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Recent eLetters

Displaying 11-20 letters out of 569 published

  1. Cardiac assessment using echocardiography in the sick neonate - An unmet need for a training syllabus for aspiring neonatologists

    In the UK speciality training through the grid scheme has been in existence for about a decade with a well-defined syllabus of knowledge and skills deemed necessary for the qualified neonatologist. Although much emphasis is laid on various aspects of neonatal care and the acquisition of procedural skills including cranial ultrasound, cardiac assessment using echocardiography is still considered to be an optional skill (1).

    There are many reasons why this position should now be challenged. Not least the greatly enhanced armentarium of the neonatologist when considering therapy, coupled to the relative ease of access to the equipment necessary to undertake such an evaluation.

    Hence our question 'Should cardiac assessment using echocardiography be considered an essential skill for the neonatologist?'

    The recent article by Kluckow (2) highlights the value of clinician performed cardiac ultrasound in neonatal practice. The ability to undertake a timely competent functional cardiac assessment - even of limited parameters - might help optimise therapy, reduce morbidity and potentially mortality. Yet this ability is not yet deemed essential in the training of those looking after the most vulnerable babies.

    A syllabus in functional cardiac assessment for the neonatologist needs to be developed as a matter of priority, with access to structured training in order that all those aspiring to be neonatologists learn the potential of these techniques and are able to acquire the skills during their time as a trainee. It might be argued that it would be advantageous for those already working in the field but who lack these abilities to do likewise.

    References

    1. http://www.rcpch.ac.uk/training-examinations-professional- development/postgraduate-training/sub-specialty-training/neonatal

    2. Kluckow M. Use of ultrasound in the haemodynamic assessment of the sick neonate. Arch Dis Child Fetal Neonatal Ed. 2014 Apr 15. doi: 10.1136/archdischild-2013-30492

    Conflict of Interest:

    None declared

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  2. Decision-making during preterm birth in Italy

    Dear Dr. Gallagher,

    We read with great interest your paper "European variation in decision-making and parental involvement during preterm birth". We would like to point out that in Italy there are not national guidelines for the resuscitation of infants at 22 to 25 weeks of gestation as reported in table 1. In 2008 the Italian National Committee of Bioethics published, with the endorsement of our Government, a document on the bioethical questions regarding the resuscitation of extremely preterm infants 1. Briefly, the document states the following recommendations: 1. The resuscitation of extremely preterm infants must be made without considering the gestational age, using criteria similar to that adopted for children and adults; 2. The sole high probability of severe disabilities does not justify a decision not to resuscitate an infant in the delivery room; 3. Neonatologists can discontinue the assistance (starting palliative care) when it appears futile and inappropriate; 4.Parental opinion is central, but when it is in contrast with that of Neonatologists, this late must prevail. The Italian Society on Neonatology, the most important Italian association of Neonatologists, substantially agree this document. Thus, in the majority of Italian Hospitals extremely preterm infants are resuscitated in the delivery room on the basis of their viability and not merely evaluating their gestational age.

    Prof. Carlo Dani, Division of Neonatology, Careggi University Hospital of Florence, Italy. Prof. Costantino Romagnoli, Division of Neonatology, Sacred Heart Catholic University of Rome, Italy. President of Italian Society of Neonatology Prof. Giovanni Corsello, Department of Sciences for Health Promotion and Mother and Child Care, University of Palermo President of Italian Society of Pediatrics.

    Conflict of Interest:

    None declared

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  3. Response to the two letters regarding tongue-tie, from Dr Essex and Mr Mercer

    Dr Essex and Mr Mercer highlight many of the reasons why we undertook the Bristol Tongue Tie trial. Ankloglossia is a spectrum condition, which overlaps with 'normal' variation in anatomy, and milder forms do not result in feeding impairment. There is very limited evidence of the need for frenotomy in mild-moderate degrees of tongue tie. However, it is also true that at the severe end of the spectrum infants can be limited in their ability to breastfeed efficiently because they are not able to latch effectively.

    We agree that it is easy to blame a visible tongue tie for breast feeding difficulties which may be due to other factors, and entirely support the view that good breastfeeding support is essential in helping mothers with feeding difficulties.

    The inequity in the use of frenotomy worldwide and within the UK is exactly why well conducted trials are needed, to clarify which babies should be offered frenotomy and when. The widespread use of social media, and campaigning by some pressure groups, has resulted in an increase in demand for the procedure. Good quality evidence from randomised trials is needed to inform evidence- based clinical practice and the rational commissioning of services.

    Conflict of Interest:

    None declared

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  4. Banked donor human milk: more research is needed

    We thank Dr. Verd and colleagues for their comments [1] on our review of the use of human milk for preterm infants. Our aim was certainly not to discourage the use of donor human milk, but rather to look objectively at the evidence base that currently exists for its use.

    The authors of the letter refer to a 1984 study by Narayanan et al [2] which appeared to show a reduction in the risk of infection in infants fed pasteurised human milk. This study, which looked at 226 low birth weight infants, randomised them to receive unpasteurised human milk or pasteurised human milk, with or without formula. Many of the anti- infective factors in human milk are preserved after pasteurisation, and we therefore do not dispute the potential of donor breast milk (DEBM) to protect against infection. However, deductions from this paper about the benefits of pasteurised DEBM have to be made with caution because (a) no distinction was made in the analysis between mothers' own milk (MEBM) and DEBM, (b) there is no description of anti-infective precautions in reconstituting and feeding formula in a study carried out in a very different setting to a modern NICU, and (c) there is no suggestion of masking of analysis to study group. The second study referred to, the R?nnestad study [3], is a national survey of late onset sepsis which relates to babies who were predominantly fed unpasteurised human milk, and thus does not have direct relevance to our practice -we are aware of only one country in Europe (Norway) in which unpasteurised donor milk is routinely used. A Cochrane review which we cited in our article [4] looked at whether donor human milk might be better than formula in terms of rates of invasive infection. They found only one study that they judged to be of sufficient quality to include in their analysis, the final study quoted by Verd and colleagues, that by Schanler et al [5]. This study found no statistically significant difference in the incidence of one or more episodes of invasive infection when donor milk, rather than formula, was used to feed preterm infants. Babies were randomised to receive DEBM or PTF to make up any shortfall of MEBM in preterm infants. Although there was a (barely statistically significant) lower rate of chronic lung disease in infants fed DEBM as opposed to PTF, the authors rightly state that this is one of several outcomes assessed which the study was not designed to look at, and requires more research.

    We welcome an open discussion of the evidence base for the use of DEBM. Currently, the use of DEBM varies from not at all to extensive use in preterm infants in place of formula milk. If we over-interpret the current data, there is the very real risk that we may discourage the funding of research studies which have the potential to measure the cost- effectiveness of DEBM more fully and thus the potential to benefit the care of a larger number of infants by allowing the development of evidence -based guidelines.

    References 1. Verd S, Porta R and Ginovart G. Human milk feeding. Arch Dis Child Fetal Neonatal Ed, 2014. 99(2): F172-3.

    2. Narayanan I, Prakash K, Murthy NS, et al. Randomised controlled trial of effect of raw and holder pasteurised human milk and of formula supplements on incidence of neonatal infection. Lancet 1984;2:1111-13.

    3. Ronnestad A, Abrahamsen TG, Medb? S, et al., Late-Onset Septicemia in a Norwegian National Cohort of Extremely Premature Infants Receiving Very Early Full Human Milk Feeding. Pediatrics, 2005. 115(3): p. e269- e276.

    4. Quigley MA, Henderson G, Anthony MY, et al. Formula milk versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev 2007;(4):CD002971.

    5. Schanler RJ, Lau C, Hurst NM, et al. Randomized trial of donor human milk versus preterm formula as substitutes for mothers' own milk in the feeding of extremely premature infants. Pediatrics 2005;116:400-6.

    Conflict of Interest:

    None declared

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  5. The child has rights!

    Sirs

    The tongue remains with in the boundaries of the mandible during suckling and so it is difficult to see the anatomical or the physiological basis for how a frenulectomy works in reducing breast and nipple discomfort during feeding. This randomised trial does not seem to assess the potential, positive psychological impact of the mother being told their child has had a frenulectomy. That is the question that must be answered before a procedure performed on the most sensitive organ in the body, with out anaesthesia is undertaken routinely.

    Tongue tie is not proven to impact upon speech and if a release is performed in a child with a small chin, with or without a cleft palate, it can cause airway obstruction. A significant tongue tie causes social embarrassment in later life but it has no other proven physical impact on the child and so more concrete evidence of benefit for the procedure being performed upon a neonate, with out anaesthesia, must be provided before the practice is offered routinely. Every surgical procedure has complications and surely there must be greater proof of benefit than relieving nipple pain in the mother? When else is a procedure inflicted on any patient, let alone a child, for the benefit of reducing discomfort in a third party? With out this additional proof, practitioners may well be performing unnecessary procedures on a defenceless infant.

    With out a "sham" group, the psychological impact on the mother cannot be excluded.

    Nigel Mercer

    MB ChB ChM FRCS FRCPCH

    Conflict of Interest:

    None declared

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  6. Most tongue tie is the medicalisation of childhood

    Lawson's editorial and Emond and colleagues' article exposes potentially bad medicine: lack of knowledge of normal and variations of normal; lack of knowledge of the natural history of a condition; a desire to do something - Ulysses syndrome (1); medicalising the child by giving the condition a name; and then ascribing any improvement to the intervention, forgetting that association does not mean causation.

    This writer did many years of community child health clinics seeing babies with a variety of problems that never went near a hospital: a W- shaped tongue [M-shaped from the baby's perspective] is a normal finding. To describe it as tongue tie and to intervene are medicalising normality in the majority of cases. As Illingworth says in The Normal Child (2) [which should be required reading for all health professionals involved with children] "The tongue is always short at birth but as the infant grows the tongue becomes longer and thinner. Many mothers [and health professionals - my insertion] ascribe their children's feeding difficulties and lateness in speaking to tongue tie".

    Unfortunately blaming tongue tie becomes self-perpetuating. The fact that parents want subsequent children to have a frenotomy after their first child has had one and doctors acquiesce to this or lactation experts believe it is the cause of breastfeeding difficulties does not represent proof nor does it justify performing the operation. Countries with initial and sustained high breastfeeding rates such as New Zealand, where this writer worked for several years, do not have high rates of frenotomy to ensure that breastfeeding is successful. Rather it is good breastfeeding support.

    Recently a tongue-tie service was set up in my local area. I can predict the outcome. In 12 months' time those who promoted and run the service will announce how many tongue tie operations they done, how parents are pleased and feel the baby is feeding better and how "successful" the service is. The specious conclusion will be that tongue tie was a significant problem for these babies which frenotomy cured. I consider this is 21st Century charlatanism.

    Signed

    Dr Charles Essex Consultant Neurodevelopmental Paediatrician Suite 115 41 Oxford Street Leamington Spa CV32 4RB

    References

    1. Essex C. Ulysses syndrome. BMJ 2005; 330: 1268.

    2. Illingworth RS. The Normal Child. Churchill Livingstone, Edinburgh 1983.

    Conflict of Interest:

    None declared

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  7. Re: Strengthening the evidence base on frenulotomy

    Dear Editors:

    We read Val Finigan's letter with interest, and agree with her experience that most mothers do report an improvement in the comfort and efficacy of breastfeeding after their baby has had a frenotomy. The difficulty is in showing objective improvement in breastfeeding after division of less severe degrees of tongue tie.

    In the Bristol Tongue Tie Trial, the median age of the babies at recruitment was 5 days, and the median age at follow-up for the primary outcome was 11 days. We are now planning a larger trial of frenotomy, involving all degrees of tongue tie, with a primary outcome 2 weeks after recruitment, using a more detailed tool to assess breastfeeding. For more information on the proposed trial design, please contact alan.emond@bristol.ac.uk

    Yours sincerely,

    Alan Emond

    Jenny Ingram

    Centre for Child and Adolescent Health, University of Bristol

    Conflict of Interest:

    None declared

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  8. Concerns regarding statistical presentation and interpretation

    I am writing to express my concern regarding the discordance between the results and conclusions of this paper. The paper compares a point of care glucose measurement with a laboratory "gold standard". The results are presented in a number of forms (and with no consistency regarding units of measurement). The error-grid analysis is unhelpful as high levels will be high and low levels will be low for both methods and the scale of the graph is too large to see what the real differences are. The "accurate estimate zone" includes potential values 4mmol/l above and below zero in the lower glucose range. Whilst the authors are to be applauded for inserting a Bland Altman plot, this plot demonstrates "limits of agreement" which are around 0.5mmol/l above and below the line of zero. 6 points lie outside the limits of agreement with the extremes being 0.7mmol/l above and below zero. Therefore the plot demonstrates that in an unpredictable manner the glucometer may be over reading or under reading by a value as great as 0.7mmol/l. This is not of clinical significance in the normoglycaemic or hyperglycaemic range, but acquires clinical significance when blood glucose levels are low. For example if a glucometer reading is 2.0mmol/, the accurate level (at the extreme) could be 1.3-2.7mmol/l which will result in over diagnosis and treatment or under diagnosis and treatment. The authors state in the results section that the plot shows "good correlation", but the plot does not represent correlation, and the agreement between the values is not good. The conclusion that there is good "correlation" between the glucometer and the laboratory measurement draws on the wrong statistical method. Correlation does not provide accuracy data. Under "what this study adds" it is stated that the glucometer provides accurate results and is suitable for measuring glucose levels in premature infants. I suggest that the results as plotted on Bland Altman plot are directly counter to this conclusion.

    Conflict of Interest:

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  9. Strengthening the evidence base on frenulotomy

    Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie. Edmond et al (2014)

    Dear Editor, I read this report on frenotomy to support breastfeeding with great interest as currently there is limited evidence to support this procedure. The outcomes contrast considerably with my own experience and audit data, particularly with regard to persistence of breastfeeding for more than 5 days with painful breast and objective improvement in breastfeeding at 5 days. Of course, it is not uncommon for mothers and babies to attend for frenotomy after 5 days as time is needed to learn the art and skill of breastfeeding before intervention, but that was not the scope of this report. That mothers report improved self-efficacy after frenotomy certainly fits with my experience and data, but I find that most continue to breastfeed as their babies can latch, and both enjoy breastfeeding post -frenotomy. I have run frenulotomy clinics for the north west region of England for six years, using validated assessment tools for frenulotomy , latch, self- efficacy and pain. The women's experience of feeding is assessed pre- operatively and immediately post-frenulotomy, and then by telephone at 24- 48 hours and again at 3 months. Of 2048 babies that were in need of frenuotomy (November 2008 to January 2014), 62.7% of had 100% tongue-tie (to the tip of the tongue), 12.2% had 75% tongue-tie, and 15.7% had a posterior tongue-tie. All were referred for assessment and division by a person skilled in infant feeding and following support with positioning and attachment to improve breastfeeding. If the baby was formula milk-fed by bottle, the referring practitioner had provided support with the technique. Assessment carried out by two International Board Certified Lactation Consultants indicated that the babies referred with notable feeding challenges had limitations when extending, lifting and lateralising their tongues. Following frenotomy, 96% of mothers reported an immediate difference with feeding. For example, breastfeeding mothers reported reduction in pain, improved latch was noted, and later improved contentment and in some cases weight gain. Bottle-feeding mothers suggested improvements such as baby not chomping on the teat, no spurting of milk from the sides of the baby's mouth, and more controlled and faster feeding. At 48 hours, 71% of mothers who responded continued to experience improved feeding, 29% of the sample either did not answer the phone, or were already managing problems such as fungal infections, sore nipples or low milk supply that would take time to resolve. At 3 months the sample size was poor: only 21% of mothers answered the call. Yet 43% of this group were continuing with exclusive breastfeeding and suggested that without frenulotomy they would not have achieved this. A study to provide stronger evidence of these outcomes is being submitted for funding, and a comparison of results will be interesting. The reasons for differences in outcomes will be important in enhancing frenulotomy and breast-feeding support services.

    Dr Val Finigan MBE Consultant Midwife infant feeding Pennine Acute NHS Hospitals Trust Rochdale Road Oldham OL1 2JH

    Conflict of Interest:

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  10. Neonatal rotavirus immunisation, and breast feeding friendly hospitals

    Sirs, we were surprised to read that11 out of 56 units in the resource rich UK did not administer Rotavirus vaccine to their babies. (1) Thirty years ago, one of us described a neonatal rotavirus outbreak that had a considerable morbidity (2). Although these outbreaks continue(3.), some low resource units like ours (Birth rate 3000/year) are accredited as Breast Feeding Friendly and have adopted a very enthusiastic breast feeding friendly initiative. See Compliance with the Baby-Friendly Hospital Initiative and impact on breastfeeding rates (4) In comparison to the high resource US units of Summer Sherburne Hawkins's study, our units have 100% compliance. Probably because our initiative was spearheaded by the pediatricians in charge (RT). All the students and staff in the nursery and maternity unit endorsed it. All babies irrespective of birth weight (700 g upwards) and gestation (27 weeks) get exclusively breast fed, or expressed raw breast milk from birth onwards. No artificial milks or fortifiers are used. There are no bounty boxes, advertising, or free samples endorsing bottle feeding. And no rotavirus immunization. Since then, there have been no outbreaks of diarrhoeal disease or necrotising entercolitis in either unit. So, a UK neonatologist faced with the choice to immunize or not, may have a cost effective and low resource alternative.. Dr John Dearlove, paediatrician, Dr Rosemary Taun, Director of paediatric services, Port Vila Central Hospital, Port Vila, Vanuatu. References

    1. Jaques S, Bhojnagarwala B, et al Slow uptake of rotavirus vaccination in UK neonatal units.Arch Dis Child Fetal Neonatal Ed 2014 March 4, 2014 as 10.1136/archdischild-2014-306067

    2.Dearlove J C,.Latham P. Et al. Clinical range of neonatal rotavirus gastroenteritis Br Med J (Clin Res

    Ed) 1983;286:1473

    3. de Villiers FP , Driessen M. Clinical neonatal rotavirus infection: association with necrotising enterocolitis.S Afr Med J. 2012 Jun 6;102(7):620-4.

    4. Summer Sherburne Hawkins, Ariel Dora Stern et al2, Compliance with the Baby-Friendly Hospital Initiative and impact on breastfeeding rates. Arch Dis Child Fetal Neonatal Ed 2014;99:F138-F143 doi:10.1136/archdischild-2013-304842

    Conflict of Interest:

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