In this review (Eye disorders in newborn infants (excluding
retinopathy of prematurity), Wan MJ, VanderVeen DK, Arch Dis Child Fetal
Neonatal Ed. 2015 May;100(3):F264-9. doi: 10.1136/archdischild-2014-
306215. Epub 2014 Nov 13, PMID:25395469) the authors describe clinical
presentation, natural history and treatment of infantile haemangiomas
(IH). These vascular tumors are common and if left untreated will result
in visua...
In this review (Eye disorders in newborn infants (excluding
retinopathy of prematurity), Wan MJ, VanderVeen DK, Arch Dis Child Fetal
Neonatal Ed. 2015 May;100(3):F264-9. doi: 10.1136/archdischild-2014-
306215. Epub 2014 Nov 13, PMID:25395469) the authors describe clinical
presentation, natural history and treatment of infantile haemangiomas
(IH). These vascular tumors are common and if left untreated will result
in visual compromise and we agree that an urgent ophalmological opinion is
warranted.
According to the authors treatment options include beta blockers,
corticosreroids, surgery for small lesions and laser therapy for
superficial lesions. However in reality beta blockers would be used in the
vast majority of patients and to not clarify this point is misleading. The
first report of the successful use of propranolol in 2008 and subsequent
randomised controlled trials totally revolutionised treatment of IHs and,
since then, propranolol has become the first-line therapeutic agent in the
management of IHs. (1,2) Propranolol has been shown to be more effective
than corticosteroids and it is associated with fewer side effects.
Therefore surgical treatment is rarely required. Pulse dye laser may
occasionally be an appropriate treatment for residual skin changes at a
later stage.
We feel that this is an important message to the readers of this journal:
along with the ophthalmologist these patients need an urgent referral to a
paediatric dermatologist for the medical treatment of IH.
References:
1. A randomized, controlled trial of oral propranolol in infantile
hemangioma. Leaute-Labreze C,et al, N Engl J Med. 2015 Feb 19;372(8):735-
46. doi: 10.1056/NEJMoa1404710.
2. Propranolol for severe hemangiomas of infancy.Leaute-Labreze C, Dumas
de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taeeb A.N Engl J Med.
2008 Jun 12;358(24):2649-51. doi: 10.1056/NEJMc0708819
We thank Dr Perlin for his response which specifically refers to the
prevention of early onset Group B streptococcus (GBS) infection.
Similar declines in GBS EONS have been seen in many other countries
that have introduced screening for GBS and IAP. In contrast, in the UK the
RCOG recommendation for a risk based approach has not been associated with
a fall in the incidence of GBS EONS. If the incidence fell by 75%,...
We thank Dr Perlin for his response which specifically refers to the
prevention of early onset Group B streptococcus (GBS) infection.
Similar declines in GBS EONS have been seen in many other countries
that have introduced screening for GBS and IAP. In contrast, in the UK the
RCOG recommendation for a risk based approach has not been associated with
a fall in the incidence of GBS EONS. If the incidence fell by 75%, as
would be predicted from the experience of other countries, this would
reduce GBS infection in at least 300 babies per year in the UK.
The UK National Screening Committee do not recommend universal
screening for GBS for a number of reasons including that it is not cost
effective. However Colbourn et al (BMJ. 2007;335:655) concluded from a
detailed analysis that "culture testing for low risk term women, while
treating all preterm and high risk term women, would be the most cost
effective option". Kaambwa et al (BJOG. 2010;117:1616) concluded that "The
current strategy of risk-factor-based screening is not cost-effective
compared with screening based on culture". The best test for GBS is
enhanced culture medium (ECM) testing of low vaginal and rectal swabs at
an estimated cost of ?11, but is not routinely available in the UK.
Conventional tests may miss GBS even if it is present.
Concerns have been expressed about penicillin allergy but true
anaphylaxis is rare. Law et al reported (J Med Screen 2005;12:60) that
there were no recorded deaths in the first 1.8 million women given IAP in
the USA, and other reports have stressed that giving IAP under direct
supervision is very safe. Concern has been expressed about the practice of
giving women (and therefore their fetuses) large doses of broad spectrum
antibiotic before skin incision for caesarean section, as currently
recommended by the RCOG, in terms of the effect it might have on the
development of the newborn's immune system. Around 33% of pregnant women
currently receive antibiotics at some stage during pregnancy, including
erythromycin for which there is now evidence of harm, yet the RCOG
continue to recommend its use for women with preterm, pre-labour rupture
of membranes (Meeraus et al, PLOS ONE | DOI:10.1371/journal.pone.0122034
March 25, 2015.)
In contrast, penicillin is narrow spectrum, GBS has never developed
resistance to it, and there is no evidence that preventing GBS EONS
encourages other organisms to invade. The widespread use of penicillin for
over 60 years means that any organisms able to become resistant to it will
likely already have done so.
Current RCOG guidelines recommend giving IAP if a woman is found by
chance to be a GBS carrier, yet is managed as if negative for GBS if no
swab has been obtained. Her baby Is also managed differently if she is
known to be GBS positive. This is illogical and women who have knowledge
of GBS have very clearly stated that they wish to be screened for GBS. On
the grounds of equity and choice, pregnant women at 35-37 weeks should be
offered an equal opportunity to determine their GBS status and protect
their babies, which can only be done by screening.
To the Editors:
We have read with interest the article by Ingram et al (1) entitled "The
development of a tongue assessment tool to assist with tongue-tie
identification". The authors should be commended for simplifying and
validating the ATLAF assessment. However, using their tool to decide upon
whether or not to carry out lingual frenotomy has neither been proven nor
is it justified. Unfortunately, this study, similar...
To the Editors:
We have read with interest the article by Ingram et al (1) entitled "The
development of a tongue assessment tool to assist with tongue-tie
identification". The authors should be commended for simplifying and
validating the ATLAF assessment. However, using their tool to decide upon
whether or not to carry out lingual frenotomy has neither been proven nor
is it justified. Unfortunately, this study, similar to most of the current
discourse about lingual frenotomy, involves only terms pertaining to the
descriptive anatomy of the tongue. Even the erroneously labeled "function
items" in Hazelbaker's ATLAF (2) as well as those in the current study are
actually descriptions of tongue mobility and not of the function of the
tongue during breastfeeding. As our group recently demonstrated by means
of an indirect ultrasound analysis, tongue biomechanics during
breastfeeding are highly complex (3).
No published studies have thus far succeeded in establishing a significant
correlation between the description of the tongue by physical examination
and the clinical presentation of breastfeeding difficulties. Indeed, the
studies by Griffiths (4) and by our group (5), which were specifically
designed to correlate anatomy with breastfeeding difficulties, had failed
to identify such a correlation.
In a recently published prospective study, we described the anatomy of the
tongue in a group of non-selected infants without our having prior
knowledge of the presence or absence of breastfeeding difficulties (6). We
found no correlation between the appearance of the tongue and
breastfeeding difficulties as reported by the mother. We therefore
suggested that the terminology currently used to describe situations in
which the lingual frenulum affects breastfeeding be altered, since the
interchangeable terms of ''tongue-tie" "ankyloglossia'', ''sublingual
frenulum'', and ''short frenulum" are misleading to both lay people and
professionals. Our proposed terminology uses not only descriptive anatomy
but also the previously overlooked but indispensable part of every
clinical diagnosis, that of the patient's story. We had further suggested
that infant and mother dyads who have breastfeeding difficulties that had
not been solved by a lactation consultation and that were judged as being
due to the infant's lingual frenulum be clinically diagnosed and termed as
having ''symptomatic tongue-tie'' (or ''symptomatic ankyloglossia"), while
infants with no breastfeeding difficulties and, alternatively, those with
breastfeeding difficulties that had been corrected after a lactation
consultation should be considered as having an asymptomatic ''sublingual
frenulum", which is universally present (6). We believe that the terms
''short frenulum'' and "non-symptomatic tongue-tie" should be abandoned.
Using the Bristol Tongue Assessment Tool as a means to decide upon
performing lingual frenotomy is, therefore, not appropriate. Not only may
the posterior symptomatic frenulum be missed, but based upon current
research, we suggest that the decision to perform lingual frenotomy should
depend primarily on the clinical picture, e.g., pain and latching
difficulties during breastfeeding, and not upon visual inspection of the
tongue. These symptoms, together with failure of improvement of these
breastfeeding difficulties after professional lactation consultation,
should be the almost exclusive medical indication to perform lingual
frenotomy in a breastfed infant during the neonatal period.
Shaul Dollberg, MD Beilinson Medical Center and Eyal Botzer DMD, Tel
Aviv Medical Center
References:
1. Ingram J, Johnson D, Copeland M, et al, The development of a tongue
assessment tool to assist with tongue-tie identification. Arch Dis Child
Fetal Neonatal Ed. 2015 (Online first)
2. Hazelbaker AK. Tongue-tie morphogenesis, impact, assessment and
treatment. Columbus Ohio: Aiden & Eva Press, 2010.
3. Elad D, Kozlovsky P, Blum O, et al. Biomechanics of milk extraction
during breast-feeding. Proc Natl Acad Sci. 2014;111:5230-5.
4. Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lact.
2004;20:409-14.
5. Dollberg S, Marom R, Botzer E. Lingual frenotomy for breastfeeding
difficulties: A prospective follow-up study. Breastfeed Med. 2014;9:286-9.
6. Haham A, Marom R, Mangel L, et al. Prevalence of breastfeeding
difficulties in newborns with a lingual frenulum: A prospective cohort
series. Breastfeed Med 2014;9:438-44.
I have read the most excellent review of early onset neonatal sepsis
(EONS) published recently in these Archives by Dr's Bedford Russell and
Kumar. We, in America, have witnessed the gradual evolution from a risk
factor approach initially advocated by the American College of
Obstetricians and Gynecologists, (as opposed to universal screening during
gestation, as recommended by the American Academy of P...
I have read the most excellent review of early onset neonatal sepsis
(EONS) published recently in these Archives by Dr's Bedford Russell and
Kumar. We, in America, have witnessed the gradual evolution from a risk
factor approach initially advocated by the American College of
Obstetricians and Gynecologists, (as opposed to universal screening during
gestation, as recommended by the American Academy of Pediatrics), to
universal screening proposed by both organizations. This concordance of
governing opinions was reached after data collection by the Centers for
Disease Control determined a lower attack rate of EONS via the universal
screening method as opposed to the risk factor approach. Dr's Bedford
Russell and Kumar have identified this welcome reduction in the USA as
well as the controversial nature of a continued risk factor approach in
the UK.
I hope the Royal College of Obstetricians and the UK National
Screening Committee come to soon support the relevant change in practice.
We read with interest the publication by Bialkowski et al (1). Their
paper on infants with congenital chylothorax (CCT) in Germany focused in
detail on this patient group, in comparison to our recently published
paper reporting on all infants and children >24 weeks gestation to
<16 years who developed a chylothorax in UK (2).
When reviewing data from infants with CCT from our epidemiological
study, we hav...
We read with interest the publication by Bialkowski et al (1). Their
paper on infants with congenital chylothorax (CCT) in Germany focused in
detail on this patient group, in comparison to our recently published
paper reporting on all infants and children >24 weeks gestation to
<16 years who developed a chylothorax in UK (2).
When reviewing data from infants with CCT from our epidemiological
study, we have included those defined with either a neonatal 'congenital'
primary diagnosis of chylothorax, i.e. development of a chylothorax that
was thought to be associated with any congenital condition or malformation
existing at or before birth, e.g. lymphangiectasis, hydrops fetalis,
prematurity, Down syndrome or Noonan syndrome, and presenting early in
life; or those with a neonatal 'other' (non-cardiac) primary diagnosis,
i.e. development of a chylothorax that was thought to be associated with
any disorder, or condition that developed or occurred during the first
month of life, e.g. persistent pulmonary hypertension of the newborn
(PPHN), birth trauma or asphyxia. The number of all of these infants
equaled 20% (34 /173) of our total study population of children with
chylothorax. Of note, neonates who were identified as having developed
chylothorax following congenital cardiac surgery were excluded from our
CCT figures.
Using Office for National Statistics (ONS) data for live births in
the UK (3) during our 13-month study period in 2010-11(874,800 live
births), the calculated UK incidence of CCT infants was 1 in 25,000:
* Incidence = 34 / 874,800 = 0.00004 x 100% = 0.004% (4 in 100,000) =
1 in 25,000
Therefore, the overall UK incidence of CCT was very similar to the
incidence of 1 in 24,000 in Germany, as reported by Bialkowski, and as
noted in their study, much lower than previous estimates (4,5).
The gestational age of the CCT infants differed somewhat between the
two studies, with the majority of the German CCT population (89%; 24/27)
being born at <37 weeks gestation (range 30.0-39.1 weeks) following a
prenatal diagnosis, a higher percentage than our UK study, in which 65%
(22/34) of the infants were born at <37 weeks gestation (range 27.5-41
weeks). This difference was reflected in the birth weight of the infants,
the UK group having a median weight of 2880g (range 960-4290g), which was
slightly higher than the median weight of 2500g (range 740-3940g) reported
in Bialkowski's study.
Similar to the German study, the majority of CCT infants in the UK
were treated with insertion of a pleural drain and a medium-chain
triglyceride (MCT) diet, 76% (26/34), with 50% (17/34) also receiving TPN
and 20% (7/34) also receiving Octreotide/Somatostatin. Our study
identified 15% (5/34) of infants as having additional syndromal anomalies
(Downs Syndrome 3/34; Noonan's Syndrome 2/34), which was half the rate
reported in Germany (32%; 9/28).
Within our UK study, 71% of the CCT infants were male (24/34), in
line with the reported male:female ratio of 2:1 in other studies (5,6),
including that of Bialkowski. However the reasons for this gender
difference remain unclear. There was an overall mortality rate for CCT in
the UK of 20% (7/34), which is in line with previously published figures
(5,7), but is substantially higher than the reported 11% in Germany.
Further investigation of the mortality rate and its causes in CCT would
seem beneficial.
Whilst reporting some differences, which may be explained by the
small numbers of infants affected, these two distinct national
epidemiological studies have identified similar overall incidences for CCT
across their populations, and both provide greater evidence for clinicians
caring for infants with CCT.
References
1. Bialkowski A., Poets CF, Franz AR. Congenital chylothorax: a
prospective nationwide epidemiological study in Germany. Arch Dis Child
Fetal Neonatal Ed 2015; 100:F169-F172
2. Haines C., Walsh B., Fletcher M, Davis PJ. Chylothorax development
in infants and children in the UK. Arch Dis Child 2014; 99:724-30.
3. Office of National Statistics 2015
(http://ons.gov.uk/ons/taxonomy/index.html?nscl=Live+Births+and+Stillbirths#tab
-data-tables)
4. Ergaz Z, Bar-Oz B, Yatsiv I, et al. Congenital chylothorax:
clinical course and prognostic significance. Pediatr Pulmonol 2009; 44:
806-11.
5. Rocha G, Fernandez P, Rocha P, et al. Pleural effusions in the
neonate. Acta Paediatr 2006; 95: 791-8
6. Downie I, Sasi A, Malhotra A. Congenital chylothorax: associations
and neonatal outcomes. J Paediatr Child Health 2014; 50: 234-8
We were interested to read the experiences of other units 1-4 sharing
their findings of increased duration of antibiotics, length of stay in
hospital and lumbar punctures (LP) performed following implementation of
the NICE guideline on prevention of early onset neonatal infection
(EONI)5. We recently changed our practice to follow these NICE
recommendations advocating observation of low risk infants to reduce
antibiotic...
We were interested to read the experiences of other units 1-4 sharing
their findings of increased duration of antibiotics, length of stay in
hospital and lumbar punctures (LP) performed following implementation of
the NICE guideline on prevention of early onset neonatal infection
(EONI)5. We recently changed our practice to follow these NICE
recommendations advocating observation of low risk infants to reduce
antibiotic exposure whilst commencing antibiotics in those deemed higher
risk 5. We have not yet found that the change in practice has increased
our infant's length of stay, antibiotic days or LPs performed.
In the two months (September/October) prior to our change of
practice, 69 babies were treated with IV antibiotics, averaging 2.4
babies/day, with 33.3% requiring treatment for >24hrs. In the two
months (November/December) following the new guideline implementation a
total of 66 babies required antibiotics, averaging 1.7 babies/day with
21.1% requiring treatment for >24hrs. We have seen no increase in the
frequency of LPs performed since the change (5 babies total
September/October vs. 2 November/ December). We have seen additional
testing in the form of repeat FBC, UEs, LFTs for the small number of
babies continuing antibiotics >24 hours as recommended by NICE (5 in
the first month following implementation). We recognise this is a small
sample population but our findings do not suggest a trend towards an
increase in antibiotics or invasive procedures as experienced by other
centres 1-4.
We acknowledge that the wide variation in clinical practice prior to
the publication of NICE EONI guidelines makes it challenging to compare
findings between units and may account for the differences observed. For
example, we have always investigated infants receiving antibiotics with an
initial CRP/blood cultures and repeat CRP at 18-24 hours to inform the
decision to cease antibiotics. Conversely, our colleagues' letters suggest
the second CRP is a change in their practice and therefore may account for
the increased antibiotic duration they observed 1-4.
Variation in the threshold to perform an LP may account for the
differing trends in frequency between units. NICE suggests consideration
of LP with a CRP >10 2. Locally we do not have a set CRP number that
would prompt an LP but make this decision based upon the baby's clinical
picture with acknowledgment of the CRP. In our babies that had an LP,
their CRP's ranged from 24-160. In our first month post-implementation we
saw 5 babies with a CRP rise (13-25) that necessitated a prolonged
antibiotic course but did not have an LP as the baby was clinically well,
with no signs of CNS involvement.
We have developed a monitoring chart, the Neonatal Early Warning
Score (NEWs) in order to record observations for all babies at risk of
EONI. In our first month we saw 51 babies on NEWs monitoring - 32 required
antibiotics and 16 on NEWs monitoring only. Despite initial concerns of
increased workload for postnatal staff these charts have embedded into
practice with the majority of infants (78%) appropriately commenced on the
chart for the required time period and we hope this will improve with
further familiarity and education. We acknowledge that our experiences are
early but we will continue to practice the new guideline following an
audit that has identified no significant issues or clinical concerns.
Further audit will be undertaken in due course, combined with other units
in our MCN who are shortly integrating the new guideline into their
practice.
References
1) Naydeva-Grigorova T, Manzoor A, Ahmed M. Arch Dis Child Fetal
Neonatal Ed 2015; 100:F93-F94.
2) Mukherjee A, Davidson L, Anguvaa L et al. NICE neonatal early
onset sepsis guidance: greater consistency, but more investigations, and
greater length of stay. Arch Dis Child Fetal and Neonatal Ed. Published
online first: 25 Jul 2014 doi:10.1136/archdischild-2014-306349
3) Mukherjee A, Ramalingaiah B, Kennea N et al. Letter: Management of
neonatal early onset sepsis (CG149): compliance of neonatal units in the
UK with NICE recommendations. Arch Dis Child Fetal Neonatal Ed. Published
Online First: 19 December 2014 doi:10.1136/archdischild-2014-307776
4) Mukherjee A, Davidson L, Anguvaa L et al. Short research report:
NICE neonatal early onset sepsis guidance: greater consistency, but more
investigations and greater length of stay. Arch Dis Child Fetal Neonatal
Ed. Published Online First: 25 July 2014 doi:10.1136/archdischild-2014-
306349
5) http://www.nice.org.uk/guidance/CG149 (accessed 19 Jan 2015)
The alternative explanation for the cardiovascular differences
between immediate and delayed cord clamping at birth suggested in this
commentary is not new and has been acknowledged for over 50 years. The
basic premise is that asphyxia is the underlying cause of birth-related
bradycardias and that avoiding asphyxia will avoid the bradycardia and
associated cardiac instability. However, neonatologists have known for
almo...
The alternative explanation for the cardiovascular differences
between immediate and delayed cord clamping at birth suggested in this
commentary is not new and has been acknowledged for over 50 years. The
basic premise is that asphyxia is the underlying cause of birth-related
bradycardias and that avoiding asphyxia will avoid the bradycardia and
associated cardiac instability. However, neonatologists have known for
almost as long that lung aeration is the primary consideration when
resuscitating bradycardic infants at birth. While it was thought that the
beneficial effects are due to increased oxygenation, the Bhatt (1) study
showed that increasing pulmonary blood flow and restoring venous return
lost due to cord clamping, was also a major contributing factor. This is
supported by studies in asphyxic, bradycardic lambs (2).
Although the association between severe asphyxia and bradycardia is well-
established, most birth related bradycardias are unlikely to be caused by
asphyxia. Indeed, the birth-related cardiovascular changes are often
unrelated to changes in oxygenation, which is shown in the heart rate
normograms published by Dawson (3) et al. In normal healthy term infants,
over 50% had a heart rate below 100 bpm at 1 min after birth and in some
infants, the heart rates increased while oxygenation remained unchanged or
decreased. The Bhatt et al (1) study was designed to replicate a
relatively common clinical scenario, whereby the elapsed time between
delivery, cord clamping and effective ventilation onset is ~2min. As
preterm infants are commonly given an opportunity to transition unassisted
at birth, a 2 min time window between birth and the onset of effective
respiratory support is not uncommon. To put this into context, lambs at
this age do not initiate gasping until 4-5 min after cord clamping, can
easily be resuscitated after 10 min and take 12-13 min before becoming
asystolic (4). In the Bhatt (1) study, lambs did not gasp and heart rates
did not decrease below 100 bpm and so they were only mildly asphyxic at
worst.
As the fetal heart rate (in utero) responses to cord clamping markedly
differ from the heart response to cord clamping ex utero (4), making
conclusions about neonatal cardiac responses based on fetal data is
problematic. Similar problems arise if the newborn's face is surrounded by
liquid (4). We note that in the study cited by the author, a saline-filled
bag was placed over the lamb's head and the lambs were ventilated via a
tracheostomy. Nevertheless, the alternative interpretation of their
findings is that reducing the timing between cord clamping and ventilation
onset leads to a more labile transition not because of oxygenation
differences, but because it reduces the time that venous return and
cardiac output are reduced. This is consistent with the conclusion of
Bhatt et al (1).
We disagree with the author's suggestion that avoiding asphyxia will by
itself improve cardiovascular stability at birth. This is not only because
of the reasons cited above, but because this simple view of the physiology
surrounding transition will encourage clinicians to intervene and attempt
to assist infants earlier than is perhaps necessary.
1. Bhatt S, Alison B, Wallace EM, et al. Delaying cord clamping until
ventilation onset improves cardiovascular function at birth in preterm
lambs. J Physiol. 2013;591:2113-26.
2. Klingenberg C, Sobotka KS, Ong T, et al. Effect of sustained
inflation duration; resuscitation of near-term asphyxiated lambs. Arch Dis
Child Fetal Neonatal Ed. 2013;98:F222-7.
3. Dawson JA, Kamlin CO, Wong C, et al. Changes in heart rate in the
first minutes after birth. Arch Dis Child Fetal Neonatal Ed. 2010;95:F177-
81.
4. Sobotka KS, Morley C, Ong T, et al. Circulatory Responses to
Asphyxia Differ if the Asphyxia Occurs In Utero or Ex Utero in Near-Term
Lambs. PLoS One. 2014;9:e112264.
The review by Hooper et al1 is timely and mounts a compelling case
for a stable circulatory transition during preterm birth. However,
advocacy of early ventilation with delayed cord clamping as the primary
way forward to ensure such a transition is open to question, as the main
supportive evidence for this paradigm comes from an experimental study by
the same group,2 for which an alternative interpretation of observed
f...
The review by Hooper et al1 is timely and mounts a compelling case
for a stable circulatory transition during preterm birth. However,
advocacy of early ventilation with delayed cord clamping as the primary
way forward to ensure such a transition is open to question, as the main
supportive evidence for this paradigm comes from an experimental study by
the same group,2 for which an alternative interpretation of observed
findings has recently come to light.
Thus, in preterm lambs, Bhatt et al2 reported relatively minor perinatal
changes in heart rate, blood pressure and right ventricular output with
early ventilation and delayed cord clamping. By contrast, early cord
clamping followed by ventilation 2 minutes later was associated with 1)
bradycardia, arterial blood pressure swings and large reductions in right
ventricular output before ventilation, and 2) substantial rises in heart
rate, blood pressure and right ventricular output after ventilation.
The 2 minute interval employed by Bhatt et al2 between early cord clamping
and the onset of ventilation is potentially problematic, however, as prior
studies in fetal lambs have shown that asphyxia can develop within 2
minutes after complete occlusion of uterine arteries or the umbilical
cord.3 4 Indeed, a preterm lamb birth study employing a lesser cord clamp-
to-ventilation interval (1.5 minutes) has now shown that an asphyxial
state rapidly develops by 45 seconds after cord clamping on aortic blood
gas analysis, with a haemoglobin O2 saturation of <10% and O2 tension
of <10 mmHg, associated with a fall in pH and rise in CO2 tension.5
Furthermore, similar to the onset and offset phases of brief in utero
asphyxia,3 4 this asphyxial state was accompanied by 1) bradycardia,
marked falls in ventricular outputs/central blood flows and redistribution
of systemic flow towards the brain before ventilation, and 2) tachycardia
with blood pressure and flow surges after ventilation.5 These data
therefore suggest that the findings of Bhatt et al2 primarily reflected
the haemodynamic effects of asphyxia occurring with an extended cord
clamping-to-ventilation interval, rather than beneficial effects per se of
early ventilation with delayed cord clamping.
Consistent with the foregoing proposition, reducing the cord clamping-to-
ventilation interval from 1.5 to 0.5 minutes (to avoid development of an
established asphyxial state) markedly blunted perinatal haemodynamic
fluctuations.5 This finding thus implies that circulatory stability during
the preterm birth transition hinges on avoidance of asphyxia. Such
avoidance can be achieved not only with the advocated paradigm of early
ventilation and delayed cord clamping,1 but also with early cord clamping,
if this is followed by a short interval before the onset of ventilation.5
References
1. Hooper SB, Polglase GR, te Pas AB. A physiological approach to the
timing of umbilical cord clamping at birth. Arch Dis Child Fetal Neonatal
Ed 2014; DOI: 10.1136/archdischild-2013-305703.
2. Bhatt S, Alison BJ, Wallace EM, et al. Delaying cord clamping until
ventilation onset improves cardiovascular function at birth in preterm
lambs. J Physiol 2013;591:2113-26.
3. Jensen A, Garnier Y, Berger R. Dynamics of fetal circulatory responses
to hypoxia and asphyxia. Eur J Obstet Gynecol Reprod Biol 1999;84:155-72.
4. Hunter CJ, Blood AB, Power GG. Cerebral metabolism during cord
occlusion and hypoxia in the fetal sheep: a novel method of continuous
measurement based on heat production. J Physiol 2003;552:241-51.
5. Smolich JJ, Kenna KR, Cheung MM. Onset of asphyxial state in non-
respiring interval between cord clamping and ventilation increases
hemodynamic lability of birth transition in preterm lambs. J Appl Physiol
2015; DOI: 10.1152/japplphysiol.01147.2014.
From: Dr Janet M Rennie Dr Giles S Kendall (NICU UCLH London)
Dr Caroline May (NICU & NTS The Royal London Hospital, London)
Comment on: Neonatal Airway Practices: Whitby T et al ADC Fetal and
Neonatal Edition 2015:100: F92-93
We read the letter from Whitby et al regarding neonatal airway
practice with interest. We agree that neonatal units need a "difficult
airway" trolley, a guideline, and a "Can't Intubate, Can't ventilate"
(CICV) algorithm. Like many units, we have thought hard about this over
the last year and have reflected on our own clinical experiences.
We suggest that the CICV algorithm proposed by Whitby et al is not
suitable for translation to the newborn. There are several reasons why the
newborn require a special approach; this is not "inequality". Most
importantly, as pointed out by Johansen and colleagues, the cricothyroid
space is simply too small to cannulate in a neonate and surgical
cricothyrotomy is not an option (Johansen et al., 2012). Very few neonatal
units would be able to obtain the services of an experienced paediatric
ENT surgeon, or have the equipment for emergency tracheostomy, and this is
only feasible in the larger term newborn even then and very few patients
are unconscious at the time of acute airway compromise. Storz
laryngoscopes (and other indirect laryngoscopes) are fantastic aids but it
is impractical for such valuable equipment to form part of a "difficult
airway" set kept in storage on a neonatal unit.
We have had good success with the use of a bougie and the "railroad"
technique, which is not mentioned at all in the algorithm proposed by
Whitby et al. Laryngeal mask airways can certainly help, and the Igel
devise looks promising. Further, a neonatal algorithm needs to recognise
the possibility of a congenital problem such as Pierre Robin sequence,
which requires recognition and special management (Abel et al., 2012)
(Evans et al., 2011). Anticipation and planned securing of difficult
airways is particularly important where congenital anomalies are known and
rather disappointingly there is no mention of such planning in the Whitby
algorithm. Such plans often need to be bespoke and carefully considered
when facing such unique clinical situations and the baby's clinical
condition may in fact be exacerbated by cricothyrotomy/tracheostomy eg.
laryngeal web.
In short, we agree that a CICV algorithm and a realistic "difficult
airway" kit list are needed, but these need to be appropriate for the
newborn and to be achievable by all units.
Yours, etc..
Reference List
Abel, F., Bajaj, Y., Wyatt, M. & Wallis, C. (2012). The
successful use of the nasopharyngeal airway in Pierre Robin sequence: an
11-year experience. Arch Dis Child 97, 331-4.
Evans, K. N., Sie, K. C., Hopper, R. A., Glass, R. P., Hing, A. V. &
Cunningham, M. L. (2011). Robin sequence: from diagnosis to development of
an effective management plan. Pediatrics 127, 936-48.
Johansen, L. C., Mupanemunda, R. H. & Danha, R. F. (2012). Managing
the newborn infant with a difficult airway. Infant 8, 116-119.
Cleminson and co-authors are to be commended for their excellent and
comprehensive work, which raises awareness to an important health
issue(1). Breastfeeding has undoubted benefits. However, it is important
to recognise, when promoting the health benefits, of breastfeeding that
breastmilk has very low levels of vitamin D (20IU or
0.5micrograms/litre)(2,3). This places infants, who are exclusively
breastfed, at risk of...
Cleminson and co-authors are to be commended for their excellent and
comprehensive work, which raises awareness to an important health
issue(1). Breastfeeding has undoubted benefits. However, it is important
to recognise, when promoting the health benefits, of breastfeeding that
breastmilk has very low levels of vitamin D (20IU or
0.5micrograms/litre)(2,3). This places infants, who are exclusively
breastfed, at risk of vitamin D deficiency and even rickets. The World
Health Organisation (WHO) recommends that infants be exclusively breastfed
in their first six months. However this would not satisfy a child's daily
vitamin D requirements. Such an infant would receive less than a tenth of
the daily 8.5micrograms recommended by the Department of Health (DoH) for
infants aged 0-6months(3); and required for normal growth(4).
The majority of vitamin D originates from dermal photosynthesis, in
Europe and the USA (5). At latitudes greater than 33 degrees North, there
is insufficient sunlight to generate adequate vitamin D in the winter
months. In Edmonton, Canada (52 degrees North) and Newcastle, UK (54
degrees North); vitamin D dermal photosynthesis is not possible for six
months of the year(6). The magnitude of the problem cannot be overstated.
Hospitalisation for rickets, for those under 15 years, has increased five-
fold in the UK between 1990 and 2011(7). According to the UK National Diet
and Nutrition Survey, 25% of the UK population are vitamin D deficient (25
-hydroxyvitamin D<25nmol/l)(8).
The DoH 2012, NICE 2008/2014 and Scientific Advisory Committee on
Nutrition 2007 guidance recommend that all pregnant and lactating mothers
receive a daily supplement containing 10micrograms of vitamin D
(8,9,10,11). They also advocate that all children from 6 months to 5years
receive vitamin D supplements. However, vitamin D supplementation is
indicated from birth for infants, if the mother did not receive vitamin D
supplements during pregnancy or if they belong to at-risk groups. This
includes those with dark skin types and/or with little sunlight exposure.
UNICEF explicitly supports this NICE guidance within the Baby
Friendly Initiative(12). The US Centre for Disease Control (CDC), for
their part, recommend 400IU daily vitamin D supplementation for all
breastfed infants, from birth(13,14). UNICEF, NICE, DoH and CDC emphasise
the importance of educating mothers and healthcare professionals on the
vital role of supplementary vitamin D for mothers and infants during
lactation. This important message must be promulgated along with the
health benefits of breastfeeding.
1. Cleminson J, Oddie S, Renfrew MJ, McGuire W. Being baby
friendly: evidence-based breastfeeding support. Arch Dis Child Fetal
Neonatal Ed. 2014 Oct 7. pii: fetalneonatal-2013-304873. doi:
10.1136/archdischild-2013 -304873.
2. Vitamin D deficiency Holick NEJM 2007; 357:266-81
4. Jeans PC, Stearns G. Effectiveness of vitamin D in infancy in
relation to the vitamin source. Proc Soc Exp Biol Med 1934; 31:1159-61
5. Braegger C, Campoy C, Colomb V, Decsi T, Domellof M, Fewtrell
M, Hojsak I, Mihatsch W, Molgaard C, Shamir R, Turck D, van Goudoever J;
on Behalf of the ESPGHAN Committee on Nutrition.Vitamin D in the Healthy
European Paediatric Population. J Pediatr Gastroenterol Nutr. 2013;56:692-
701
6. Wacker M, Holick MF. Sunlight and Vitamin D: A global
perspective for health. Dermatoendocrinol. 2013; 5:51-108
7. Goldacre M, Hall N, Yeates DG. Hospitalisation for children
with rickets in England: a historical perspective. Lancet. 2014; 383: 597-
8
In this review (Eye disorders in newborn infants (excluding retinopathy of prematurity), Wan MJ, VanderVeen DK, Arch Dis Child Fetal Neonatal Ed. 2015 May;100(3):F264-9. doi: 10.1136/archdischild-2014- 306215. Epub 2014 Nov 13, PMID:25395469) the authors describe clinical presentation, natural history and treatment of infantile haemangiomas (IH). These vascular tumors are common and if left untreated will result in visua...
We thank Dr Perlin for his response which specifically refers to the prevention of early onset Group B streptococcus (GBS) infection.
Similar declines in GBS EONS have been seen in many other countries that have introduced screening for GBS and IAP. In contrast, in the UK the RCOG recommendation for a risk based approach has not been associated with a fall in the incidence of GBS EONS. If the incidence fell by 75%,...
To the Editors: We have read with interest the article by Ingram et al (1) entitled "The development of a tongue assessment tool to assist with tongue-tie identification". The authors should be commended for simplifying and validating the ATLAF assessment. However, using their tool to decide upon whether or not to carry out lingual frenotomy has neither been proven nor is it justified. Unfortunately, this study, similar...
Dear Sir:
I have read the most excellent review of early onset neonatal sepsis (EONS) published recently in these Archives by Dr's Bedford Russell and Kumar. We, in America, have witnessed the gradual evolution from a risk factor approach initially advocated by the American College of Obstetricians and Gynecologists, (as opposed to universal screening during gestation, as recommended by the American Academy of P...
We read with interest the publication by Bialkowski et al (1). Their paper on infants with congenital chylothorax (CCT) in Germany focused in detail on this patient group, in comparison to our recently published paper reporting on all infants and children >24 weeks gestation to <16 years who developed a chylothorax in UK (2).
When reviewing data from infants with CCT from our epidemiological study, we hav...
We were interested to read the experiences of other units 1-4 sharing their findings of increased duration of antibiotics, length of stay in hospital and lumbar punctures (LP) performed following implementation of the NICE guideline on prevention of early onset neonatal infection (EONI)5. We recently changed our practice to follow these NICE recommendations advocating observation of low risk infants to reduce antibiotic...
The alternative explanation for the cardiovascular differences between immediate and delayed cord clamping at birth suggested in this commentary is not new and has been acknowledged for over 50 years. The basic premise is that asphyxia is the underlying cause of birth-related bradycardias and that avoiding asphyxia will avoid the bradycardia and associated cardiac instability. However, neonatologists have known for almo...
The review by Hooper et al1 is timely and mounts a compelling case for a stable circulatory transition during preterm birth. However, advocacy of early ventilation with delayed cord clamping as the primary way forward to ensure such a transition is open to question, as the main supportive evidence for this paradigm comes from an experimental study by the same group,2 for which an alternative interpretation of observed f...
To: The Editor, Archives of Disease in Childhood
From: Dr Janet M Rennie Dr Giles S Kendall (NICU UCLH London)
Dr Caroline May (NICU & NTS The Royal London Hospital, London)
Comment on: Neonatal Airway Practices: Whitby T et al ADC Fetal and Neonatal Edition 2015:100: F92-93
We read the letter from Whitby et al regarding neonatal airway practice with interest. We agree that neonat...
Cleminson and co-authors are to be commended for their excellent and comprehensive work, which raises awareness to an important health issue(1). Breastfeeding has undoubted benefits. However, it is important to recognise, when promoting the health benefits, of breastfeeding that breastmilk has very low levels of vitamin D (20IU or 0.5micrograms/litre)(2,3). This places infants, who are exclusively breastfed, at risk of...
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