This review on alloimmune thrombocytopenic purpura (ATP) by OUWEHAND et al is excellent and describes the current
knowledge on ATP. Regarding the management of this condition, since no
randomised trials have been performed using IVIg or intravenous
corticosteroids during pregnancy, no evidence-based guidelines for the use
of either treatment exist. I believe it is necessary for a
multi-institutuional trial on the preventio...
This review on alloimmune thrombocytopenic purpura (ATP) by OUWEHAND et al is excellent and describes the current
knowledge on ATP. Regarding the management of this condition, since no
randomised trials have been performed using IVIg or intravenous
corticosteroids during pregnancy, no evidence-based guidelines for the use
of either treatment exist. I believe it is necessary for a
multi-institutuional trial on the prevention of ATP to be performed. Since
ATP is relatively rare, with an estimated incidence of 1 in 1100 births,
it is rather difficult even for hospitals with 10,000-15,000
deliveries/year to have enough patients for study. On the other hand, a
multi-institutional comparison of the two preventive modalities, in women
whose previous pregnancies were affected by ATP, is feasible and will
provide firm evidence of efficacy (or lack of) for IVIg or
corticosteroids.
Neonates are exposed to many procedures, including intubation, IV
access, central line placement, chest tube insertion, lumber puncture,
catheterisation, suprapubic aspiration etc. These procedures are
associated with pain and stress. No clear guidelines are available for
alleviating the distress by premedication before such procedures.
Researchers are looking for methods to minimise the pain and distre...
Neonates are exposed to many procedures, including intubation, IV
access, central line placement, chest tube insertion, lumber puncture,
catheterisation, suprapubic aspiration etc. These procedures are
associated with pain and stress. No clear guidelines are available for
alleviating the distress by premedication before such procedures.
Researchers are looking for methods to minimise the pain and distress in
neonates during these procedures.
Examples include the use of thiopental as premedication before
intubation,(1) local anaesthetics before heel prick,(2) and response to
cutaneous stimulus.(3) In the recent issue of the journal three articles (1,3,4) were on the issue of
premedication before procedures in neonates. However, there is no
consensus regarding the policy and protocol for use of premedication
before procedures in neonates. The issue of is not so simple. In the
present era of evidence medicine, more
randomised control trials are needed so that the experts can reach to a
consensus. The questions need research are: the type of drug (analgesic,
sedative or anaesthetics), the mode of administration (IM, IV, ET) and the
dose to be used.
Yours sincerely,
Dr.Shabih Manzar,FAAP
Assistant Professor, Department of Pediatrics
King Fahd University Hospital
P.O.Box 40211, Al-Khobar 31952
Saudi Arabia
References:
1. Bhutada A, Sahni R,Rastogi S, Wung JT. Randomised controlled trial
of thiopental for intubation in neonates. Arch Dis Child Fetal Neonatal Ed
2000;82:F34-F37
2. Barker DP, Rutter N. Lignocaine ointment and anaesthesia in
preterm infants. Arch Dis Child Fetal Neonatal Ed 1995;72:F203-4
3. Jain A, Rutter N. Local anaesthetic effect of topical amethocaine
gel in neonates: randomised controlled trial. Arch Dis Child Fetal
Neonatal Ed 2000;82:F42-F45
4. Whyte S, Birrell G, Whyllie J. Premedication before intubation in
UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41
I read with interest the article by Marlow et al(1) on sensorineural
hearing loss and prematurity. In their study of preterm infant of less
that 33 weeks gestation, they put the cut-off value of serum creatinine
(as one of the variables) as 60 mmol/l. My comment is regarding the cut-
off of 60. In a recent study from Leeds, UK, Miall et al(2) have shown
that preterm babies have higher serum creatinine an...
I read with interest the article by Marlow et al(1) on sensorineural
hearing loss and prematurity. In their study of preterm infant of less
that 33 weeks gestation, they put the cut-off value of serum creatinine
(as one of the variables) as 60 mmol/l. My comment is regarding the cut-
off of 60. In a recent study from Leeds, UK, Miall et al(2) have shown
that preterm babies have higher serum creatinine and the mean value was
reported to be 73 micromol/l. (95% CI: 68-79 micromol/l). Similarly, in
another study from Royal Hospital London, Finney et al (3) have described
the serum creatinine ranges for 29-36 weeks gestation as 27-175 micromol/l
(median 75 micromol/l).
In addition to this low cut-off value of serum creatinine in preterm
infants, the unit reported by Marlow et al (1)was mmol/l instead of
micromol/l, which was probably a typing error, but still needed to be
corrected.
Your's sincerely,
Shabih Manzar
Assistant Professor, Department of Pediatrics
King Fahd University Hospital
P.O.Box 40211, Al-Khobar 31952
Saudi Arabia
References:
1. Marlow ES, Hunt LP, Marlow N.Sensorineural hearing loss and
prematurity. Arch Dis Child Fetal Neonatal Ed 2000;82:F141-F144
2. Miall LS, Henderson MJ, Turner AJ, et al. Plasma creatinine rises
dramatically in the first 48 hours of life in preterm infants. Pediatrics
1999;104:e76
3. Finney H, Newman DJ, Thakkar H, et al. References ranges for
plasma cystatin C and creatinine measurements in premature infants,
neonates and older children. Arch Dis
Child 2000;82:71-75
The paper by Bhutada et al (1) adds to the growing body of evidence
that premedication for tracheal intubation in neonates both improves
physiological stability and makes the procedure easier to perform. The
results of the telephone survey of premedication use in UK neonatal units
by Whyte et al (2) helps to define current practice. In a similar study,
we recently tried to define the routine use of premedication for trac...
The paper by Bhutada et al (1) adds to the growing body of evidence
that premedication for tracheal intubation in neonates both improves
physiological stability and makes the procedure easier to perform. The
results of the telephone survey of premedication use in UK neonatal units
by Whyte et al (2) helps to define current practice. In a similar study,
we recently tried to define the routine use of premedication for tracheal
intubation in term and pre-term neonates in Australia and the UK -
allowing comparisons to be made.
A survey was conducted of practice in Australian level 3 units (21)
and UK units with 6 or more intensive care cots (52). The format was a
semi-structured telephone interview of the nurse in charge of the shift
when the call was made. All interviews were conducted by one of two of the
authors (SWH and JB) in September 1999.
There was a 100% response rate. Results were:
United Kingdom
Australia
Term
Pre-term
Term
Pre-term
Routine premedication (%)
22(42)
18(34)
15(71)
14(67)
Opiate
13
11
2
4
Benzodiazepine (BDZ)
1
0
2
1
Opiate + BDZ
1
1
0
0
Opiate + muscle relaxant +/- atropine
6
6
11
9
BDZ + muscle relaxant +/- atropine
1
0
0
0
Seven different combinations of premedication drugs were in routine
use in Australia compared to 14 different combinations in the UK.
In Australian units, the routine administration of premedication for
non-emergency tracheal intubation of term and pre-term neonates is common
practice and there is some uniformity in the combinations of drugs used.
In contrast this practice is less common in the UK and there is more
diversity of prescribing. In both countries premedication was more
commonly used for term neonates. This difference in practice may reflect
the fact that larger babies are more likely to struggle when intubated -
making the procedure more technically demanding.
We agree with Whyte et al that there is a strong evidence-based
argument for premedication for tracheal intubation in neonates to be
routine. Our work brings added clarity to the existing picture and
confirms that there is little consensus as to the best combination of
drugs to use. Further work to define best practice is urgently required.
1 Bhutada A, Sahani R, Rastogi S, Wung J-T. Randomised controlled
trial of thiopental for intubation in neonates. Arch Dis Child Fetal
Neonatal Ed 2000;82:F34-F37.
2 Whyte S, Birrell G, Wyllie J. Premedication before intubation in UK
neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41.
Sir,
We read with interest the article by Isaacs on the rationing of antibiotic
use in neonatal units.(1) This encourages the use, where possible, of
flucloxacillin and an aminoglycoside as empiric therapy of late onset
sepsis.
While this represents a valid approach to the empiric therapy of late
onset infection, the epidemiology of bacterial sepsis will vary from unit
to unit. In our unit we use a combination...
Sir,
We read with interest the article by Isaacs on the rationing of antibiotic
use in neonatal units.(1) This encourages the use, where possible, of
flucloxacillin and an aminoglycoside as empiric therapy of late onset
sepsis.
While this represents a valid approach to the empiric therapy of late
onset infection, the epidemiology of bacterial sepsis will vary from unit
to unit. In our unit we use a combination of vancomycin and cefotaxime as
empiric treatment of late onset sepsis. In 1999, of 159 positive blood
cultures, coagulase negative staphylococci were isolated from 124 (80%).
All were sensitive to vancomycin. Sixty-three (63%) were resistant to
netilmicin, 89% to cefotaxime and 91% to flucloxacillin. In the majority
of cases there was a sudden rather than insidious deterioration in the
baby with elevation of the CRP suggesting true infection rather than
contamination. This is further supported by the fact that in 94% of
cases a coagulase negative staphylococcus was the sole isolate and the
patients responded to appropriate therapy.
Although we consider the use of vancomycin to be essential for
empiric therapy of late onset sepsis, we are aware of the problems
associated with its overuse. The emergence of vancomycin resistant
organisms including vancomycin resistant enterococci and vancomycin
insensitive staphylococcus aureus is, of coarse, a concern but in spite of
continuing surveillance this has not been observed in our unit. In order
to prevent the emergence of resistant gram positive organisms we agree
that it is vitally important to stop vancomycin therapy if cultures are
negative after 48 hours. Ninety 96 (96%) of blood cultures that grow an
organism do so within 48 hours,(2) and discontinuation after this time is
not associated with increased morbidity.(3)
In conclusion, we would suggest that antibiotic policies remain unit
specific based on the prevalent microorganisms and their known
sensitivities.
Dr Laura Stewart
Dr Charles H Skeoch
Neonatal Unit, Glasgow Royal Maternity Hospital
Rottenrow, Glasgow G4 ONA, UK
Dr Brian Jones
Department of Microbiology
Glasgow Royal Infirmary
Glasgow
References:
1. Isaacs D. Rationing antibiotic use in neonatal units. Arch Dis
Child Fetal Neonatal Ed 2000:82:F1-F2
In a recent, elegant study Govaert et al published their ultrasonographical observations in newborn infants with perinatal cortical infarctions (1). Like many others before them, they could not find a cause for stroke in a
high proportion in (25%) of cases. They also confirmed an association between stroke and pulmonary hypertension requiring assisted ventilation (2).
In a recent, elegant study Govaert et al published their ultrasonographical observations in newborn infants with perinatal cortical infarctions (1). Like many others before them, they could not find a cause for stroke in a
high proportion in (25%) of cases. They also confirmed an association between stroke and pulmonary hypertension requiring assisted ventilation (2).
We have previously published observations on arteficially
ventilated newborn piglets with pneumothorax and pulmonary hypertension, where we demonstrated cerebral arterial air microembolisations microscopically (3,4). In the case of arteficial ventilation, which is accompanied frequently by
pulmonary air leak syndrome (pulmonary interstitial emphysema, pneumomediastinum, pneumothorax), air can reach easily the cerebral vasculature, especially when there
is persistent pulmonary hypertension and right-to-left intracardial shunts.
In the light of our observations, as air microemboli could not be detected ultrasonographically, I have a suspicion that perinatal cortical infarction might have been due to cerebral arterial air embolisation in some patient in the study by Govaert et al.
References
1. Govaert P, Matthys E, Zecic A, Roelens F, Oostra A, Vanzieleghem B. Perinatal cortical infarction within middle cerebral artery trunks. Arch Dis Child 2000;82:F59-F63.
2. Klesh KW, Murphy TF, Scher MS, Buchanan DE, Maxwell EP, Guthrie RD. Cerebral infarction in persistent pulmonary hypertension of the newborn. Am J Dis Child 1987;141:852-7.
3. Temesvári P, Kovács J, Rácz K. Cerebral arterial air embolisation in experimental neonatal pneumothorax. Arch Dis Child 1989;64:179.
4. Temesvári P, Kovács J, Ábrahám CS. Pneumothorax and neonatal stroke. Neuropediatrics 1996;27:167-8.
Péter Temesvári
University Teaching Hospital
Department of Pediatrics
Kecskemét, Hungary
We read with great interest the consensus article on the
investigation and management of hyperinsulinism in infancy (1). The
authors discuss the value of the intra-arterial calcium stimulation test,
but speculate that there is a significant risk of bowel infarction.
Intra-arterial calcium stimulation for localisation of insulinomas in
adult patients has been described by several authors (2,3,4). To our
knowledge...
We read with great interest the consensus article on the
investigation and management of hyperinsulinism in infancy (1). The
authors discuss the value of the intra-arterial calcium stimulation test,
but speculate that there is a significant risk of bowel infarction.
Intra-arterial calcium stimulation for localisation of insulinomas in
adult patients has been described by several authors (2,3,4). To our
knowledge, bowel infarction has never been reported as a complication.
We have used the intra-arterial calcium stimulation test in infants
with hyperinsulinism to localise the site of hypersecretion of insulin,
and to determine whether it is focal or diffuse (5). In six procedures
performed on children (age range 2 months to 3 years) there has been no
clinical or radiological evidence of bowel ischaemia or infarction, and no
evidence of arterial spasm has been demonstrated on coeliac or mesenteric
arteriograms.
We conclude that this is a safe and valuable investigation, and we
believe that it is less invasive than the alternative technique of
transhepatic portal venous sampling.
L J Abernethy Consulatant Paediatric Radiologist
G L Lamont Consultant paediatric Surgeon
D C Davidson Consulatant Paediatrician
References:
1.
A Aynsley-Green, K Hussain, J Hall, J M Saudubray, C Nihoul-Fékété, P De
Lonlay-Debeney, F Brunelle, T Otonkoski, P Thornton, and K J Lindley
Practical management of hyperinsulinism in infancy
Arch. Dis. Child. Fetal Neonatal Ed. 2000; 82: F98-F107
2. Doppman JL, Miller DL, Chang R, Shawker TH, Gorden P, Norton JA.
Insulinomas: localization with selective intra-arterial injection of
calcium.
Radiology 178: 237 - 241.
3. O'Shea D, Rohrer-Theurs AW, Lynn JA, Jackson JE, Bloom SR
Localization of insulinomas by selective intaarterial calcium injection.
J Clin Endocrinol Metab 1996 81: 1623-7.
4. Pereira PL, Roche AJ, Maier GW, Huppert PE, Dammann F, Farsworth
CT, Duda SH, Claussen CD.
Insulinoma and islet cell hyperplasia: value of the calcium intarterial
stimulation test when finding of other preoperative studies are negative.
Radiology 1998: 206: 703-9.
5. Abernethy LJ,Davidson DC, Lamont G, Shepherd RM, Dunne MJ
Intra-arterial calcium stimulation test in the investigation of
hyperinsulinaemic hypoglycaemia.
Arch Dis Child 1998; 78:359-63
Wonderful work by Vyas et al on ROP and its incidence in different
cities of Britain. The statistically significant difference in the
incidence of ROP in different centres may be related to the differences in
the level of care provided. The advancements in neonatal care,
particularly the use of surfactant and the resultant reduction in the
requirements of O2 has greatly influenced outcome and possible development
of ROP (...
Wonderful work by Vyas et al on ROP and its incidence in different
cities of Britain. The statistically significant difference in the
incidence of ROP in different centres may be related to the differences in
the level of care provided. The advancements in neonatal care,
particularly the use of surfactant and the resultant reduction in the
requirements of O2 has greatly influenced outcome and possible development
of ROP (Hussain et al, Pediatrics 1999). Obviously all factors need to be
taken into account while comparing results at widely differing centres.
The finding of Pladys et al (1), that preterm infants are able to
compensate for deficiencies in hematocrit by increasing cardiac output is
reassuring. However, it would seem to be a good idea to attempt to
minimize the need for such efforts, which are another added stress to an
already overburdened newborn’s system.
There is a simple procedure with little, if any risk that can
increase red cell transport or...
The finding of Pladys et al (1), that preterm infants are able to
compensate for deficiencies in hematocrit by increasing cardiac output is
reassuring. However, it would seem to be a good idea to attempt to
minimize the need for such efforts, which are another added stress to an
already overburdened newborn’s system.
There is a simple procedure with little, if any risk that can
increase red cell transport or oxygen-carrying capacity and help reduce
the need for increased stress on the cardiovascular system. I am
referring to the practice of delayed clamping of the umbilical cord.
I would like to take this opportunity to extol some of the virtues of
this practice, since there are numerous health benefits that can be
reaped, especially in regards to increased red cell transport and other
hematological factors.
Hematocrit levels and neonatal blood volume have been shown to
increase significantly, with clamping being delayed for 3 minutes (2). The
increase in blood volume due to placental transfusion is especially
significant in premature infants due to the fact that a lower percentage
of the total feto-placental circulation is in the fetal circulation, as
compared with term infants. The hypovolemic state that most preterm
infants face, can thereby be eliminated or at least reduced.
It has also been shown to increase iron stores substantially, which
may help in the prevention of a later deficiency (3). Additionally,
initial packed cell volume and blood viscosity increases and median red
cell transfusion requirements decrease with late clamping (4). Lastly,
losses of crucial stem cells are reduced, providing numerous benefits (5).
In addition to the clinical benefits of late clamping, it has also
been proposed to result in significant healthcare cost savings (4,5).
Unfortunately, immediate cord clamping is apparently the standard
practice with preterm deliveries, in most areas, although I hope that this
may change. Although there is still ongoing research on this topic,
changes in standard practice need not wait for these results. This is
because it is the practice of immediate clamping that is the intervention,
which requires justification. Delayed clamping is the normal
physiological approach that should not be abandoned without just cause.
References:
1. Pladys P, Beuchee A, Wodey E, Tison L, Betremieux P. Haematocrit
and red blood cell transport in preterm infants: an observational study.
Arch Dis Child Fetal Neonatal Ed 2000; 82: F150-155.
2. Linderkamp O, Nelle M, Kraus M, Zilow EP. The effect of early and
late cord clamping on blood viscosity and other hemorheological parameters
in full-term neonates. Acta Paediatr 1992; 81: 745-50.
3. Pisacane A. Neonatal prevention of iron deficiency. Placental
transfusion is a cheap and physiological solution. BMJ 1996; 312: 136-
137.
4. Kinmond S, Aitchison TC, Holland BM, Jones JG, Turner TL, Wardrop
CA. Umbilical cord clamping and preterm infants: a randomised trial. BMJ
1993; 306: 172-175.
5. Wardrop CA, Holland BM. The roles and vital importance of
placental blood to the newborn infant. J Perinat Med 1995; 23: 139-143.
This review on alloimmune thrombocytopenic purpura (ATP) by OUWEHAND et al is excellent and describes the current knowledge on ATP. Regarding the management of this condition, since no randomised trials have been performed using IVIg or intravenous corticosteroids during pregnancy, no evidence-based guidelines for the use of either treatment exist. I believe it is necessary for a multi-institutuional trial on the preventio...
Editor,
Neonates are exposed to many procedures, including intubation, IV access, central line placement, chest tube insertion, lumber puncture, catheterisation, suprapubic aspiration etc. These procedures are associated with pain and stress. No clear guidelines are available for alleviating the distress by premedication before such procedures. Researchers are looking for methods to minimise the pain and distre...
Editor,
I read with interest the article by Marlow et al(1) on sensorineural hearing loss and prematurity. In their study of preterm infant of less that 33 weeks gestation, they put the cut-off value of serum creatinine (as one of the variables) as 60 mmol/l. My comment is regarding the cut- off of 60. In a recent study from Leeds, UK, Miall et al(2) have shown that preterm babies have higher serum creatinine an...
The paper by Bhutada et al (1) adds to the growing body of evidence that premedication for tracheal intubation in neonates both improves physiological stability and makes the procedure easier to perform. The results of the telephone survey of premedication use in UK neonatal units by Whyte et al (2) helps to define current practice. In a similar study, we recently tried to define the routine use of premedication for trac...
Sir, We read with interest the article by Isaacs on the rationing of antibiotic use in neonatal units.(1) This encourages the use, where possible, of flucloxacillin and an aminoglycoside as empiric therapy of late onset sepsis.
While this represents a valid approach to the empiric therapy of late onset infection, the epidemiology of bacterial sepsis will vary from unit to unit. In our unit we use a combination...
Sir,
In a recent, elegant study Govaert et al published their ultrasonographical observations in newborn infants with perinatal cortical infarctions (1). Like many others before them, they could not find a cause for stroke in a high proportion in (25%) of cases. They also confirmed an association between stroke and pulmonary hypertension requiring assisted ventilation (2).
We have previously published...
We read with great interest the consensus article on the investigation and management of hyperinsulinism in infancy (1). The authors discuss the value of the intra-arterial calcium stimulation test, but speculate that there is a significant risk of bowel infarction.
Intra-arterial calcium stimulation for localisation of insulinomas in adult patients has been described by several authors (2,3,4). To our knowledge...
Wonderful work by Vyas et al on ROP and its incidence in different cities of Britain. The statistically significant difference in the incidence of ROP in different centres may be related to the differences in the level of care provided. The advancements in neonatal care, particularly the use of surfactant and the resultant reduction in the requirements of O2 has greatly influenced outcome and possible development of ROP (...
The finding of Pladys et al (1), that preterm infants are able to compensate for deficiencies in hematocrit by increasing cardiac output is reassuring. However, it would seem to be a good idea to attempt to minimize the need for such efforts, which are another added stress to an already overburdened newborn’s system.
There is a simple procedure with little, if any risk that can increase red cell transport or...
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