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 the review by AR Bedford Russell and F
Kumar[1] about challenges in diagnosing EONS.
The authors state to await a 100% sensitive and 100% specific test. In
theory, this gold standard is obtained by observing infants while
withholding antibiotics, which obviously is unacceptable. Instead
combinations of laboratory and clinical signs are used to exclude EONS.
Understandably, these tests must have hi...
We read with interest the review by AR Bedford Russell and F
Kumar[1] about challenges in diagnosing EONS.
The authors state to await a 100% sensitive and 100% specific test. In
theory, this gold standard is obtained by observing infants while
withholding antibiotics, which obviously is unacceptable. Instead
combinations of laboratory and clinical signs are used to exclude EONS.
Understandably, these tests must have high sensitivity. High sensitivity
in a test with poor test characteristics means by definition poor
specificity, resulting in overtreatment and all its associated drawbacks,
as described in the review.
We are thus waiting for new tests with equal sensitivity but higher
specificity. However, problems arise when developing this test. First of
all, since the sensitivity of the new test must be close to 100%, and the
non-inferiority margin must be small to prove non-inferiority an enormous
sample size is needed. Secondly, the sample size needed cannot be
calculated due to the lack of a gold standard. The same holds true for the
numbers needed to treat (NNT), sensitivity and specificity. For these
numbers, the incidence or prevalence of EONS in the population is needed.
Finally, it is unclear to what extent shortening of the course of
antibiotics would be of benefit, and thus the advantage of a more specific
test would be unclear.
In the context of all these considerations it is remarkable that in the
past neonatal antibiotic treatment has been shortened without scientific
sound underpinning. So it seems that the only way to move forward is to
just shorten treatment and monitor closely, and accept that strong
scientific foundation for optimizing EONS treatment will never be obtained
before changing the policy.
Reference list
1 A R Bedford Russell, R Kumar. Early onset neonatal sepsis: diagnostic
dilemmas and practical management. Arch Dis Child Fetal Neonatal Ed
2015;100:F350-F354.
To the Editor:
I read the article by Prendergast et al with great interest (1). The
results of this study are in contrast to our traditional belief. In this
regard, I would like to point out few issues that needs urgent explanation
before the study results can be accepted.
First, the part of the hypothesis stating poor lung function in preterm
infants exposed to chorioamnionitis is not fully correct as in various
animal m...
To the Editor:
I read the article by Prendergast et al with great interest (1). The
results of this study are in contrast to our traditional belief. In this
regard, I would like to point out few issues that needs urgent explanation
before the study results can be accepted.
First, the part of the hypothesis stating poor lung function in preterm
infants exposed to chorioamnionitis is not fully correct as in various
animal models antenatal inflammation has been found to increase the
surfactant production and enhances lung maturation (2). Moreover in many
human studies chorioamnionitis is associated with decreased incidence of
RDS (3).
Second, the distribution of the number of patients requiring any
resuscitation after birth in each group is missing. Any positive pressure
ventilation given during resuscitation will have influence on the lung
functions.
Third, the distribution of the infants in each group from the previous two
studies is important to know because the various practices of
resuscitation like use of air and oxygen mixture instead of 100% oxygen,
use of PEEP, prolonged initial inflation time and introduction of early
CPAP have changed over last few years, though the authors claim that there
is no change in routine policies like antenatal steroid, surfactant etc.
All this will affect the lung function and possibly BPD also (4, 5).
Fourth, the first lung function measurement should have been done at the
earliest after the initial stabilization rather than on D2 of life. The
various interventions like amount of fluid received, presence of PDA,
initiation of ventilation (invasive/non-invasive), will alter the lung
function and the true influence of chorioamnionitis will get nullified.
Fifth, more infants in the chorioamnionitis group were exposed to
antenatal steroids (p=0.04) which could have partly influenced the lung
function.
Sixth, the surfactant has been given to symptomatic infants (rescue
therapy). It is not the prophylactic use of surfactant as has been
highlighted.
Despite these limitations, I would like to appreciate the authors for
their work, which has opened up the Pandora's Box.
References
1.Prendergast M, May C, Broughton S, Pollina E, Milner AD, Rafferty GF et
al. Chorioamnionitis, lung function and bronchopulmonary dysplasia in
prematurely born infants. Arch Dis Child Fetal Neonatal Ed 2011;96:270-74.
2.Kramer BW, Kallapur S, Newnham J, Jobe AH. Prenatal inflamemation and
lung development. Semin Fetal Neonatal Med 2009;14:2-7.
3.Andrews WW, Goldenberg RL, Faye Petersen O, Cliver S, Goepfert AR, Hauth
JC. The Alabama Preterm Birth Study: polymorphonuclear and mononuclear
cell placental infiltrations, other markers of inflammation, and outcomes
in 23 to 32 week preterm newborn infants. Am J Obstet Gynecol 2006;195:803
-8.
4.Siew ML, Te Pas AB, Wallace MJ, Kitchen MJ, Lewis RA, Fouras A et al.
Positive end expiratory pressure enhances development of a functional
residual capacity in preterm rabbits ventilated from birth. J Appl
Physiol. 2009;106:1487-93.
5.Te Pas AB, Siew M, Wallace MJ, Kitchen MJ, Fouras A, Lewis RA et al.
Establishing functional residual capacity at birth: the effect of
sustained inflation and positive end-expiratory pressure in a preterm
rabbit model. Pediatr Res. 2009;65:537-41.
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.
To the editor,
We were most interested to read the review by Sie et al.1 The authors
reviewed the literature on the effects of SRI use in pregnancy for mothers
and their offspring, and formulated guidelines. However, although their
review could have been more comprehensive, our main concern is with their
"practical recommendations". Several guidelines produced by psychiatric
governing bodies have been published regarding...
To the editor,
We were most interested to read the review by Sie et al.1 The authors
reviewed the literature on the effects of SRI use in pregnancy for mothers
and their offspring, and formulated guidelines. However, although their
review could have been more comprehensive, our main concern is with their
"practical recommendations". Several guidelines produced by psychiatric
governing bodies have been published regarding this subject, which were
formulated using evidence-based information with a multidisciplinary
approach.2 Therefore, we feel that some of Sie et al recommendations are
not only redundant but may not be in the best interests of either the
mother or baby.
There were several recommendations that we found troubling: 1) there is no
such thing as a "safe" antidepressant to use in pregnancy. The danger is
that a woman will switch and her depression will not be treated
effectively, increasing the risk of depression. 2) Tapering of
antidepressants doses is not useful, since there is no linear dose-
response curve, and therefore effects of changes in dose are very hard to
predict.3 3) Regarding breastfeeding, because the pharmacodynamics of
these drugs are individual, discouraging continuation of use of an
antidepressant (fluoxetine) solely based on an M/P ratio of maximally 11
percent is arbitrary. In addition, none of the antidepressants (including
fluoxetine) are excreted in breast milk in large enough amounts to
disallow breastfeeding, and there are very few reports of adverse effects
in the infant.4 4) The Finnegan score (as the authors acknowledge) was not
designed for SRI-related symptoms in neonates, but for fetal exposure to
opioids. Therefore, clinical decision making when suspecting poor neonatal
adaptation syndrome, should not be based solely on a Finnegan score, and
finally, 5) we are not aware of any evidence suggesting an anticonvulsant
such as phenobarbital for treatment of symptoms.2
Geert.W. 't Jong MD PhD
Clinical Fellow in Clinical Pharmacology Division of Clinical Pharmacology
& Toxicology and The Motherisk Program, The Hospital for Sick
Children, University of Toronto, Toronto ON, Canada
Adrienne Einarson RN
Consultant, The Motherisk Program, The Hospital for Sick Children,
University of Toronto, Toronto ON, Canada
References
1. Sie SD, Wennink JMB, van Driel JJ, et al. Maternal use of SSRIs, SNRIs
and NaSSAs: practical recommendations during pregnancy and lactation. Arch
Dis Child Fetal Neonatal Ed. 2011. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21798871. Accessed August 4, 2011.
2. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression
during pregnancy: a report from the American Psychiatric Association and
the American College of Obstetricians and Gynecologists. Gen Hosp
Psychiatry. 2009;31(5):403-413.
3. Burke MJ, Harvey AT, Preskorn SH. Pharmacokinetics of the newer
antidepressants. Am. J. Med. 1996;100(1):119-121.
4 Kendall-Tackett K, Hale TW The use of antidepressants in pregnant and
breastfeeding women: a review of recent studies. J Hum Lact. 2010
May;26(2):187-95. Review.
We appreciate the feedback and clarity provided by the letter in
response to our review article. We agree in principle with the authors
that beta-blockers have rapidly become the standard of care for infantile
haemangiomas (IHs), and for this reason listed it first in our short
review of treatment options. Indeed, a recent meta-analysis of 35 studies
(representing 572 paediatric patients with IHs) strongly supported the...
We appreciate the feedback and clarity provided by the letter in
response to our review article. We agree in principle with the authors
that beta-blockers have rapidly become the standard of care for infantile
haemangiomas (IHs), and for this reason listed it first in our short
review of treatment options. Indeed, a recent meta-analysis of 35 studies
(representing 572 paediatric patients with IHs) strongly supported the
superior efficacy of propranolol in comparison to alternative therapeutic
options including steroids, vincristine, and laser treatment.(1) Patients
with periorbital IHs should be urgently referred to both paediatric
ophthalmology and dermatology in order to initiate treatment with
propranolol when clinically indicated.
Although propranolol is generally well tolerated by infants, systemic
beta-blockers are not without potential risks and side effects. A number
of serious adverse effects have been reported with propranolol use in
children, including bradycardia, hypotension, hypoglycaemia, bronchospasm,
and hyperkalemia.(2) A consensus conference was held in 2011 to develop
guidelines for the use of propranolol in children and the following
relative contraindications were suggested: cardiogenic shock, sinus
bradycardia, hypotension, heart failure, bronchial asthma, and
hypersensitivity to propranolol.(2) Therefore, for cases in which
propranolol is either ineffective or contraindicated, it remains important
to be aware of alternative therapeutic options for IHs.
References
1. Lou Y, Peng W-J, Cao Y, Cao D-S, Xie J, Li H-H. The effectiveness
of propranolol
in treating infantile haemangiomas: a meta-analysis including 35
studies. Br J
Clin Pharmacol. 2014 Jul 1;78(1):44-57.
2. Drolet BA, Frommelt PC, Chamlin SL, Haggstrom A, Bauman NM, Chiu
YE, et al.
Initiation and use of propranolol for infantile hemangioma: report of
a
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,
We read with interest the paper by Rovamo et al in which the authors
assessed the resuscitation skills of physicians on a manikin using a
standard simulation scenario of birth asphyxia.(1) They used a30-item
checklist to score the technical skills of each participant. The cut-off
point for passing or failing each of the 30 items was determined by
experts using the Angoff method for absolute standards setting...
Dear Editor,
We read with interest the paper by Rovamo et al in which the authors
assessed the resuscitation skills of physicians on a manikin using a
standard simulation scenario of birth asphyxia.(1) They used a30-item
checklist to score the technical skills of each participant. The cut-off
point for passing or failing each of the 30 items was determined by
experts using the Angoff method for absolute standards setting, as stated
by the authors.(2) The results they obtained showed a high prevalence of
inadequate skills in neonatal resuscitation.
The Angoff method is based on the estimated percentage of borderline
candidates who will adequately perform each assessment item, as judged by
a large panel of experts in that field. The scores (or percentages) for
all the items defining the whole assessment are summed up then averaged
and that obtained average constitutes the final passing score.(2) It is
widely used and recommended for standard setting of objective structured
clinical examinations (OSCE) even when used in simulation on a manikin
such in this study.(3)
We have concerns regarding the way in which this method was used by the
authors. It seems that the same score of 0.662 (or 66% of borderline
participants) was estimated for each of the 30 items of neonatal
resuscitation and the total passing mark was calculated accordingly. We
feel that this methodology is intrinsically flawed and likely to have
influenced the obtained results. This is because it is extremely unlikely
and indeed implausible that exactly the same percentage of participants
(66%) would be expected to adequately perform each of the separate 30
skills encompassing an extremely wide range of complexity, for example
something as simple as drying the baby or as technically demanding as
performing endotracheal intubation. Without adopting the proper standard
setting methodology, the stated results cannot be taken at face value.
There could be, worryingly, even far more physicians with inadequate
resuscitation skills than stated by the authors, or, reassuringly, many
more who can perform adequate neonatal resuscitation. The resulting
implications for corrective strategies for neonatal resuscitation training
are too important.
References
1. Rovamo L, Mattila MM, Andersson S, et al. Assessment of newborn
resuscitation skills of physicians with a simulator manikin. Archives of
disease in childhood Fetal and neonatal edition 2011;96:F383-9.
2. Angoff WH. Scales, Norms and Equivalent Scores. Educational
Measurement. Washington, DC: American Council on Education, 1971:508-600.
3. Pell G, Fuller R, Homer M, et al. How to measure the quality of
the OSCE: A review of metrics - AMEE guide no. 49. Medical teacher
2010;32:802-11
I read this Randomised controlled trial with great interest. I
applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside
round is appropriate is of limited value and so deeper qualitative
discourse is needed. This can consider more meaningful questions such as
'how', 'why' and 'when' such parental presence impacts the neonatal
j...
I read this Randomised controlled trial with great interest. I
applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside
round is appropriate is of limited value and so deeper qualitative
discourse is needed. This can consider more meaningful questions such as
'how', 'why' and 'when' such parental presence impacts the neonatal
journey.
This is where I feel the authors do not fulfil the full potential of
this work. Whilst some limited analysis is made, it appears that a huge
volume of rich qualitative data has either not been analysed or analysed
in a manner that does not synthesise useful outcomes.
By not employing appropriate qualitative synthesis I feel we are left
with a piece that only tantalisingly points to the questions that will
help us to understand the value of parental presence during this aspect of
neonatal care.
I appeal to the authors to complete and publish such analysis of the
data from their focus group discussions.
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.
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 the review by AR Bedford Russell and F Kumar[1] about challenges in diagnosing EONS. The authors state to await a 100% sensitive and 100% specific test. In theory, this gold standard is obtained by observing infants while withholding antibiotics, which obviously is unacceptable. Instead combinations of laboratory and clinical signs are used to exclude EONS. Understandably, these tests must have hi...
To the Editor: I read the article by Prendergast et al with great interest (1). The results of this study are in contrast to our traditional belief. In this regard, I would like to point out few issues that needs urgent explanation before the study results can be accepted. First, the part of the hypothesis stating poor lung function in preterm infants exposed to chorioamnionitis is not fully correct as in various animal m...
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...
To the editor, We were most interested to read the review by Sie et al.1 The authors reviewed the literature on the effects of SRI use in pregnancy for mothers and their offspring, and formulated guidelines. However, although their review could have been more comprehensive, our main concern is with their "practical recommendations". Several guidelines produced by psychiatric governing bodies have been published regarding...
We appreciate the feedback and clarity provided by the letter in response to our review article. We agree in principle with the authors that beta-blockers have rapidly become the standard of care for infantile haemangiomas (IHs), and for this reason listed it first in our short review of treatment options. Indeed, a recent meta-analysis of 35 studies (representing 572 paediatric patients with IHs) strongly supported the...
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, We read with interest the paper by Rovamo et al in which the authors assessed the resuscitation skills of physicians on a manikin using a standard simulation scenario of birth asphyxia.(1) They used a30-item checklist to score the technical skills of each participant. The cut-off point for passing or failing each of the 30 items was determined by experts using the Angoff method for absolute standards setting...
I read this Randomised controlled trial with great interest. I applaud the authors for including focus group discussions in the study.
A study that simply tells us 'whether' parental presence on a bedside round is appropriate is of limited value and so deeper qualitative discourse is needed. This can consider more meaningful questions such as 'how', 'why' and 'when' such parental presence impacts the neonatal j...
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...
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