In a recent article Stevenson and colleagues[1] report further data
showing increased vulnerability of male compared to female infants in
early life, and comment that the biological mechanisms contributing to the
male disadvantage or female advantage have not been elucidated.
In fact, male vulnerability in early life is consistent with an
aspect of evolutionary theory described by Trivers...
In a recent article Stevenson and colleagues[1] report further data
showing increased vulnerability of male compared to female infants in
early life, and comment that the biological mechanisms contributing to the
male disadvantage or female advantage have not been elucidated.
In fact, male vulnerability in early life is consistent with an
aspect of evolutionary theory described by Trivers and Willard in 1973.[2] Their theory addressed changes in the sex ratio at birth in relation
to the quality of the maternal environment during pregnancy. Further
elaboration of the theory allows post-natal morbidity and mortality to be
included within the same mechanism.[3] Relative to female infants, male
infants represent a better maternal "strategy" for maximising reproductive
success in a good environment, but a worse maternal "strategy" in a poor
environment. Evolution has therefore favoured enhanced male vulnerability
in poor environments as a means of maximising maternal lifetime
reproductive success.[2] [3]
Increased male mortality and morbidity have been reported throughout
the 20th century,[3] and are reflected in increased male rates of
hospitalisation and outpatient admission. The male disadvantage may
therefore be considered a natural aspect of human biology, although
differential medical care appears to overcome the deficit in societies
where male offspring are preferred to female offspring.[4] As medical
care improves, and more low birth weight and preterm infants initially
survive, excess male morbidity and subsequent mortality are predicted to
increase, as has already been observed in recent decades.[3]
Jonathan CK Wells
MRC Childhood Nutrition Research Centre
Institute of Child Health
30 Guilford Street
London WC1N 1EH
References
(1) Stevenson DK, Verter J, Faranoff AA, et al. Sex differences in
outcomes of very low birthweight infants: the newborn male disadvantage.
Arch Dis Fetal Neonatal Ed 2000;83:F182-5.
(2) Trivers RL, Willard DE. Natural selection of parental ability to
vary the sex ratio of offspring. Science 1973;179:90-2.
(3) Wells JCK. Natural selection and sex-differences in morbidity and
mortality in early life. J Theor Biol 2000;202:65-76.
(4) Xu B, Rantakallio P, Järvelin M-J, Fang XL. Sex differentials in
perinatal mortality in China and Finland. Soc Biol 1997;44:170-8.
The three excellent articles on twin to twin transfusion syndrome
(TTTS) provide futher important data for clinical decisions and parental
counselling. We would like to comment on the paper by Cincotta et al.[1]
We are interested in the incidence of hydrops and absence of end
diastolic velocity of the umbilical artery in the cohort and their
correlation with outcome. A recent study of 33 pregn...
The three excellent articles on twin to twin transfusion syndrome
(TTTS) provide futher important data for clinical decisions and parental
counselling. We would like to comment on the paper by Cincotta et al.[1]
We are interested in the incidence of hydrops and absence of end
diastolic velocity of the umbilical artery in the cohort and their
correlation with outcome. A recent study of 33 pregnancies with TTTS by
Mari et al[2] showed that the presence of hydrops of the recipient and
absence of the end-diastolic velocity of the umbilical artery in one of
the twins were associated with poor prognosis.
In contrast with the findings of Mari et al[2] the Brisbane group did
not find any significant difference in the mean weight between the donor
and recipient twins. We wondered whether this is due to efficacy of
obstetrics interventions, a less severe nature of the TTT or a shorter
duration between time of diagnosis and delivery. We believe that the data
should have included a comparison between the donor and recipient twins in
both short term and longer-term outcomes. Interestingly Mari et al found
3 of 28 recipient twins had periventricular leukomalacia compared with
none of the 23 donor live born twins although the difference was not
significant.
The authors should state how many of the babies in their cohort were
less than 27 weeks' gestation at birth as one study of 112 cases of TTTS
showed a drop in survival from 70% at 27 weeks to less than 25% at 26
weeks or earlier.[3]
We also note that 8 babies in the cohort had chronic lung disease.
The findings by Shinwell et al published in the same issue of the ADC
emphasised yet again the worrisome association between post natal steroids
with increased cerebral palsy[4]; it would therefore be useful to know
how many of the babies in the TTTS group had post natal steroids and
whether these babies were over represented in those with cerebral palsy.
It would also be interesting to know what percentage of the cohort
were IUGR. We believe that TTTS could provide an ideal situation to test
Barker’s hypothesis of in utero programming for morbidities during later
life.[5]
THHG Koh MA FRCPCH FRACP Senior Staff Specialist in Neonatal
Paediatrics
Collie L RN Neonatal Research Nurse
Budge D RN Neonatal Research Nurse
Regional NICU, Kirwan Hospital
Townsville, Great Barrier Reef Queensland 4817 Australia
fax 0747730320
References
(1) Cincotta RB, Gray PH, Phythian G, Rogers YM, Chan FY. Long term outcome of twin-twin transfusion syndrome. Arch Dis Child Fetal Neonatal Ed 2000;83:F171-6.
(2) Mari G, Detti L, Oz U, Abuhamad AZ. Long-term outcome in twin-twin transfusion syndrome treated with serial aggressive amnioreduction. Am J Obstet Gynecol 2000;183:211-17.
(3) Dickinson JE, Evans SF. Obstetric and perinatal outcomes from the
Australian and New Zealand Twin-Twin Syndrome Registry. Am J Obstet Gynecol 2000;182:706-12.
(4) Shinwell ES, Karplus M, Reich D, Weintraub Z, Blazer S, Bader D, Yurman S, Dolfin T, Kogan A, Dollberg S, Arbel E, Goldberg M, Gur I, Naor N, Sirota L, Mogilner S, Zaritsky A, Barak M, Gottfried. Early postnatal
dexamethasone treatment and increased incidence of cerebral palsy. Arch Dis Child Fetal Neonatal Ed 2000;83:F177-F81.
(5) Barker DJ. In utero programming of cardiovascular disease. Theriogenology. 2000;53:555-74.
Whitelaw and Thoresen recently reviewed the current evidence
concerning the effects of antenatal steroids on brain development, and
made suggestions for clinical practice.
We believe that interpretation of current evidence is not yet clear
enough to determine clinical practice, and further research is necessary
before such recommendations are possible. No randomised controlled trials
comparing si...
Whitelaw and Thoresen recently reviewed the current evidence
concerning the effects of antenatal steroids on brain development, and
made suggestions for clinical practice.
We believe that interpretation of current evidence is not yet clear
enough to determine clinical practice, and further research is necessary
before such recommendations are possible. No randomised controlled trials
comparing single with multiple courses of corticosteroids have been
completed, and current evidence is from observational studies of humans
and animal experiments. There are several problems with interpretation of
these results.
Firstly, animal experiments have demonstrated impaired
growth of the brain after antenatal exposure to corticosteroids, but it is
not known to what extent similar changes may occur in human brains, nor
whether they lead to functional problems. Secondly, observational studies
may suffer from several sources of bias; for example, infants exposed to
single and multiple courses of antenatal steroids may be born at different
gestational ages, may be born to mothers suffering from different
conditions, or may be exposed to a high-risk situation for different
amounts of time. These biases could influence the results of observational
studies in either direction. Finally, publication bias may have
influenced the available evidence; papers suggesting harmful effects from
multiple courses of steroids may have been more readily published during
recent years than those showing no effect or benefit. No firm conclusions
can be drawn from the available evidence and we cannot say whether
multiple courses of antenatal steroids are beneficial, harmful or have no
effect.
Better evidence is needed to resolve this issue, and several large
randomised controlled trials comparing single and multiple courses of
antenatal steroids are either planned or in progress around the world.
Until these trials are completed the uncertainty about the risks and
benefits of multiple courses of antenatal steroids must remain. The best
policy for obstetricians would therefore be to take part in the current
trials in order to resolve this issue as quickly as possible.
In the UK the TEAMS trial is currently recruiting, and more centres
are needed. The study can be contacted by telephone (+44 (0) 1865 227122), or
email (teams@perinat.ox.ac.uk).
Simon Gates
Peter Brocklehurst
Ann Johnson
National Perinatal Epidemiology Unit Institute of Health Sciences
Old Road, Oxford OX3 7LF, UK
Zarko Alfirevic
Department of Obstetrics and Gynaecology Liverpool Women's Hospital
Crown Street, Liverpool L8 7SS, UK
Geoffrey Chamberlain
Department of Gynaecology, Singleton Hospital Sketty, Swansea SA2 8QA, UK
We appreciate Dr Pharoah's comments on the definitions of incidence
and prevalence.[1] However, his interpretation of the data appears
erroneous.[2]
Dr Pharoah suggests that perhaps the dexamethasone-treated infants
were sicker than the control infants and were saved by the intervention
only to go on to suffer from cerebral palsy. This interpretation is
incompatible with the data. There were...
We appreciate Dr Pharoah's comments on the definitions of incidence
and prevalence.[1] However, his interpretation of the data appears
erroneous.[2]
Dr Pharoah suggests that perhaps the dexamethasone-treated infants
were sicker than the control infants and were saved by the intervention
only to go on to suffer from cerebral palsy. This interpretation is
incompatible with the data. There were no differences in the prenatal
characteristics, delivery type or severity of disease after birth between
the groups. There was no evidence to suggest that dexamethasone improves
survival as has been borne out by other studies.
In addition, Dr Pharoah points to the infant who had cerebral palsy
with normal ultrasound scans. The most likely explanation of these
findings is that ultrasound has inadequate sensitivity in order to detect
subtle fidings which may be picked up by other methods such as MRI.
Thus, our study does not address issues of prenatal timing of the
pathogenesis of cerebral palsy, but rather points to a serious and
potentially preventable postnatal cause.
References
(1) Pharoah POD. Dexamethasone treatment and cerebral palsy [Rapid Response]. http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;83/3/F177#EL1 (8 November 2000)
(2) Shinwell ES, Karplus M, Reich D, et al. Early postnatal dexamethasone treatment and increased incidence of cerebral palsy. Arch Dis Child Fetal Neonatal Ed 2000;83:F177-81.
In view of the increasing interest in the special nutritional care of
nutritionally-compromised infants, we should like to identify an incorrect
description of our work on the subject. In their Current Topic article
on Feeding issues in preterm infants, Cooke and Embleton[1] cited our
randomised trial[2] showing faster linear growth and weight gain in post-discharged preterm infants assigned to a specially...
In view of the increasing interest in the special nutritional care of
nutritionally-compromised infants, we should like to identify an incorrect
description of our work on the subject. In their Current Topic article
on Feeding issues in preterm infants, Cooke and Embleton[1] cited our
randomised trial[2] showing faster linear growth and weight gain in post-discharged preterm infants assigned to a specially designed post-discharge
formula - the first of its type at the time. Cooke and Embleton state
that in our trial "no differences were detected in nutrient intake between
groups [making differences in growth difficult to explain]". Had this
been so, we agree our study would appear to disobey the laws of
thermodynamics.
However, it was volume intake, not nutrient intake that was the same
between those fed the nutrient enriched versus standard formulas.[2]
Clearly, if the two groups consumed formulas with different nutrient
concentrations and the volume intake did not differ between groups, then
the nutrient intake would be higher in the group that consumed the more
nutrient enriched formula - hence the better growth.
This has biological and practical implications. In previous attempts
to make growth -retarded infants grow, energy supplements were used, which
resulted in down-regulation of milk volume intake by the infant,[3]
counteracting the effect of the enriched diet on weight gain. When we
designed our post-discharge formula in the mid 1980s for our first trial,
we decided to use a predominantly protein-enriched rather than energy-
enriched formula since protein was arguably the most limiting major
nutrient for tissue growth (our formula was also enriched in minerals and
micronutrients to fuel the predicted increase in growth). Based on our
findings on the similar formula volume consumed by the protein-enriched
versus standard formula-fed groups, a key message of our study, perhaps
overlooked by Cooke and Embleton, is that protein, as opposed to energy,
does not appear to cause down-regulation of milk volume intake.[2] [4]
Thus, infants fed on protein-enriched formula grew well. This has
practical importance for the design of future post discharge formulas and
for any feeding regime aimed at producing catch-up growth in ad-libitum
fed infants.
We have now confirmed the validity of this principle in two
further large nutritional intervention trials involving around 600 infants
that show catch-up growth can be achieved, well beyond the period of
dietary intervention, in both post discharge preterm and full term small-
for-gestational age infants.[5] [6]
A Lucas
M Fewtrell
MRC Childhood Nutrition Research Centre
Institute of Child Health
30 Guilford Street, London, UK
cnrc@ich.ucl.ac.uk
References
(1) Cooke RJ, Embleton ND. Feeding issues in preterm infants. Arch Dis Child Fetal Neonatal Ed 2000;83:F215-17.
(2) Lucas A, Bishop NJ, Cole TJ. Randomised trial of nutrition for
preterm infants after discharge. Arch Dis Child 1992;67:324-7.
(3) Brooke OG, Kinsey JM. High energy feeding in small for gestation
infants. Arch Dis Child 1985;60:42-6.
(4) Lucas A, King FJ, Bishop NJ. Postdischarge formula consumption in
infants born preterm. Arch Dis Child 1992;67:691-2.
(5) Fewtrell MS, Morley R, Abbott RA, Stephenson T, MacFadyen UM, Lucas A. Randomised trial of high protein and energy formula versus standard
formula in growth retarded term infants [abstract]. Arch Dis Child 1999;80(Suppl I):A4.
(6) Lucas A, Fewtrell MS, Abbott RA, Stephenson T, MacFadyen UM, Morley R. Randomised trial of nutrient enriched formula versus standard formula
for post-dishcharge preterm infants [abstract]. Arch Dis Child 1999;80(Suppl I):A31.
In their study on time to positivity of neonatal blood
cultures, Kumar et al[1] conclude that a period of 36 hours is sufficient to
exclude sepsis in otherwise well neonates. They documented that the
negative predictive value of neonatal blood cultures at 36 hours is 98%
for definite or possible pathogenic bacteria. This is also true in our
experience using a different automated blood culture system...
In their study on time to positivity of neonatal blood
cultures, Kumar et al[1] conclude that a period of 36 hours is sufficient to
exclude sepsis in otherwise well neonates. They documented that the
negative predictive value of neonatal blood cultures at 36 hours is 98%
for definite or possible pathogenic bacteria. This is also true in our
experience using a different automated blood culture system to that
employed by Kumar et al[1].
We chose to analyse in detail, neonatal blood culture samples taken
within 48 hours of birth for two reasons. Firstly, neonates with early
suspected sepsis constitute a unique group, as the pathogens are usually
acquired intra-partum. Secondly, the impact on early cessation of
antibiotics and early discharge from the neonatal unit would potentially
be great in this group. We studied a total of 936 neonatal blood cultures
taken from November 1999 to October 2000 of which 189 (20.2%) were
positive. Of the total of 142 neonatal blood cultures taken within 48
hours of birth, the positivity rate was similar (19%). Organisms isolated
were classified as either pathogens or possible contaminants, based on the
identity of the organism, clinico-pathological markers like C-Reactive
Protein (CRP), neutrophil count and clinical picture. 15 of the 27
positive early neonatal blood cultures yielded pathogens. All the
significant cultures became positive within 27 hours of incubation in the
Vital automated blood culture system (bioMerieux, France).
The advent of automated blood culture detection systems allows
significantly earlier detection of most aerobic bloodstream pathogens than
manual systems[2]. Previous data supporting the need for longer
observation times utilized non-automated systems and were reported in an
era when the distribution of pathogenic micro-organisms causing infection
in neonatal units may have been different[3]. Also, as the incidence of
nosocomial neonatal septicaemia varies significantly between units, it is
important to validate locally any changes to current protocols[4]. We
conclude that negative blood cultures at 36 hours can be used to
discontinue antibiotics in cases of suspected early neonatal sepsis. We
encourage others to consider adopting this approach to minimise needless
use of antibiotics with consequent pressure for antimicrobial resistance.
References
(1) Kumar Y, Qunibi M, Neal TJ, Yoxall CW. Time to positivity of
neonatal blood cultures. Arch Dis Child Fetal Neonatal Ed 2001; 85: F182-
6.
(2) Rohner P, Pepey B, Auckenthaler R. Comparison of BacT/Alert with
Signal blood culture system. J Clin Microbiol 1995; 33: 313-7.
(3) Sidebottom DG, Freeman J, Platt R, Epstein MF, Goldmann DA.
Fifteen-year experience with bloodstream isolates of coagulase-negative
staphylococci in neonatal intensive care. J Clin Microbiol 1988; 26: 713-
8.
(4) Brodie SB, Sands KE, Gray JE, Parker RA, Goldmann DA, Davis RB,
Richardson DK. Occurrence of nosocomial bloodstream infections in six
neonatal intensive care units. Pediatr Infect Dis J 2000; 19: 56-65.
Premedication for neonatal intubation has become a hot topic
recently, and in their letter Attardi et al[1] make an interesting
contribution to the debate. However the significant increase in
oxyhaemaglobin desaturation in those neonates intubated following
administration of midazolam when compared to placebo is not surprising.
Midazolam is a hypnotic agent and as such can only be useful as part
of...
Premedication for neonatal intubation has become a hot topic
recently, and in their letter Attardi et al[1] make an interesting
contribution to the debate. However the significant increase in
oxyhaemaglobin desaturation in those neonates intubated following
administration of midazolam when compared to placebo is not surprising.
Midazolam is a hypnotic agent and as such can only be useful as part
of an anaesthetic procedure. The so called triad of anaesthesia comprises
hypnosis, analgesia and muscle relaxation. Modern practice commonly
employs a number of drugs each with a single primary effect which are
combined in low doses to allow the minimum effective dose of each to be
used - this is termed balanced anaesthesia. As a single agent midazolam
does not produce anaesthesia and will not confer good intubating
conditions. Any cardiovascular and respiratory depression during its long
onset time of up to 5 minutes will also make adverse events more likely.
If we are to truly move forward in our goal to make intubation of
neonates both safer and less stressful we must follow the lead given to us
by our colleagues in paediatric anaesthesia. Careful assessment of the
airway, a skilled operator with an experienced assistant and application
of the principles of balanced anaesthesia are the keys to success.
References
(1) Attardi DM, Paul DA, Tuttle DJ, Greenspan JS. Premedication for intubation in neonates [letter]. Arch Dis Child Fetal Neonatal Ed 2000;83:F160.
The authors of this paper need all appreciation in trying out this
“magic cream” on babies, which already finds an established role in
children as a topical anaesthetic.
However as one goes through this interesting article, a striking feature
is the small numbers in the study. I find no mention as regards to the
power of the study. The confidence limits while expressing significant p
values is...
The authors of this paper need all appreciation in trying out this
“magic cream” on babies, which already finds an established role in
children as a topical anaesthetic.
However as one goes through this interesting article, a striking feature
is the small numbers in the study. I find no mention as regards to the
power of the study. The confidence limits while expressing significant p
values is not mentioned.
Assessment of pain in neonates is a difficult area. The use of
validated pain scores as a bedside tool is well taken. However in
literature published on this subject, many authors express the importance
of assessing the physiological response of babies to pain, like changes
in heart rate, respiration, blood pressure,and saturation of oxygen. Moreover the level
of arousal at the time of stimulation seems to hold a lot of importance.
A baby who is asleep is far less prone to cry than one who is awake. In the
present paper there seems to be no mention of the state of arousal of the
baby at the moment of cannulation. Inclusion of neonatal behaviour scales
would have boosted the value of this useful study.
As regards to the safety profile of the drug, it is not clear as to
whether one could use 4% amethocaine in preterm babies as well. In
preterm babies the risk of systemic absorption needs further looking into.
It is interesting to see in the future how topical amethocaine and
oral sucrose fare against each other or add up to provide effective pain
relief to the neonate.
Dr R Srinivasan
Department of Paediatrics
Scunthorpe General Hospital
North Lincolnshire, UK
References
(1) Jain A, Rutter N. Does topical amethocaine gel reduce the pain of venupuncture in newborn infants? A randomised double blind controlled trial. Arch Dis Child Fetal Neonatal Ed 2000:83:F207-10.
(2) Bozzette M. Observation of pain behavior in the NICU: an exploratory study. J Perinat Neonatal Nurs 1993;7:76-87.
(3) Grunau RV, Craig KD. Pain expression in neonates: facial action and cry. Pain 1987;28:395-410.
(4) Rushforth JA, Levene MI. Behavioral response to pain in healty neonates. Arch Dis Child Fetal Neonatal Ed 1994;70:F174-6.
(5) Ramenghi LA, Wood CH,Griffith GC, Levene MI. Reduction of pain response in premature infants using intraoral sucrose. Arch Dis Child Fetal Neonatal Ed 1996;74:F126-8.
The study of Groenland et al contributes remarkably to the
understanding of the role of intenstinal colonisation and the maturation
of the mucosal immune system.
However, with reference to reports of MacDonald,[1] Savilahti,[2] and Burgio et al,[3] they suggest that the mucosal immune system with its
predominant secretory IgA is quantitatively and functionally defective for
a variable peri...
The study of Groenland et al contributes remarkably to the
understanding of the role of intenstinal colonisation and the maturation
of the mucosal immune system.
However, with reference to reports of MacDonald,[1] Savilahti,[2] and Burgio et al,[3] they suggest that the mucosal immune system with its
predominant secretory IgA is quantitatively and functionally defective for
a variable period after birth.
Within the last 10 years growing evidence could be found that the
mucosal immune system is well established and we have recently shown that
high levels of secretory IgA can be found in saliva of newborn infants
shorty after birth.[4] Additionally we could not analyse any significant
differences in secretory IgA levels comparing preterm and term infants in
their first 9 months of life.[5]
We therefore believe that the mucosal immune in infancy is well
developed as early as in the first days after birth and should be
considered when evaluating the protective potential as well as the
potential for developing allergic diseases.
BM Seidel
S Schubert
Children's Hospital, University of Leipzig
Division of Paediatric Immunology
Oststrasse 21-25
04317 Leipzig, Germany
References
(1) MacDonald TT. Development of mucosal immune function in man:
potential for GI disease states. Acta Paediatr Jpn 1994;36:532-6.
(2) Savilahti E. Immunoglobulin-containing cells in thew intestinal
mucosa and immunoglobilins in the intestinal juice in children. Clin Exp Immunol 1972;11:415-25.
(3) Burgio GR, Lanzavecchia A, Plebani A, Jayakar S, Ugazio AG.
Ontogeny of secretory immunity: levels of secretory IgA and natural
antibodies in saliva. Pediatr Res 1980;14:1111-14.
(4) Seidel BM, Schulze B, Kiess W, Vogtmann C, Borte M. Determination
of secretory IgA and albumin in saliva of newborn infants. Biol Neonate 2000;78:186-90.
(5) Seidel BM, Schulze B, Schubert S, Borte M. Oral mucosal
immunocompetence in preterm infants in the first 9 months. Eur J Pediatr 2000;159:789.
We read the article by Reece et al [1] and closely followed the responses
to it. We even went ahead to carry out a study looking at identification
of the tip of the long lines using inversion of image technique on PACS
(picture archiving and communication system).
Background: Positioning of long lines into the heart has serious
consequences including death due to cardiac tamponade.[2] The...
We read the article by Reece et al [1] and closely followed the responses
to it. We even went ahead to carry out a study looking at identification
of the tip of the long lines using inversion of image technique on PACS
(picture archiving and communication system).
Background: Positioning of long lines into the heart has serious
consequences including death due to cardiac tamponade.[2] The tip of long
lines is accurately visible in only 50 % of plain radiographs.[1]
Identification of the line using radio opaque contrast media requires
caution. The use of an insufficient volume of contrast will falsely
identify the tip in an apparently more proximal position, whereas a film
taken during active injection may cause the line to appear longer due to a
jet of contrast issuing from the tip of the line. Bernard I and Banerjee
I, from Glan Clwyd Hospital, wrote in their E-letter on the use of PACS in
their hospital to identify the tip of the long lines.[3] Ultrasound may be
of value but it requires expertise to perform and interpret.[2]
Methods: At Hinchingbrooke Hospital, Huntingdon, X-rays are taken on a
phosphor plate which are later processed through PACS and image is
available on computer terminal on the Special care baby unit. The Hospital
use Frame wave dicom view version 3.0 software that allows for image
inversion, image magnification and image sharpening. Using the technique
of image inversion supplemented by image magnification and sharpening of
image, the tips of the long line are much better seen than on plain X-rays. Our this observation lead us to carry out a study looking at the
tips of the long lines on plain X-ray and then on the same image on PACS
with image inversion. Three investigators including an experienced SHO, a
consultant paediatrician and a consultant neonatologist participated in
this study. The study was retrospective and included the long lines
inserted between the periods of January 2000 to July 2001.
Results:
Observer
Tip visible on plain X ray
Tip visible on inverted image
Improvement
A
06/24 (25%)
15/24 (63%)
38%
B
12/23 (52%)
17/23 (74%)
22%
C
40/69 (58%)
65/69 (94%)
36%
Conclusions: Inversion of image on PACS is better than plain
radiograph in identifying the tip of the long lines. Although there is
inter observer variation, with experience of using PACS, this may be
minimized. It is important to note that there is improvement in
recognition of line tip by each observer.
Recommendations: We recommend that units having facility of PACS should
use them to identify the long line tips and there is a need for
prospective randomized study comparing contrast study v/s image inversion
technique on PACS, before accepting contrast as the only way of
identifying the tips of long lines.
Other uses of PACS with regards to neonatal long lines:
1. Accurate line manipulation. Once it is noted that the long line is in
right atrium, one can measure the distance on the image by which it should
be pulled back to be in acceptable place, rather than guessing the
distance by which line is pulled back.
2. Monitoring of long line on subsequent X rays: Most unit that uses
contrast to identify the long line tip does it only once to confirm the
position and subsequently look at the plain X rays (taken for other
clinical indications) to see the long line position. We know that long
lines do migrate over a course of time and plain X rays are less sensitive
to detect the tip accurately. The use of PACS allows each image to be
reviewed with same accuracy as first image. This can detect the potential
line migration and allows adjustments in line position to be made.
References
(1)Reece A et al. positioning long lines: contrast versus plain
radiography. Arch Dis Child Fetal Neonatal Ed 2001; 84:F129-30.
(2) Review of four neonatal deaths due to cardiac tamponade associated with
the presence of a central venous catheter: Recommendations and department
of health response. June 2001.
(3) Bernard I, Banerjee I. E-letter. Arch Dis Child 14th May 2001.
Dear Editor,
In a recent article Stevenson and colleagues[1] report further data showing increased vulnerability of male compared to female infants in early life, and comment that the biological mechanisms contributing to the male disadvantage or female advantage have not been elucidated.
In fact, male vulnerability in early life is consistent with an aspect of evolutionary theory described by Trivers...
The three excellent articles on twin to twin transfusion syndrome (TTTS) provide futher important data for clinical decisions and parental counselling. We would like to comment on the paper by Cincotta et al.[1]
We are interested in the incidence of hydrops and absence of end diastolic velocity of the umbilical artery in the cohort and their correlation with outcome. A recent study of 33 pregn...
Whitelaw and Thoresen recently reviewed the current evidence concerning the effects of antenatal steroids on brain development, and made suggestions for clinical practice.
We believe that interpretation of current evidence is not yet clear enough to determine clinical practice, and further research is necessary before such recommendations are possible. No randomised controlled trials comparing si...
We appreciate Dr Pharoah's comments on the definitions of incidence and prevalence.[1] However, his interpretation of the data appears erroneous.[2]
Dr Pharoah suggests that perhaps the dexamethasone-treated infants were sicker than the control infants and were saved by the intervention only to go on to suffer from cerebral palsy. This interpretation is incompatible with the data. There were...
In view of the increasing interest in the special nutritional care of nutritionally-compromised infants, we should like to identify an incorrect description of our work on the subject. In their Current Topic article on Feeding issues in preterm infants, Cooke and Embleton[1] cited our randomised trial[2] showing faster linear growth and weight gain in post-discharged preterm infants assigned to a specially...
Dear Editor
In their study on time to positivity of neonatal blood cultures, Kumar et al[1] conclude that a period of 36 hours is sufficient to exclude sepsis in otherwise well neonates. They documented that the negative predictive value of neonatal blood cultures at 36 hours is 98% for definite or possible pathogenic bacteria. This is also true in our experience using a different automated blood culture system...
Premedication for neonatal intubation has become a hot topic recently, and in their letter Attardi et al[1] make an interesting contribution to the debate. However the significant increase in oxyhaemaglobin desaturation in those neonates intubated following administration of midazolam when compared to placebo is not surprising.
Midazolam is a hypnotic agent and as such can only be useful as part of...
The authors of this paper need all appreciation in trying out this “magic cream” on babies, which already finds an established role in children as a topical anaesthetic.
However as one goes through this interesting article, a striking feature is the small numbers in the study. I find no mention as regards to the power of the study. The confidence limits while expressing significant p values is...
Dear Editor,
The study of Groenland et al contributes remarkably to the understanding of the role of intenstinal colonisation and the maturation of the mucosal immune system.
However, with reference to reports of MacDonald,[1] Savilahti,[2] and Burgio et al,[3] they suggest that the mucosal immune system with its predominant secretory IgA is quantitatively and functionally defective for a variable peri...
Dear Editor
We read the article by Reece et al [1] and closely followed the responses to it. We even went ahead to carry out a study looking at identification of the tip of the long lines using inversion of image technique on PACS (picture archiving and communication system).
Background: Positioning of long lines into the heart has serious consequences including death due to cardiac tamponade.[2] The...
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