We thank Dr Srinivasan for his interest in our paper. For clarity,
some of the original results were not included in the published paper. In
response to his points:
To be clinically effective, a topical local anaesthetic agent should
work in almost all cases. Whether the sample size was 20 or 100 seems
less relevant. However, we considered that to be clinically effective, the
proportion of newbo...
We thank Dr Srinivasan for his interest in our paper. For clarity,
some of the original results were not included in the published paper. In
response to his points:
To be clinically effective, a topical local anaesthetic agent should
work in almost all cases. Whether the sample size was 20 or 100 seems
less relevant. However, we considered that to be clinically effective, the
proportion of newborn infants who feel pain in the topical amethocaine gel
group should be no greater than 15%. In the placebo group, the rate of
painful response to venepuncture was 70%. A Casagrande and Pike power
computation (Fisher's Exact approximation) was conducted. A sample size
of 11 per group would have a power of 83% to detect a statistically
significant result (specifically a reduction from 70% to 15% painful
response) (level of significance p=0.05).
As the data were non-parametric, a confidence limit was not calculated.
The Prechtl behaviour scores prior to venepuncture were not
significantly different between treatment groups (amethocaine median 2
(IQR 1 - 3) vs. placebo median 0 (IQR 1 - 2), Z= -0.231, p= 0.841).
Recommendations for the safe use of topical amethocaine gel in the
NICU are described in the penultimate paragraph of the paper. We are
currently in the process of analysing the blood concentration of
amethocaine and its metabolites following topical application in the
newborn infant.
Armstrong and Simpson’s letter in May’s edition of Archives of Disease in Childhood highlights the difficulties encountered by junior medical staff when examining the
neonatal palate.[1] Their concern is echoed by a presentation at the recent Royal
College of Paediatrics and Child Health spring meeting. Habel et al. presented the
results of their audit revealing that 31 % of isolated cleft pal...
Armstrong and Simpson’s letter in May’s edition of Archives of Disease in Childhood highlights the difficulties encountered by junior medical staff when examining the
neonatal palate.[1] Their concern is echoed by a presentation at the recent Royal
College of Paediatrics and Child Health spring meeting. Habel et al. presented the
results of their audit revealing that 31 % of isolated cleft palate (ICP) cases over a ten-year period were missed in the first 24 hours.[2] Neither of these authors describe the
circumstances of the routine neonatal examination.
It is recommended that the examination be performed under direct vision with a torch
and spatula. Our experience is that this is only possible if the paediatrician performs the examination with an assistant. We discovered this when we introduced a clinic
setting for all weekday routine neonatal examinations to overcome the problems
created by early maternity discharges. The paediatric Senior House Officer is assisted
by a nurse whom can then support the baby’s head with the neck extended whilst
placing a finger on the baby’s chin. The paediatrician is then able to examine the
whole palate without difficulty with torch and spatula. Examinations not performed in
the clinic setting, usually at the weekend, encounter the difficulties described by
Armstrong and Simpson. Failing in the neonatal examination can result from the
circumstances in which it is performed rather than the examination itself.
Christopher S. James
Peter J. Todd
Department of Paediatrics
Arrowe Park Hospital
Arrowe Park
Wirral CH49 5PE
UK
References
(1) H Armstrong and R M Simpson. Examination of the neonatal palate. Arch Dis Child Fetal Neonatal Ed 2002;86:F210.
(2) Habel A, Elhadi N, Sommerlad B. Delay in detection of cleft palate, an audit of newborn clinical examination. Arch Dis Child 2002;86(suppl 1):A59.
We at our unit in Karachi deal with a spectrum of parents ranging
from the highly educated cosmopolitan couple to the the very illiterate
labobourer family on the verge of poverty.Our practice has been to address
the risk of long-term neurodevelopmental outcome right from day 1, based
on the prematurity.During subsequent discussions the range of such
disability gets...
We at our unit in Karachi deal with a spectrum of parents ranging
from the highly educated cosmopolitan couple to the the very illiterate
labobourer family on the verge of poverty.Our practice has been to address
the risk of long-term neurodevelopmental outcome right from day 1, based
on the prematurity.During subsequent discussions the range of such
disability gets discussed from severe disability to "a touch of cerebral
palsy". My experience is that it makes acceptibility much easier for
parents from all walks of life and helps in ensuring follow-up for
sequential re-evaluations
I also forewarn them about the risks of intraventricular haemmorhage
as there have been times when parents have focussed on the ventilator and
the lung and have had difficulty dealing with the sudden IVH.
Finally,the housestaff has realised the value of this appraoch and
are proactive in the appropriate counselling.
We read with interest the findings of Wolke et al.[1] regarding maternal
satisfaction with routine examination of the newborn. Whilst appreciating
their conclusions and those reached by others (Lee TWR et al.[2] and Walker
D[3])we wish to provide further comment.
Perhaps an equally valuable study
would be one which explores the attitudes of senior house officers to
performing this examinat...
We read with interest the findings of Wolke et al.[1] regarding maternal
satisfaction with routine examination of the newborn. Whilst appreciating
their conclusions and those reached by others (Lee TWR et al.[2] and Walker
D[3])we wish to provide further comment.
Perhaps an equally valuable study
would be one which explores the attitudes of senior house officers to
performing this examination and assessing the perceived benefits to their
professional development. Possible questions may include:
(i) Did you receive formal training from a senior paediatrician?
(ii) Do you feel comfortable performing this task and subsequently
reassuring parents about their infant?
(iii) Do you feel competent to discuss aspects of general neonatal care
and education with parents?
(iv) Do you think this task contributes positively to your training?
It is important to note that whilst not subjecting senior house
officers to vast numbers of repetitive neonatal examinations, a formal
system of training in all aspects of routine neonatal care followed by
subsequent assessment might be educationally beneficial. It is surely
questionable to expect paediatric senior house officers to progress to GPs
and higher specialist trainees managing common problems in newborn infants if their
previous experience is being reduced further. The correct balance between
education and service provision is essential to prevent future
deficiencies in general paediatric knowledge.
Guy C Millman
Prakash Satodia
References
(1) Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. Routine examination of the newborn and
maternal satisfaction: a randomised controlled trial. Arch Dis Child
Neonatal Fetal Ed 2002;86:F155-60.
(2) TWR Lee, R E Skelton, and C Skene. Arch Dis Child Fetal Neonatal Ed 2001;85:F100-4.
(3) Walker D. Role of routine neonatal examination. It probably makes
more sense for other staff to carry out neonatal examinations [letter].
BMJ 1999;318:1766.
This was an interesting and useful article on birth customs from a
religion and culture dfferent from my own, and should be compulsory
reading for those invloved in obstetrics and neonates.
There is, however, one practice which I would like to comment on. The use
of honey in young children (under 6 months) is not usually recommended
because of the (rare) risk of botulism. Honey is the one dietary re...
This was an interesting and useful article on birth customs from a
religion and culture dfferent from my own, and should be compulsory
reading for those invloved in obstetrics and neonates.
There is, however, one practice which I would like to comment on. The use
of honey in young children (under 6 months) is not usually recommended
because of the (rare) risk of botulism. Honey is the one dietary resevoir
of C botulinum spores that has been definitively linked to infant
botulism. Spores have been found in honey from US, Canada, China, Japan
and Central America, but interestingly not the UK! The AAP (American Academy of Pediatrics) recommends that
honey should not be fed to infants unless it is certified free from C botulinum.
In the UK the risk appears to be far lower than that seen in the US
but the honey we eat is from all over the world and there is a potential
risk that should be highlighted.
Sweet et al investigated the serum transferrin receptor
(sTfR) and, for the first time in neonates, transferrin receptor-log
ferritin (TfR-F) ratio in a prospective series of cord blood taken from
term infants and their mothers. They are to be congratulated on completing
another piece of the complex jigsaw that is fetal and neonatal iron
metabolism.
sTfR and TfR-F were increased in iron deficient m...
Sweet et al investigated the serum transferrin receptor
(sTfR) and, for the first time in neonates, transferrin receptor-log
ferritin (TfR-F) ratio in a prospective series of cord blood taken from
term infants and their mothers. They are to be congratulated on completing
another piece of the complex jigsaw that is fetal and neonatal iron
metabolism.
sTfR and TfR-F were increased in iron deficient mothers, but not in
their infants. The authors discussed at some length the translational (not
transcriptional as stated in the discussion) control of intracellular
ferritin synthesis.[1]
They measured serum ferritin (SF), which is a glycosylated form of L-
ferritin, and has been shown to correlate with intracellular iron in the
absence of confounding factors.[2] However, SF is secreted in response to
a wide variety of other stimuli, including, for example, inflammation and
shows gender differences in newborns.[3] Under these circumstances SF may
not accurately represent tissue iron stores.
It has already been reported that sTfR does not correlate with other
measures of iron metabolism in the newborn,[4] mainly since it is highly
expressed by reticulocytes and other immature erythroid cells, with or
without iron deficiency.
The high sensitivity and specificity of the TfR-F ratio in adults is
based upon their relationship in iron deficiency in the absence of factors
that might otherwise elevate sTfR levels.[5] With both variables subject
to these confounding factors in the neonate, I don't agree with the
author's assertion that the TfR-F index "gives a measure of iron
requirements in relation to iron availability" in this unique population.
References
(1) Sweet DG, Savage G, Tubman TRJ, Lappin
TRJ, Halliday HL. Study of maternal influences on fetal iron status at term using cord blood transferrin receptors. Arch Dis Child Fetal Neonatal Ed 2001;84:F40-3.
(2) Finch CA, Huebers HA. Perspectives in iron metabolism. N Engl J Med 1982;306:1520-8.
(4) Kuiper-Kramer EP, Baerts W, Bakker R, van
Eyck J van Rann J, van Eijk HG. Evaluation of the iron status of the newborn by soluble
transferrin receptors in serum. Clin Chem Lab Med 1998;36:17-21.
(5) Punnonen K, Irjala K, Rajamaki A. Serum transferrin receptor and its ratio to serum ferritin in the
diagnosis of iron deficiency. Blood 1997;89:1052-7.
we would like to thank Drs Millman and Satodia for their considerate
comments on our paper.[1] The randomised controlled trial reported in the
Archives is part of a larger evaluation study of the implications and cost
effectiveness of extending the role of midwives to include the routine (24
hour) examination of the newborn. The evaluation study includes, apart
from the RCT, a longer term follow-up (...
we would like to thank Drs Millman and Satodia for their considerate
comments on our paper.[1] The randomised controlled trial reported in the
Archives is part of a larger evaluation study of the implications and cost
effectiveness of extending the role of midwives to include the routine (24
hour) examination of the newborn. The evaluation study includes, apart
from the RCT, a longer term follow-up (safety and referrals), videotaped
quality assessments and interviews with health professionals involved in
the newborn assessment and with parents and all stakeholders (Royal
Colleges, professional organisations and consumer groups). Furthermore a
national survey of current practice was conducted. The findings have been
written up in a number of papers that are submitted or in press and our
full report will be published by the NHS Executive Research and
Development Programme Health Technology Assessment Programme this year.
The questions raised by Millman & Satodia have been addressed in
the interviews with senior house officers (SHOs) (and midwives, General
Practioners (GPs), consultant paediatricians). The full findings from the
interviews with the SHOs and GPs were fairly consistent and clearcut:
1. they value the neonatal examination to screen for major anomalies;
2. they
value the examination to reassure the parents about the normality of their
child;
3. there were mixed opinions of whether "a quick SHO check"
provides opportunities for any health education. Some felt not confident
of providing such information while others were pro-active in discussing
history or baby care issues. In contrast midwives consider the examination
as an ideal opportunity to discuss feeding and baby care issues.
4. SHOs
reported that they received very little, if any, training and the usual
procedure was to be shown once and let to get on with it. 5. SHOs did not
feel comfortable about some aspects of the examination such as the hips,
taking pulses or the red reflex. They would have liked more training by
senior paediatricians and more supervision. 6. Many SHOs and GPs felt that
doing the examinations was useful for their training but there were too
many examinations and they were often rushed. Others reported that
"doctors have more important things to do"; 7. SHOs and GPs were broadly
the view that any midwife, if trained, could do the newborn examination as
well as the junior doctor. This concurred with mothers views who would be
happy for midwives to examine babies, and some expressed they had more
confidence in midwives than SHOs.
Taking the findings of our evaluation study together, it is apparent
that a system of formal training for SHOs would be highly desirable to
increase quality of examinations and parental satisfaction. The training
would need to include, apart from technical components, education in
communication skills and knowledge on child care issues. SHOs, and in
particular those who progress to GPs require some experience with normal
newborns. In a programme of training there should be enough opportunities
for newborn examinations by SHOs alongside or together with midwives.
However, as one GP expressed it: "ultimately, the examination should not
be education for an SHO but for the benefit of the baby".
Reference
(1) Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. Routine
examination of the newborn and maternal satisfaction: a randomised
controlled trial. Arch Dis Child Neonatal Fetal Ed2002;86:F155-60.
This article on Muslim birth customs[1] makes good and very useful
reading not only to non-Muslim professionals who work with children but
also to Muslims, like me, who are not familiar with these practices which
are seen basically in Muslims from the Indian subcontinent and are, many
times, cultural rather than based on clear religious directions.
Many of
these practices are not known to Muslim Ar...
This article on Muslim birth customs[1] makes good and very useful
reading not only to non-Muslim professionals who work with children but
also to Muslims, like me, who are not familiar with these practices which
are seen basically in Muslims from the Indian subcontinent and are, many
times, cultural rather than based on clear religious directions.
Many of
these practices are not known to Muslim Arabs in the Middle East and North
Africa who, I am sure, have their own very different practices. The paper
should probably be better labelled Birth customs in Muslim families of
Indian subcontinent origin.
References
(1) Gatard AR, Sheikh A. Muslim birth customs. Arch Dis Child Fetal Neonatal Ed 2001;84:F6-8.
We read with interest the paper by Dimitriou et al.,[1] in which it
was confirmed again that head up tilting to 45 degrees results in better
oxygenation in stable preterm neonates. However compared to our study,[2]
in which the same effect was observed, there is a (probably) significant
difference. Their infants were studied in the horizontal prone, in the
horizontal supine and in the 45 degre...
We read with interest the paper by Dimitriou et al.,[1] in which it
was confirmed again that head up tilting to 45 degrees results in better
oxygenation in stable preterm neonates. However compared to our study,[2]
in which the same effect was observed, there is a (probably) significant
difference. Their infants were studied in the horizontal prone, in the
horizontal supine and in the 45 degree head up tilt supine position
whereas in our study all infants were studied in the prone position
including the 45 degree head up tilt. We had then hypothesised that the
combination of the prone position and the 45 degree head up tilt could
facilitate diaphragmatic activity.
I do not think that this hypothesis can be totally dismissed by the
results of Dimitriou et al.,[1] as suggested by the authors, since their
infants were studied in different positions (i.e. supine in their study and
prone in our study)
I should be grateful for the authors' views
H.D. Dellagrammaticas
References
(1) Dimitriou G, Greenough A, Pink L, McGhee A, Hickey A, Rafferty GF.
Effect of posture on oxygenation and respiratory muscle activity in
convalescent infants. Arch Dis Child Fetal Neonatal Ed 2002;86:F147-50.
(2) Dellagrammaticas HD, Kapetanakis J, Papadimitriou M, Kourakis G.
Effect of body tilting on physiological functions in stable very low
birthweight neonates. Arch Dis Child 1991;66:429-32.
We thank Peter Reynolds for congratulating us for adding a piece to
the jigsaw of fetal iron metabolism.[1] We would like to reply to some of
his other comments. We feel that use of the term post-transcriptional to
describe the regulation of intracellular iron metabolism was correct
rather than post-translational as suggested by Reynolds. Iron regulatory
elements (IREs) are stem cell loop structures of s...
We thank Peter Reynolds for congratulating us for adding a piece to
the jigsaw of fetal iron metabolism.[1] We would like to reply to some of
his other comments. We feel that use of the term post-transcriptional to
describe the regulation of intracellular iron metabolism was correct
rather than post-translational as suggested by Reynolds. Iron regulatory
elements (IREs) are stem cell loop structures of several key messenger RNA
(mRNA)-encoding proteins of iron metabolism. IREs can be located in the
5' region (eg, ferritin) or 3' region (eg, transferrin receptor) of the
untranslated region of the mRNA. In relative iron deficiency, through
interaction of the IREs with iron responsive proteins, transferrin uptake
increases because the transferrin receptor mRNA is stabilised, whereas
ferritin storage of iron decreases because translation of ferritin mRNA is
blocked. These are clearly post-transcriptional, not post-translational
events. The reciprocal regulation of the transferrin receptor and
ferritin have recently been expertly reviewed by Hentze and Kuhn.[2]
We agree that serum ferritin is increased in response to inflammation
but the infants that we studied were born at term following normal
pregnancies. All the babies were well at birth and did not require
neonatal care. We think that it is unlikely that inflammation or other
stimuli affected our serum ferritin values. Furthermore, in this study[3] and in our previous study of preterm infants[4] we found no gender
differences in contrast to the results published by Tamura et al.[5] Our
figure for cord ferritin levels at term (listed first as mean + SD) in
female infants is almost identical to that of Tamura et al (164 + 106 microg/l vs 166 + 110 microg/l), but our value for male
infants is higher (160 + 97 microg/l vs 123 + 71 microg/l).
We doubt if there are real gender differences in fetal ferritin levels.
Therefore we are still of the opinion that TfR-F index is a measure of
iron requirements in relation to iron availability in the fetus and
newborn as in adults and children.
Professor H L Halliday
Department of Child Health
Professor TRJ Lappin
Department of Haematology
The Queen’s University of Belfast
Belfast, Northern Ireland, UK
References
(1) Reynolds P. Newborns have unique confounding factors regarding the TfR-F ratio [Rapid Response]. Arch Dis Child 12 January 2001. http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;84/1/F40#EL2
(2) Hentze MW, Kuhn LC. Molecular control of vertebrate iron
metabolism: mRNA-based regulatory circuits operated by iron, nitric oxide
and oxidative stress. Pro Natl Acad Sci USA 1996;93:8175-82.
(3) Sweet DG, Savage G, Tubman TRJ, Lappin TRJ, Halliday HL. Study
of maternal influences on fetal iron status at term using cord blood
transferrin receptors. Arch Dis Child Fetal Neonatal Ed 2001;84:F40-F3.
(4) Halliday HL, Lappin TRJ, McClure BG. Iron status of the preterm
infant during the first year of life. Biol Neonate 1984;45: 228-35.
We thank Dr Srinivasan for his interest in our paper. For clarity, some of the original results were not included in the published paper. In response to his points:
To be clinically effective, a topical local anaesthetic agent should work in almost all cases. Whether the sample size was 20 or 100 seems less relevant. However, we considered that to be clinically effective, the proportion of newbo...
Dear Editor
Armstrong and Simpson’s letter in May’s edition of Archives of Disease in Childhood highlights the difficulties encountered by junior medical staff when examining the neonatal palate.[1] Their concern is echoed by a presentation at the recent Royal College of Paediatrics and Child Health spring meeting. Habel et al. presented the results of their audit revealing that 31 % of isolated cleft pal...
I agree with Professor Marlow.
We at our unit in Karachi deal with a spectrum of parents ranging from the highly educated cosmopolitan couple to the the very illiterate labobourer family on the verge of poverty.Our practice has been to address the risk of long-term neurodevelopmental outcome right from day 1, based on the prematurity.During subsequent discussions the range of such disability gets...
Dear Editor
We read with interest the findings of Wolke et al.[1] regarding maternal satisfaction with routine examination of the newborn. Whilst appreciating their conclusions and those reached by others (Lee TWR et al.[2] and Walker D[3])we wish to provide further comment. Perhaps an equally valuable study would be one which explores the attitudes of senior house officers to performing this examinat...
This was an interesting and useful article on birth customs from a religion and culture dfferent from my own, and should be compulsory reading for those invloved in obstetrics and neonates.
There is, however, one practice which I would like to comment on. The use of honey in young children (under 6 months) is not usually recommended because of the (rare) risk of botulism. Honey is the one dietary re...
Sweet et al investigated the serum transferrin receptor (sTfR) and, for the first time in neonates, transferrin receptor-log ferritin (TfR-F) ratio in a prospective series of cord blood taken from term infants and their mothers. They are to be congratulated on completing another piece of the complex jigsaw that is fetal and neonatal iron metabolism.
sTfR and TfR-F were increased in iron deficient m...
Dear Editor
we would like to thank Drs Millman and Satodia for their considerate comments on our paper.[1] The randomised controlled trial reported in the Archives is part of a larger evaluation study of the implications and cost effectiveness of extending the role of midwives to include the routine (24 hour) examination of the newborn. The evaluation study includes, apart from the RCT, a longer term follow-up (...
This article on Muslim birth customs[1] makes good and very useful reading not only to non-Muslim professionals who work with children but also to Muslims, like me, who are not familiar with these practices which are seen basically in Muslims from the Indian subcontinent and are, many times, cultural rather than based on clear religious directions.
Many of these practices are not known to Muslim Ar...
Dear Editor
We read with interest the paper by Dimitriou et al.,[1] in which it was confirmed again that head up tilting to 45 degrees results in better oxygenation in stable preterm neonates. However compared to our study,[2] in which the same effect was observed, there is a (probably) significant difference. Their infants were studied in the horizontal prone, in the horizontal supine and in the 45 degre...
We thank Peter Reynolds for congratulating us for adding a piece to the jigsaw of fetal iron metabolism.[1] We would like to reply to some of his other comments. We feel that use of the term post-transcriptional to describe the regulation of intracellular iron metabolism was correct rather than post-translational as suggested by Reynolds. Iron regulatory elements (IREs) are stem cell loop structures of s...
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