End of Life Decision Making (EoL DM) in NICU is an extremely
sensitive issue. In our unit we have practiced shared DM for a long time
however as the authors write we did not come across any large studies
looking into parents perceptions of EoL DM in the long term.
1. We appreciate that telephonic interviews were discarded in this
paper to ensure accurate assessment of parent's self-perceived role. Also
interv...
End of Life Decision Making (EoL DM) in NICU is an extremely
sensitive issue. In our unit we have practiced shared DM for a long time
however as the authors write we did not come across any large studies
looking into parents perceptions of EoL DM in the long term.
1. We appreciate that telephonic interviews were discarded in this
paper to ensure accurate assessment of parent's self-perceived role. Also
interviews were conducted by three skilled interviewers and to ensure
reliability of themes extracted, however it is not clear if each parent
was interviewed three times, which if it did appeared a bit excessive.
Also it was not clear where the interview happened.
2. We noted that only 145 out of 258 eligible families were contacted. We
wonder whether inclusion of non-French speaking families would improve the
sample size?
3. As noted by the authors there were limitations in the sample with
overrepresentation of certain categories leading to limited possibility of
generalization of results.
Overall we appreciate the large amount of work into this study and hope
that such studies will prompt further large projects to improve our
strategies of decision making for these babies and families in times of
extreme grief.
Lumbar puncture is a blind procedure (no guidance about the path of
the lumbar puncture needle except for the sensory information that the
performer obtains about interspinous distance before inserting the needle
and upon puncturing the duramater).
1. We feel that the for a successful procedure, besides ensuring adequate
interspinous space to insert the needle by ensuring optimum position of
the patient it is very import...
Lumbar puncture is a blind procedure (no guidance about the path of
the lumbar puncture needle except for the sensory information that the
performer obtains about interspinous distance before inserting the needle
and upon puncturing the duramater).
1. We feel that the for a successful procedure, besides ensuring adequate
interspinous space to insert the needle by ensuring optimum position of
the patient it is very important to ensure that the patient is as calm and
comfortable as possible so that we donot have to chase a moving target
with a sharp needle. In our unit we use a few drops of 24% sucrose just
before positioning in lateral recumbent position. The observation in the
study that heart rate increases the most in sitting position (with or
without flexed hips) in itself suggests that the baby is far from calm at
that point.
2. The authors have concluded that 'Sitting flexed position of hips, which
seems to be suffciently safe and serve to enhance the success rate of a
LP' appears to be misrepresented as the authors have themselves recognized
that one of the limitations of this study is that there is absence of
performed lumbar puncture so success of the procedure cannot be gauged in
this study.
3. Sitting position may not be practically feasible in preterm and sick
ventilated neonates who have cardiovascular instability
Sir,
we read with interest the article by Dargaville et al., entitled
"Minimally-invasive surfactant therapy in preterm infants on continuous
positive airway pressure", in which the authors describe significant
results using a semirigid vascular catheter inserted into the trachea by
direct laringoscopy for surfactant administration, without analgesia and
sedation(1). However, direct laringoscopy and tracheal manipulation...
Sir,
we read with interest the article by Dargaville et al., entitled
"Minimally-invasive surfactant therapy in preterm infants on continuous
positive airway pressure", in which the authors describe significant
results using a semirigid vascular catheter inserted into the trachea by
direct laringoscopy for surfactant administration, without analgesia and
sedation(1). However, direct laringoscopy and tracheal manipulation, is an
extremely distressing and painful procedure, with potential for airway and
systemic injury. It is well established that direct laringoscopy and
tracheal intubation without analgesia should be performed only for urgent
resuscitations. Neonatal pain may result in altered systemic and cerebral
blood pressure, intracranial hemorrhage, hypersensitive pain perception
and long-term sequelaes(2). In their study 36% of the neonates had
bradycardia sustained for more than 10s during laryngoscopy or vocal cord
manipulation. It is now evident that initial stabilization with CPAP and
rescue surfactant administration if necessary, is not worse than
intubation, mechanical ventilation and surfactant administration
immediately after birth. INSURE procedure is an alternative, combining
early surfactant and CPAP. Welzing et al. have shown that INSURE can be
performed using remifentanil as premedication for tracheal intubation with
excellent neonatal outcome(3). In the same way, our group have shown that
remifentanil as premedication allows early awakening and extubation(4).
However, the short period of positive pressure ventilation required for
INSURE, even if an ultra short acting opioid is used, could compromise the
benefit of early surfactant.
In this way, some reports have shown that a laryngeal mask airway (LMA) as
a conduit for surfactant administration could be a simple and painless
procedure(5). Trials of surfactant administration through the LMA are now
being conducted. So, finding a noninvasive and painless method of
surfactant administration, without laryngoscopy, tracheal manipulation and
positive pressure ventilation, will be one of the most important subjects
for neonatology research in upcoming years.
References
1.Dargaville PA, et al. Minimally-invasive surfactant therapy in preterm
infants on continuous positive airway pressure. Arch Dis Child Fetal
Neonatal Ed 2013;98:F122-F126.
2.Carbajal R, Eble B, Anand KJ. Premedication for tracheal intubation in
neonates: confusion or controversy? Semin Perinatol 2007;3:309-17.
3.Welzing L, Kribs A, Huenseler C, Eifinger F, Mehler K, Roth B.
Remifentanil for INSURE in preterm infants: a pilot study for evaluation
of efficacy and safety aspects. Acta Paediatr 2009;98:1416-20.
4.e Silva YP, Gomez RS, Marcatto JdeO, Maximo TA, Barbosa RF, Silva AC.
Early awakening and extubation with remifentanil in ventilated premature
neonates. Paediatr Anaesth 2008;18:176-83.
5.Trevisanuto D, Grazzina N, Ferrarese P, Micaglio M, Verghese C, Zanardo
V. Laryngeal mask airway used as a delivery conduit for the administration
of surfactant to preterm infants with respiratory distress syndrome. Biol
Neonate 2005;87:217-20.
Sarah J Kotecha1, John Henderson2, Sailesh Kotecha1.
1Department of Child Health, Cardiff University, Cardiff. 2School of
Social and Community Medicine, University of Bristol, Bristol.
Re: Born just a few weeks early: does it matter? Boyle et al. 98:F85-
88. Doi:10.1136/archdischild-2011-300535.
We read with interest the review by Boyle and Boyle on early and late
morbidity in late preterm born children (1). Clearly there is increasing
interest in late preterm born infants who have both increased short- and
importantly long-term mortality and morbidity as we reviewed recently (2).
Of interest to readers of Archives of Diseases of Childhood, will be
recent publications using data from the Avon Longitudinal Study of Parents
and Children cohort on longer term respiratory function and
neurodevelopmental outcomes. Like Abe et al (3), we did not find strong
evidence of an association between asthma and late preterm birth but we
have reported decrements in FEV1 in late preterm infants, (born at 33-34
weeks gestation), at 8-9 years of age of the same magnitude as extremely
preterm infants, (born at 25-32 weeks gestation), (4), recently
highlighted in a Thorax editorial (5). Encouragingly, we did see
improvements in FEV1 when the late preterm born infants were studied again
at 14-17 years of age but clearly further studies are required to assess
if these children are candidates for chronic pulmonary obstructive disease
in adulthood especially if exposed to noxious substances such as tobacco
smoke and environmental pollution. Furthermore, children born late-preterm
are less likely to be successful in early school assessments than those
born at term (6). In addition to those mentioned by Boyle and Boyle there
is increasing literature in this field in particular reporting the longer
term outcomes of this population; despite these observations, a recent
survey by the British Thoracic Society of respiratory physicians noted
that little consideration is given to early life factors when patients
with respiratory disease are seen in their clinical practice (7). We are
sure readers of Archives of Diseases of Childhood will be as concerned as
we are about the potential public health impact of these effects if they
are carried through the life course from 8-9 years into adulthood,
especially as late preterm infants are a growing population.
1. Boyle JD, Boyle EM. Born just a few weeks early: does it matter?
Arch Dis Child Fetal Neonatal Ed 2013;98:F85-88. Doi:10.1136/archdischild-
2011-300535. 2. Kotecha SJ, Dunstan FD, Kotecha S. Long term respiratory
outcomes of late preterm-born infants. Semin Fetal Neonatal Med 2012
Apr;17(2):77-81.
3. Abe K, Shapiro-Mendoza CK, Hall LR, et al. Late preterm birth and risk
of developing asthma. J Pediatr 2010;157:74-8.
4. Kotecha SJ, Watkins WJ, Paranjothy S, Dunstan FD, Henderson AJ, Kotecha
S. Effect of late preterm birth on longitudinal lung spirometry in school
age children and adolescents. Thorax 2012 Jan;67(1):54-61.
5. Bush A, Pavord ID. Thorax: the Cappuccino years. 2013 Jan;68(1): 1-4.
6. Peacock PJ, Henderson J, Odd D, Edmond A. Early school attainment in
late-preterm infants. Arch Dis Child 2012;97:118-120. doi:10.1136/118
adc.2011.300925 7. Bolton CE, Bush A, Hurst JR, Kotecha S, McGarvey L,
Stocks J, Walshaw M. Are Early Life Factors Considered when Managing
Respiratory Disease? A British Thoracic Society (BTS) Survey of Current
Practice. Thorax 2012 Dec;67(12):1110 (Research Letter)
Quandt et al (1) have emphasised stomach insufflation as a means to
improve neonatal feeding tube location rates. Experience in our neonatal
unit indicates that other measures may be more important.
It is a practice standard in our neonatal unit for a gastric tube to
be placed prior to performing the first chest radiograph. We
retrospectively audited all first chest radiographs taken during the six
month perio...
Quandt et al (1) have emphasised stomach insufflation as a means to
improve neonatal feeding tube location rates. Experience in our neonatal
unit indicates that other measures may be more important.
It is a practice standard in our neonatal unit for a gastric tube to
be placed prior to performing the first chest radiograph. We
retrospectively audited all first chest radiographs taken during the six
month period from August 2011 to February 2012. We excluded infants who
were born in another hospital or if there was no gastric tube present on
first radiograph. Eighty-eight neonates fulfilled the inclusion criteria.
Images were viewed on PACS (online digital radiograph viewing system). We
scored the tube position as per Quandt et al (1) and images were viewed
independently by two individuals (RB and LS) and results correlated. Tube
tip was locatable in 90% of radiographs with sixty-seven in the stomach
and thirteen outside the stomach. Of the eight radiographs with an
unlocatable tip, all were explainable by truncation of the radiograph.
In summary, we did not find that prior air insufflation would have
aided location. We did however identify a requirement to specify in the
radiology request that the stomach be included in the radiographic field
and also that the procedure for measuring estimated gastric tube length
needed to be reviewed.
1. Quandt D, Brons E, Schiffer PM, et al. Improved radiological
assessment of neonatal feeding tubes. Arch Dis Child Fetal Neonatal Ed
2013;98:F78-F80.
End of Life Decision Making (EoL DM) in NICU is an extremely sensitive issue. In our unit we have practiced shared DM for a long time however as the authors write we did not come across any large studies looking into parents perceptions of EoL DM in the long term.
1. We appreciate that telephonic interviews were discarded in this paper to ensure accurate assessment of parent's self-perceived role. Also interv...
Lumbar puncture is a blind procedure (no guidance about the path of the lumbar puncture needle except for the sensory information that the performer obtains about interspinous distance before inserting the needle and upon puncturing the duramater). 1. We feel that the for a successful procedure, besides ensuring adequate interspinous space to insert the needle by ensuring optimum position of the patient it is very import...
Sir, we read with interest the article by Dargaville et al., entitled "Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure", in which the authors describe significant results using a semirigid vascular catheter inserted into the trachea by direct laringoscopy for surfactant administration, without analgesia and sedation(1). However, direct laringoscopy and tracheal manipulation...
Sarah J Kotecha1, John Henderson2, Sailesh Kotecha1.
1Department of Child Health, Cardiff University, Cardiff. 2School of Social and Community Medicine, University of Bristol, Bristol.
Re: Born just a few weeks early: does it matter? Boyle et al. 98:F85- 88. Doi:10.1136/archdischild-2011-300535.
We read with interest the review by Boyle and Boyle on early and late morbidity in late preterm bo...
Quandt et al (1) have emphasised stomach insufflation as a means to improve neonatal feeding tube location rates. Experience in our neonatal unit indicates that other measures may be more important.
It is a practice standard in our neonatal unit for a gastric tube to be placed prior to performing the first chest radiograph. We retrospectively audited all first chest radiographs taken during the six month perio...
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