Baumer reports the results of large multi-centre study comparing the
effects of patient triggered ventilation (PTV) with conventional
ventilation (IMV)1. There appears to be no benefit from PTV compared to
IMV in death rate, development of chronic lung disease, pneumothorax rates
and cerebral ultrasound abnormality. In addition, because of an increased
trend toward a higher pneumothorax rate, Baumer conc...
Baumer reports the results of large multi-centre study comparing the
effects of patient triggered ventilation (PTV) with conventional
ventilation (IMV)1. There appears to be no benefit from PTV compared to
IMV in death rate, development of chronic lung disease, pneumothorax rates
and cerebral ultrasound abnormality. In addition, because of an increased
trend toward a higher pneumothorax rate, Baumer concludes that at present,
PTV delivered with either the SLE 2000 or the Dräger babylog 8000
ventilators cannot be recommended for infants of less than 28 weeks
gestation with respiratory distress syndrome (RDS).
However, we are concerned that this may be a premature conclusion
given the significant difference in PTV delivered by the two main
ventilators used and the potential heterogeneity of clinical practice
within the different centres involved, despite agreed ventilation
protocols. Dimitriou et al2 demonstrated that neonates and infants trigger
a significantly lower proportion of breaths using the SLE 2000, an airway
pressure triggered ventilator, compared with the Dräger babylog 8000, an
airflow triggered ventilator that provides synchronised intermittent
positive pressure ventilation (SIPPV). Attempts to optimise the trigger
rate of the SLE 2000 ventilator by increasing pressure sensitivity often
results in auto triggering as discussed by Baumer. Therefore the PTV modes
of the two ventilators are substantially different. This prompts us to ask
whether the findings of this multi centre study are only applicable to PTV
provided by the SLE 2000? Would there have been a different outcome if all
the triggered babies had received SIPPV?
It is not known how many of the 40/213 babies of less than 28 weeks
gestation who had pneumothoraces were receiving SIPPV. As only 11%
(52/465) of all triggered babies ever received SIPPV, we surmise that very
few of the 40 were ventilated in this way. Is it fair to conclude that the
Dräger babylog 8000 has a trend to pneumothorax on SIPPV?
In a separate smaller study Baumer also reports 120 patients in three
centres randomly assigned to either the Dräger babylog 8000 or the SLE
2000 ventilator, and found a non-significant trend to higher pneumothorax
rate, chronic lung disease and death for the former group. But we are not
told how many of the babies were actually on trigger mode (PTV or SIPPV).
They could all have been receiving IMV on the Dräger babylog 8000.
Therefore is it possible that SIPPV is not being tested?
A further finding was a significantly higher rate (124/463) of
triggered babies that departed from their assigned mode of ventilation, 45
of these failing to trigger their ventilator. Were they all on the SLE
2000 ventilator, as Dimitriou2 would predict?
Finally, we note that 10 of the 22 neonatal units each recruited less
than 20 patients over the four year period, one contributing only 1
patient. Could the technique of PTV ventilation in units contributing so
few numbers be different to those enrolling 60-136 neonates over the same
period, despite prior visits from the trial co-ordinator? Would a logistic
regression for morbidity against number of patients contributed from each
unit reveal that the greatest morbidity occurred in units which
contributed fewer patients, rather than those using PTV or SIPPV modes?
Given the heterogeneity of the units involved and the significant
difference in ventilators used, we think that it is premature to dismiss
SIPPV on the Dräger babylog 8000 in neonates less than 28 weeks gestation
with RDS. We agree with Baumer that further studies are required, and
extend his conclusion by saying that PTV with the SLE 2000 (n=411) rather
than SIPPV from the Dräger babylog 8000 ventilator (n=52), cannot be
recommended in this group.
MARGARITA BURMESTER, ANDY PETROS
Intensive Care Units, Great Ormond Street Hospital London WC1N 3JH, UK
1. Baumer JH. International randomised controlled trial of patient
triggered ventilation in neonatal respiratory distress syndrome. Arch Dis
Child Fetal Neonatal Ed 2000;82:F5-10.
2. Dimitriou G, Greenough A, Laubscher B, Yamaguchi N. Comparison of
airway pressure triggered and airflow triggered ventilation in very
immature infants. Acta Paediatrica 1998;87:1256-60.
We were interested to read the article of Vyas et al (1) on the
incidence of severe retinopathy of prematurity (ROP) in 11 neonatal units
(NUs) from five cities in England in 1994. We have published similar data
from 8 NUs in New South Wales (NSW) Australia in 1993 and 1994.(2)
These data were prospectively collected in the NSW Neonatal Intensive Care
Unit's data collection and is stored and maintai...
We were interested to read the article of Vyas et al (1) on the
incidence of severe retinopathy of prematurity (ROP) in 11 neonatal units
(NUs) from five cities in England in 1994. We have published similar data
from 8 NUs in New South Wales (NSW) Australia in 1993 and 1994.(2)
These data were prospectively collected in the NSW Neonatal Intensive Care
Unit's data collection and is stored and maintained in the NSW Centre for
Perinatal Health Services Research, University of Sydney, NSW.
For infants <_29 weeks="weeks" gestation="gestation" there="there" was="was" no="no" significant="significant" difference="difference" in="in" severe="severe" rop="rop" greater="greater" than="than" or="Stage" _3="_3" between="between" the="the" _5="_5" cities="cities" england="england" and="and" nsw="nsw" australia="australia" table.="table." p="p"/> Table: Incidence of severe ROP in the 5 cities in England and NSW,
Australia.
Gestation
5 cities in England
NSW, Australia
Significance
< 27 weeks
20/95 (21%)*
44/157 (28%)
ns
27-28 weeks
5/162 (2.6%)
15/269 (5.6%)
ns
*= Number with severe ROP/number examined and the percent in
parenthesis.
Unlike Vyas et al (1) we could not find an association between
improved survival and the development of severe ROP. In 6 of the NUs in
our study survival
in infants <_27 weeks="weeks" gestation="gestation" ranged="ranged" from="from" _51.3="_51.3" to="to" _68.8="_68.8" two="two" nus="nus" have="have" been="been" excluded="excluded" this="this" analysis="analysis" as="as" they="they" are="are" childrens="childrens" hospitals="hospitals" and="and" very="very" few="few" small="small" premature="premature" infants.="infants." the="the" percent="percent" with="with" severe="severe" rop="rop" for="for" lowest="lowest" highest="highest" survival="survival" was="was" _15.1="_15.1" _3="_3" _20="_20" _23.8="_23.8" _5="_5" _21="_21" respectively="respectively" while="while" range="range" of="of" in="in" _6="_6" _36.0="_36.0" _9="_9" _25.="_25." infants="infants" _27-28="_27-28" _85.1="_85.1" _96.7="_96.7" _7.1="_7.1" _4="_4" _56="_56" _3.4="_3.4" _2="_2" _58="_58" respectively.="respectively." group="group" _2.01="_2.01" _50="_50" unpublished="unpublished" observations.="observations." we="we" also="also" shown="shown" that="that" despite="despite" an="an" increase="increase" preterm="preterm" following="following" introduction="introduction" surfactant="surfactant" there="there" no="no" significant="significant" impact="impact" on="on" incidence="incidence" or="or" severity="severity" rop.3="rop.3" p="p"/> In infants 29-31 weeks' gestation, 6 of 443 (1.4%)
developed severe ROP and one infant required Cryo/Laser therapy.(2)
This infant was 30 weeks' gestation with a birth weight of 1305 grams. We
therefore agree with Vyas et al (1) that there should be no reduction in
the upper limit of gestation or birth weight for screening for ROP.
David A Todd
Neonatal Unit
The Princess Anne Hospital
Coxford Road
Southampton, Hants, UK
John Kennedy
Ophthalmology Department
Westmead Hospital
Sydney, NSW
Australia
1. Vyas J, Field D, Draper ES, Woodruff G, Fielder AR, Thompson J, Shaw NJ, Clark D, Gregson R, Burke J, Durbin G. Severe retinopathy of prematurity and its association with different rates of survival in infants less than 1251 g birth weight. Arch Dis Child Fetal Neonatal Ed 2000;82:F145-F149.
2. Todd DA, Cassell C, Kennedy J, John E and the NSW Neonatal
Intensive Care Unit's study group. Retinopathy of prematurity in infants
<_32 weeks="weeks" gestation="gestation" at="at" birth="birth" in="in" new="new" south="south" wales="wales" _1993="_1993" and="and" _1994.="_1994." j="j" paediatr="paediatr" child="child" health="health" _199935355-357.="_199935355-357." p="p"/> 3. Kennedy J, Todd DA, Watts J, John E. Retinopathy of prematurity
in infants less than 29 weeks' gestation: 3 1/2 years pre- and
postsurfactant. J Pediatr Ophthalmol Strabismus 1997;34:289-292.
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.
Editor,
Baumer reports the results of large multi-centre study comparing the effects of patient triggered ventilation (PTV) with conventional ventilation (IMV)1. There appears to be no benefit from PTV compared to IMV in death rate, development of chronic lung disease, pneumothorax rates and cerebral ultrasound abnormality. In addition, because of an increased trend toward a higher pneumothorax rate, Baumer conc...
Dear Editor,
We were interested to read the article of Vyas et al (1) on the incidence of severe retinopathy of prematurity (ROP) in 11 neonatal units (NUs) from five cities in England in 1994. We have published similar data from 8 NUs in New South Wales (NSW) Australia in 1993 and 1994.(2) These data were prospectively collected in the NSW Neonatal Intensive Care Unit's data collection and is stored and maintai...
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 (...
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