylactic nystatin could be the way forward to prevent fungal
colonisation but what about colonisation from other bacterial organisms?.
The age old saying ‘Prevention is better than cure’ stands true in our
fight against infection and hence the need to maintain a clean
microenvironment in the neonatal unit.
It was with interest that I read the article by Whittaker et al
regarding toxic additives in medication for preterm infants, particularly
the assessment of alcohol intake in the infant population treated with
furosemide oral solution. I was surprised by the statement “ethanol
exposure in the preterm infants … ranged from 0.2mL to 1.8mL/ week
uncorrected for weight, the equivalent of a 70kg man consuming between 1
and 7...
It was with interest that I read the article by Whittaker et al
regarding toxic additives in medication for preterm infants, particularly
the assessment of alcohol intake in the infant population treated with
furosemide oral solution. I was surprised by the statement “ethanol
exposure in the preterm infants … ranged from 0.2mL to 1.8mL/ week
uncorrected for weight, the equivalent of a 70kg man consuming between 1
and 7 units”. I agree that the alcohol content of oral medications should
be of concern and that infants should not be exposed to alcohol if at all
possible. However I found the analogy with the weekly alcohol intake of
a 70kg man alarming and challenge this calculation.
Whittaker et al put forth two “safe limits”. The first is the
recommended safe weekly limit of ethanol consumption of 3mL/kg/week, the
other 0.14mL/kg/week. Which limit is to be used? The highest ethanol
exposure in neonates depicted in Figure 1 is approximately 0.6mL/kg/week.
Although this is equivalent to approximately 4 units of alcohol/week, it
does not exceed the stated safe weekly limit.
In Canada, furosemide 10mg/mL oral solution (Lasix) contains 0.2mL of
ethanol 95% in each milliliter (verbal communication with Sanofi-Aventis).
The usual dose used for chronic lung disease is 2mg/kg/day or
0.2mL/kg/day, equivalent to 1.4mL/kg/week. The amount of ethanol in this
volume of furosemide oral solution is 0.28mL/kg/week, equivalent to
approximately 2 units of alcohol/week, but not exceeding the stated safe
weekly limit.
The statements comparing alcohol intake in infants to that of a 70kg
male are not only alarming and sensationalized, but do not address the
balance of risk/benefit that must be considered when treating any medical
condition with a medication. Constructive alternatives should be sought to
avoid alcohol intake in infants.
We would like respond to the eLetter from Dr Schmoelzer et al,
regarding
our paper entitled "Potential Hazard of the Neopuff T-Piece Resuscitator
in
the Absence of Flow Limitation".
Dr Schmoelzer et al have verified our findings that even an increase
in
flow from 5-15L/min will bring about a four-fold increase in PEEP, a
serious
potential hazard of the Neopuff. His failure to reproduce...
We would like respond to the eLetter from Dr Schmoelzer et al,
regarding
our paper entitled "Potential Hazard of the Neopuff T-Piece Resuscitator
in
the Absence of Flow Limitation".
Dr Schmoelzer et al have verified our findings that even an increase
in
flow from 5-15L/min will bring about a four-fold increase in PEEP, a
serious
potential hazard of the Neopuff. His failure to reproduce our maximum PIP
was due to his use of a lower flush flow meter.
We encourage all users of this device to investigate the effects of
changing
gas flow on their own systems, in order to be aware of the potential
hazards of the Neopuff device. We stand by the findings of our study that
there is a "Potential Hazard with the Neopuff T-Piece Resuscitator in the
absence of flow limitation".
Verhagen et al (1) recently reported practice patterns from Dutch
NICU’s for the use of analgesia, sedation and neuromuscular blockers
(NMBs) in neonatal end-of-life (EOL) care. The authors are to be commended
for their efforts in documenting their practice. Their data show that
analgesia and sedation was provided to 292/340 newborns following the
decision to withdraw or withhold active treatment. Of particular interest...
Verhagen et al (1) recently reported practice patterns from Dutch
NICU’s for the use of analgesia, sedation and neuromuscular blockers
(NMBs) in neonatal end-of-life (EOL) care. The authors are to be commended
for their efforts in documenting their practice. Their data show that
analgesia and sedation was provided to 292/340 newborns following the
decision to withdraw or withhold active treatment. Of particular interest
to me was the fact that this type of medication was increased in 94
newborns whose death was imminent, and that NMBs were administered in 16%
of deaths. This makes me wonder whose pain and suffering our Dutch
colleagues were alleviating.
I think few neonatologists will disagree with the sentiment that
babies who are destined to die should not suffer. Therefore, in infants
who are already receiving analgesia and sedation as part of their medical
treatment, it seems eminently reasonable to continue such treatment to
avoid discomfort due to withdrawal symptoms . Also, if infants during this
process display signs of pain or discomfort, increasing analgesia is the
humane thing to do.
However, when I look at the data from Verhagen et al’s study, I find
myself wondering whether Dutch infants are “a different breed” compared to
Norwegian or U.S. babies. In my own experience, which includes >30
years in pediatrics and >20 years in full-time neonatology both in
Norway and in the USA, it is quite rare for dying infants to exhibit signs
of pain during the process of death. Parents are often worried that this
may happen, and I always assure them that analgesia will be instantly
available and given without hesitation should the baby show signs of
discomfort. The nurses I have worked with over the years have without
exception been very attentive to any signs of pain, and absolutely
unwilling to accept suffering without relief. In spite of this, the need
for additional analgesia is rare. Are Dutch infants different, or is this
apparent difference in the use of analgesia due to philosophical
differences with our Dutch colleagues as regards death and dying?
The use of NMBs documented by Verhagen et al suggests that perhaps
the latter may be true. NMBs are devoid of any analgetic or sedative
properties, therefore giving NMBs to a dying baby will not alleviate any
pain, if indeed the infant should be suffering. Quite the contrary, the
NMBs will effectively prevent the infant from signaling discomfort. NMBs
are apparently used by our Dutch colleagues to prevent or stop gasping. I
am unaware of any published evidence that terminal gasping in a dying
person is associated with pain. As respiration and circulation fail,
increasing respiratory acidosis will send the baby into CO2 anesthesia.
Gasping represents the last valiant efforts of the respiratory center to
do its job, but by this time the baby is deeply unconscious and very
unlikely to be suffering. NMBs given at this time may relieve the
discomfort of those watching, but I seriously question the wisdom of this
approach.
In my experience, honest and compassionate communication with the
parents ahead of withdrawal of life support is a sine qua non for good EOL
care in infants. We carefully explain to the parents about terminal
gasping and what it means, as well as other phenomena that may cause
concern, such as the fact that the heart will continue to beat for quite a
while after the baby has stopped breathing. The infants are typically
swaddled in their blankets and caressed, rocked, and cradled by their
parents. At least one member of the staff will be present at all times,
unless the parents signal that they wish to be alone with the child.
Family and friends are also sometimes part of this process. It is intense,
emotional, and painful, but then grief always is. In fact, there is reason
to believe that unless death is perceived as real, the healing process of
grieving may be derailed. If we, even with the best intentions, gloss over
death by pharmacological cosmetics that are aimed at the living but do not
help the dying, we may be doing a great disservice. NMBs do not help the
dying baby, and therefore should have no place in neonatal EOL care.
Thor Willy Ruud Hansen, MD, PhD, MHA, FAAP
Neonatal Intensive Care Unit
Oslo University Hospital - Rikshospitalet
University of Oslo, Norway
References
1. Verhagen AAE, Dorscheidt JHHM, Engels B, Hubben JH, Sauer PJ.
Analgesics, sedatives and neuromuscular blockers as part of end-of-life
decisions in Dutch NICU’s. ADC-FNN Online First 10.1136/adc.2008.149260
Further to the review by Brecht et al[1], we report our recent
experience of Candida blood stream infections (CBSI’s) in our tertiary
service. Over an 8 year period, we identified 30 infants with CBSI’s from
a cohort of 1474 VLBW infants (2%). The incidence was 6% and 4.3%, for
infants born weighing <750 and 750-1000 grams respectively.
This is similar to the incidence reported in 2002 by the National
Instit...
Further to the review by Brecht et al[1], we report our recent
experience of Candida blood stream infections (CBSI’s) in our tertiary
service. Over an 8 year period, we identified 30 infants with CBSI’s from
a cohort of 1474 VLBW infants (2%). The incidence was 6% and 4.3%, for
infants born weighing <750 and 750-1000 grams respectively.
This is similar to the incidence reported in 2002 by the National
Institute of Child Health and Human Development Neonatal Network[2]. More
recently, the National Nosocomial Infections Surveillance System (1995-
2004), have identified a falling incidence in infants weighing <1000g
and a very wide range in incidence between hospitals[3]. However, from
2004 we have seen an increase in CBSI’s (Table 1).
Also in our experience, the median day of life for a positive blood
culture was only 10 days (range 4-83 days). This is earlier than
expected3 and may represent an increase in perinatally acquired infection.
More than half of mothers had received antibiotics in the month before
delivery. Candida albicans species was identified in 21 cases and Candida
parasilosis in 4 cases. Seven cases (23%) cases had a either NEC or
isolated bowel perforation. All had central lines. In fourteen patients,
Candida was also found in urine (Table 2).
Since 2006, Caspofungin has been used as a second line agent in four
cases and was used as first line treatment in seven cases, with a trend
towards improved survival. We don’t routinely use intravenous antifungals
with episodes of presumed sepsis. But we now have a low threshold for
considering CBSI as a cause of sepsis, early in the neonatal period in
extremely premature babies, particularly in the presence of early broken
skin, central lines and abdominal problems.
REFERENCES
1. Brecht M, Clerihew L, McGuire W. Prevention and treatment of
invasive fungal infection in very low birthweight infants. Arch. Dis.
Child. Fetal Neonatal Ed 2009;94:F65-69.
2. Stoll B, Hansen N, Fanaroff A, et al. Late-onset sepsis in very
low birth weight neonatas: the experience of the NICHD Neonatal Research
Network. Pediatrics 2002;110:285-91.
3. Fridkin SK, Kaufman D, Edwards JR, et al. Changing incidence of
Candida bloodstream infections among NICU patients in the United
States:1995-2004. Pediatrics 2006;117:1680-7.
dear editor,
Many procedural interventions remain a burden as they result in pain or discomfort in neonates. Adequate management of pain necessitates an integrated approach. Such an approach should also include the use of the most effective methods to perform a given procedure. [1] We therefore appreciate the paper on the randomized comparison between binocular indirect ophthalmoscopy (BIO) and wide-field digit...
Azzopardi et al (1) report the experience of introducing total body cooling as a standard form of therapy for infants with moderate or severe perinatal asphyxia. It is notable that this publication includes only one level 2 neonatal intensive care unit of the 25 units providing data for the TOBY register (Royal Cornwall Hospital, Truro). The Royal Devon and Exeter Hospital (also a level 2 unit) has since joined the TOBY...
Dear editor, the article by Keren et al 'Visual assessment of jaundice in term and late preterm infants' justifies the limitations of visual assessment of jaundice in newborns. The authors have advised to do serum bilirubin levels in case of visible jaundice. The problem with total serum bilirubin level is that it is dependent on the serum albumin level. Therefore a healthy newborn with a good serum albumin will bind bili...
Dear Sir, Dr Hawkes is right, if a gas flow meter that will deliver very high flows when turned up to its maximum flow, which may be over 80 L/min, is used with the Neopuff then if the flow is increased about the set level dangerously high levels of PIP and PEEP will be delivered. What is not commonly known is that some flow meters that are marked to deliver a flow from 0 to 15 L/min can deliver these very high flows whi...
We read with interest Laing’s article on controlling an outbreak of MRSA in a neonatal unit. We have also learnt from outbreaks on our neonatal unit. Laing et al talk about cohort nursing for those babies found to be colonised. In our experience it is important to isolate/cohort not just those babies that are MRSA colonised, but also to cohort those babies whom are known contacts, with MRSA swabs repeated weekly. It is i...
We read with interest the article by K Ganesan et al 1 about using prophylactic oral Nystatin to prevent fungal colonisation and invasive fungaemia. We strongly support this practice especially in preterm babies who are on broad spectrum antibiotics.
It is interesting to know if the authors discovered any other bacterial organisms apart from candida in there routine surveillance swabs. We in our unit in Royal O...
It was with interest that I read the article by Whittaker et al regarding toxic additives in medication for preterm infants, particularly the assessment of alcohol intake in the infant population treated with furosemide oral solution. I was surprised by the statement “ethanol exposure in the preterm infants … ranged from 0.2mL to 1.8mL/ week uncorrected for weight, the equivalent of a 70kg man consuming between 1 and 7...
Dear Editor,
We would like respond to the eLetter from Dr Schmoelzer et al, regarding our paper entitled "Potential Hazard of the Neopuff T-Piece Resuscitator in the Absence of Flow Limitation".
Dr Schmoelzer et al have verified our findings that even an increase in flow from 5-15L/min will bring about a four-fold increase in PEEP, a serious potential hazard of the Neopuff. His failure to reproduce...
Verhagen et al (1) recently reported practice patterns from Dutch NICU’s for the use of analgesia, sedation and neuromuscular blockers (NMBs) in neonatal end-of-life (EOL) care. The authors are to be commended for their efforts in documenting their practice. Their data show that analgesia and sedation was provided to 292/340 newborns following the decision to withdraw or withhold active treatment. Of particular interest...
Further to the review by Brecht et al[1], we report our recent experience of Candida blood stream infections (CBSI’s) in our tertiary service. Over an 8 year period, we identified 30 infants with CBSI’s from a cohort of 1474 VLBW infants (2%). The incidence was 6% and 4.3%, for infants born weighing <750 and 750-1000 grams respectively.
This is similar to the incidence reported in 2002 by the National Instit...
Pages