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Arch Dis Child Fetal Neonatal Ed 2004;89:F279–F282 F279

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know what to do when babies on trigger infant—for example, dilutional exchange

BOOK REVIEWS ventilation drop their PCO2 to embarrassingly for polycythaemia is said to be carried out
low levels. They want the formula for calcu- in 10 ml aliquots, and does not recom-
lating the fractional excretion of sodium. mend smaller volumes for the infant of
A manual of neonatal intensive care, They need to know that separate chest and 500 g whose total blood volume may be
abdomen radiographs give much better radi- little more than 40 ml.
4th edition ological information than ‘‘babygram’’ pic-
tures. Sadly, they will be disappointed if they
N Thirdly the section on viral disease and
transmission should be more detailed.
J M Rennie, N R C Roberton. London: Edward try to find such information in this book. ‘‘Low risk’’ is not quantitated, and CMV
Arnold, 2001, £19.99, pp 565. ISBN 0340720107 The 4th edition of the Manual seems to is described variously as ‘‘largely inacti-
have lost the values of its roots. It feels like a vated by freezing’’ and (one page later)
As an SHO, I bought the first edition of the pared down version of the big Roberton book,
Manual in 1982. It was a survival guide which ‘‘does not survive freezing’’—an inconsis-
repackaged between smaller covers. It con- tency that leaves the reader feeling insecure
provided safe certainties in the small hours of tains a level of detail that is unnecessary given
the night. It was small, light, and compact. about such an important safety issue.
the alternative sources of the material. It can
There was no competition: the Roberton be hard to find in a hurry the things you need,
Manual was the book to have! Nevertheless this is a volume that is
and some of the things you want are not
Nearly 20 years on, where has the 4th informative and attractive, from the cartoon
there at all—or at any rate, I couldn’t find
edition taken us? Bigger, certainly: a behe- of a neonate’s head (front cover) to the
them, which comes to the same thing. And the
moth of a ‘‘small’’ manual with 550 pages. photograph of the three distinguished and
index is terrible. On the other hand, if you
Not much taller or wider than its predecessors, pathologically cheerful authors at the end.
want a comprehensive introduction to the
but much thicker, the rather thin and closely For all professional staff there are 300 pages
subject of neonatal intensive care medicine for
typeset pages distinctly reminiscent of a Bible. of clear descriptions containing information
under £20, look no further. This is your book.
Thirty four chapters and eight appendices. that will prove useful in organising investiga-
There’s an awful lot of information in here. M P Ward Platt tions in the neonatal unit. There are also
Road testing a book like this is quite a Neonatal Service, Royal Victoria Infirmary, modern data which can be used to defend the
challenge. Clearly one should not ask it to embattled SHO against the predatory instincts
Queen Victoria Road, Newcastle upon Tyne,
perform in a manner for which it was not of the consultant ward round. Every neonatal
NE1 4LP, UK; [Link]-platt@[Link] unit should purchase a copy. I predict that
designed, and the authors helpfully explain
in the preface that their aim ‘‘is to provide a these valuable pages will be well thumbed
guide for the management of the acute Neonatology & laboratory medicine within a month. I look forward to a further
medical and surgical problems a resident is edition, and hope that it will extend its scope
likely to encounter on a modern neonatal A Green, I Morgan, K Gray. Guildford: ACB to include other laboratory disciplines such
intensive care unit.’’ So I went for chapter 1, Venture Publications, 2003, £30.00, pp 312. as genetics and electrophysiology. The three
expecting it to plunge in where every resident ISBN 0902429418 authors deserve success with this winner.
is most nervous: resuscitation of the newborn.
Neonatology & laboratory medicine is a novel I A Laing
Instead, I got ‘‘Organization of neonatal
care’’. Admittedly it is only six pages, but concept and a valuable addition to our Simpson Centre for Reproductive Health, 51
does a resident really need this in a practical literature. The book brings together a clinical Little France Crescent, Edinburgh EH16 4SU,
manual? Especially since the big Roberton biochemist, a neonatologist, and a medical Scotland, UK; [Link]@[Link]
textbook is likely to be on hand in most microbiologist as authors in a successful
neonatal units to provide this and much more attempt to describe appropriate laboratory
investigation and clinical management of the
Fetal and neonatal brain injury:
detail on this subject. In the Manual, you have
to wait until chapter 6 to get ‘‘Resuscitation’’, neonate. This paperback aims to provide mechanisms, management and the
with ‘‘Temperature control’’, ‘‘Fluid & elec- junior doctors, laboratory scientists, and risks of practice, 3rd edition
trolytes’’, ‘‘Enteral nutrition and parenteral neonatal nurses with background informa-
nutrition’’, all packed with science and tion that will help solve common neonatal Edited by D K Stevenson, W E Benitz, P
physiology, coming first. How much physiol- problems. The chapters deal systematically Sunshine. Cambridge: Cambridge University
ogy do you want or need in a practical with common biochemical and infective Press, £140.00, pp 926. ISBN ISBN
manual? Not this much, I think. problems that may befall neonates. There 0521806917
So I tried again with the oxygenation index are also sections on breast feeding, parenteral
(OI). There must be many units where the OI nutrition, and therapeutics. Best of all it Brain injury remains a common theme in a
is used as a pragmatic threshold for giving finishes with appendices including normal large proportion of survivors of extreme
nitric oxide or high frequency oscillation, and reference ranges and a useful glossary. prematurity and/or neonatal encephalopathy.
of course for referring for extracorporeal The expenditure of £30 rewards the reader The headline rates of significant disability
membrane oxygenation (ECMO). The resi- with more than 300 pages which are clear have been largely unchanged despite the enor-
dent will want to find the page with the and well arranged. Tables and flow diagrams mous advances in neonatal intensive care
formula for calculating OI, and how to deal are easy to dip into. More senior readers may of the post-surfactant era, and more subtle
with mm Hg versus kPa for the oxygen be frustrated that the book is not referenced, educational difficulties are later declared in
tension. To the index then—but no entry for but recommended reading is provided at the many others. It is essential that clinicians
oxygenation index. To the glossary of abbrevi- end of each chapter. continue to strive for a deeper understand-
ations at the front: there, sure enough, is OI. Three small criticisms and suggestions for ing of the mechanisms of brain injury to
But where is it in the text? I could not find it the next edition. not only guide conventional management,
under PPHN, or RDS, or ventilation. Even- but also look ahead to the future strategies
tually, by close reading, I found it mentioned
under Meconium aspiration, and also under
N The chapter entitled ‘‘Drugs and the
neonate’’ is too short. The figure referring
in which neuroscientific advances may trans-
late into plausible clinical strategies—for
ECMO, but nowhere could I find the formula to biochemical and haematological mon- example, promoting the regrowth of damaged
for calculating it. By this time, the luckless itoring cites only 11 drugs, ignoring axons from intact cortical neurones across
resident will have been called away to the next commonly used drugs such as vecuro- an area of periventricular leucomalacia.
problem, and if the formula is indeed there, nium, insulin, surfactant, salbutamol, 5- The strength of a textbook such as this is to
he/she will have lost interest in finding it. flucytosine, and steroids. Even those lucky give an in depth overview of many aspects of
Residents are increasingly likely to be faced 11 have curious omissions—for example, brain injury. This is accomplished well by a
with ventilators that read out the tidal the oliguria and fluid retention associated distinguished list of mostly United States based
volume and minute volume, and display with indomethacin. contributors, who consider the many aspects
pressure-volume curves. They want to know
how to use this information. They want to
N Secondly the book recurrently ignores the
unusual demands of the extreme preterm
of neonatal brain injury in terms of aetiology,
epidemiology, diagnosis, management, and

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long term outcome. A section on medico- examination. Thickened feeds may have led course with complete remission attained after
legal issues makes interesting reading, to NEC as a result of bowel obstruction with puberty. The overall incidence of involvement
although is not directly applicable to the subsequent bacterial overgrowth or following of mucous membranes of the oral cavity,
British judicial system. Surprisingly little direct mucosal injury by calorific dense milk. eyes, and external genitalia is 57%, 40%, and
mention is made of the controversies sur- Bacterial overgrowth is plausible because 72% respectively.1 However, the mucosal
rounding the use of postnatal corticosteroids feed thickeners have been shown to signifi- involvement is not life threatening.
to treat chronic lung disease and the risk cantly increase microbial population and The other neonatal case of linear IgA
of cerebral palsy, but otherwise the range of enzyme activities in the weanling rat caecum.4 bulbous disease reported in the literature
topics is exhaustive. Particular care is also Enterocolitis has previously been reported in also showed serious mucosal involvement. It
taken to relate the bedside management to an infant secondary to feeds thickened with manifested as respiratory failure requiring
the background neuroscience—for example, pectin and cellulose,5 as has neonatal intes- treatment by extracorporeal membrane oxy-
the neuroprotective effect of brain cooling. tinal obstruction and gastric lactobezoar. genation, oesophageal dysmotility with chok-
Readers will be encouraged to catch up with Thickening feeds with carob bean gum is of ing during feeding, and blindness as a result
subsequent developments as they emerge unproven value in GOR. We feel that in of conjunctival scarring.2 In both these
in the journals. preterm infants the practice may not be free neonatal cases, complete remission was
Weaknesses are few. The section on ima- from serious adverse effects and should not attained after the unsettled neonatal period.
ging of brain injury is thorough, and as become widely adopted without a formal Hence, linear IgA bullous disease with onset
expected well illustrated. However, it leaves randomised trial. in the neonatal period contrasts sharply with
the reader wishing for more information on the classical presentation of the childhood
the prognostic value of MRI in particular. P Clarke, M J Robinson disease in having serious mucosal involve-
Other sections would have been enhanced by Neonatal Intensive Care Unit, Hope Hospital, Salford, ment and a non-relapsing course.
greater use of illustrations—for example, I UK, M6 8HD; [Link]@[Link] We hope that our report serves as a refer-
was disappointed that a section on congenital ence for neonatologists and dermatologists
malformations fails to include a single doi: 10.1136/adc.2003.036392 who may encounter similar cases in the future.
illustrative image.
In summary, this is a comprehensive References S Y R Lee, C Y Leung, C W Leung, C B Chow,
account of an area of vital importance to 1 Bosscher D, Van Caillie-Bertrand M, Van Dyck K, K M Leung, Q U Lee
obstetricians, neonatologists, and paediatric et al. Thickening infant formula with digestible Princess Margaret Hospital, Princess Margaret
neurologists. It should prove to be a useful and indigestible carbohydrate: availability of Hospital Road, Kwai Chun, NT, Hong Kong;
reference for specialists in these fields. calcium, iron, and zinc in vitro. J Pediatr leesyr@[Link]
Gastroenterol Nutr 2000;30:373–8.
M Smith 2 Huang R-C, Forbes DA, Davies MW. Feed doi: 10.1136/adc.2003.037911
Newcastle General Hospital, Queen Victoria thickener for newborn infants with gastro-
Road, Newcastle upon Tyne NE1 4LP, UK;
oesophageal reflux (Cochrane Review) Cochrane References
Library. Issue 2. Oxford: Update Software, 2003.
[Link]@[Link] 3 Carroll AE, Garrison MM, Christakis DA. A systema- 1 Rabinowitz LG, Esterly NB. Inflammatory bullous
tic review of nonpharmacological and nonsurgi- diseases in children. Dermatol Clin
cal therapies for gastroesophageal reflux in infants. 1993;11:565–81.
LETTERS Arch Pediatr Adolesc Med 2002;156:109–13. 2 Hruza LL, Mallory SB, Fitzgibbons J, et al. Linear
4 Mallett AK, Wise A, Rowland IR. Hydrocolloid IgA bullous dermatosis in a neonate. Pediatr
food additives and rat caecal microbial enzyme Dermatol 1993;10:171–6.
Thickening milk feeds may cause activities. Food Chem Toxicol 1984;22:415–18.
5 Mercier JC, Hartmann JF, Cohen R, et al.
necrotising enterocolitis [Intestinal occlusion and enterocolitis caused by Vertical transmission of
Extremely low birthweight infants have the Gelopectose.] Arch Fr Pediatr 1984;41:709–10. Citrobacter freundii
highest risk of developing necrotising entero- An infant developed early respiratory distress
colitis (NEC). We report on two infants who
developed fatal NEC while established on
Linear IgA bullous dermatosis in after delivery at 34 weeks gestation after
a neonate prolonged rupture of membranes. Citrobacter
enteral feeds. A common antecedent was freundii was cultured from a maternal mid-
recent treatment with Carobel. We encountered a neonatal case of linear IgA stream urine sample at delivery. C freundii,
An 820 g boy and a 752 g girl, both of 25 bullous dermatosis. Only one other case of resistant to ampicillin but sensitive to genta-
weeks gestation, were fully established on the disease diagnosed in the neonatal period micin, cephalosporins, and ciprofloxacin, was
enteral feeds with expressed breast milk by has been reported, so we felt that it was isolated from neonatal blood cultures taken
day 12 and 18 respectively. Non-specific important to describe this case. on admission. Gram negative rods were seen
symptoms were attributed to gastro-oesopha- Small vesicles first appeared on the face, on microscopy of cerebrospinal fluid (CSF),
geal reflux (GOR), which was empirically hands, and legs of a Chinese full term baby with no white cells and 730 red cells per high
managed by thickening milk feeds. Instant boy on day 3 of life, which evolved into bullae power field. CSF protein was 1.26 g/l and
Carobel (Cow & Gate) was started on on day 13. New bullae continued to erupt glucose 3.0 mmol/l, with blood glucose of
postnatal day 12 and 24. Onset of NEC was until day 18. By day 25, all the skin lesions 4.9 mmol/l. No organisms grew on CSF
day 26 and 30, with death one day later. had crusted, and skin healing was complete culture. Ampicillin and gentamicin were
Carobel is unlicensed in the United without scar formation. Besides skin erup- discontinued, and ciprofloxacin and cefotax-
Kingdom. The manufacturer advises that tion, the most overwhelming feature of the ime started for a three week course. Serial
two to three level scoops may be added per course was mucosal involvement. The infant cranial ultrasound and computed tomogra-
60–90 ml milk, but mentions no precautions presented with stridor on day 10 and went phy scans showed no evidence of intracranial
or contraindications for preterm infants. Its into respiratory failure requiring intubation. abscess or ventriculitis. At 1 year of age the
use in preterm infants may have crept in On day 30, bronchoscopy revealed a swollen infant is neurodevelopmentally normal.
since the withdrawal of cisapride in July larynx and a vesicle on the left ari-epiglottic Neonatal infection with Citrobacter species
2000. Although feed thickening may reduce fold. He was extubated on day 38 in the is usually acquired in a nosocomial fashion,
the frequency and volume of regurgitation, middle of a three week course of predniso- and causes septicaemia, meningitis, and
acid reflux remains unaffected, and a para- lone. After extubation, stridor gradually sub- brain abscesses associated with a high
doxical increase in the occurrence of GOR has sided in a couple of weeks. morbidity and mortality. Eleven cases of
been described. Moreover, milk thickened The diagnosis of linear IgA bullous derma- vertically acquired Citrobacter koseri infection
with carob bean gum is less nutritive because tosis was made by skin biopsy on a bulla. have been reported.1 However, the only
of decreased bioavailability of essential ele- Histological sections showed splitting of the previous report of vertical transmission of
ments.1 Two recent reviews found no evi- skin at the dermo-epidermal junction with C freundii describes a 32 week infant in whom
dence to support the practice of feed predominant polymorph infiltrate. Immuno- the organism was identified from maternal
thickening in infants with GOR.2 3 fluorescence showed a linear deposit of IgA at high vaginal swab and infant gastric aspirate,
We are concerned that carob thickened the dermo-epidermal junction. Staining for but not from blood cultures.2 Neonatal
milk may have played a role in the demise of IgG and C3 was also positive. septicaemia with meningitis, as in our
these infants. The exact pathophysiology Linear IgA bullous disease commonly patient, has not been previously described.
could not be further investigated because occurs in childhood with onset from 6 months C freundii differs from other organisms caus-
neither infant underwent postmortem to 10 years.1 It classically runs a relapsing ing neonatal meningitis by being able to

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PostScript F281

replicate within brain capillary epithelium, per-

haps accounting for the propensity of this
organism for causing cerebral abscesses.3
However, including this case, this complica-
tion appears to be confined to late onset
disease, with possible explanations being the
early use of antibiotics, and absence of a
putative virulence factor.1
The combination of cefotaxime and an
aminoglycoside is recommended for neonatal
Gram negative meningitis, but CSF concen-
trations of gentamicin may only be mar-
ginally above the minimum bactericidal
concentration of Gram negative organisms.4
Ciprofloxacin has been shown to be effective
in Gram negative meningitis, and should be
considered in the treatment of this condition.5

T J Malpas, J J Munoz
Department of Paediatrics, The General Hospital,
Jersey JE1 3QS, Channel Islands; [Link]@[Link]

I Muscat
Department of Pathology, The General Hospital, Jersey

doi: 10.1136/adc.2003.043398

References
1 Doran TI. The role of Citrobacter in clinical disease
of children: review. Clin Infect Dis 1999;28:384–94.
2 Gupta P, Gupta D, Singh NP, et al. Vertical
transmission of Citrobacter freundii.
Indian J Pediatr 2001;38:110–11.
3 Badger JL, Stins MF, Kim KS. Citrobacter freundii
invades and replicates in human brain micro-
vascular cells. Infect Immun 1999;67:4208–15.
4 Heath PT, Nik Yusoff NK, Baker CJ. Neonatal
meningitis. Arch Dis Child Fetal Neonatal Ed
2003;88:F173–8.
5 Green SDR, Ilunga F, Cheesbrough JS, et al.
The treatment of neonatal meningitis due to
Gram-negative bacilli with ciprofloxacin:
evidence of satisfactory penetration into the
cerebrospinal fluid. J Infect 1993;26:253–6.
Figure 1 Recruitment to research project on neonatal unit (NNU) over 12 month period.

Recruitment failure in early With additional local research ethics com- References
mittee permission, we tried to recruit women
neonatal research at high risk of delivering before term from 1 Department of Health. Research governance
Rates of neurodevelopmental handicap are 25 weeks gestation. The consent process was framework for health and social care. London:
high among extremely low birthweight sur- DoH, 2001. [Link]/.
more complex in this group, as the explanation
2 Hassan IA, Spencer SA, Wickramasinghe YA,
vivors, and the first 48 postnatal hours had to include information about standard et al. Measurement of peripheral oxygen
probably give the greatest opportunity for neonatal care and procedures. Parents in this utilisation in neonates using near infrared
preventing damage. However, at this time, group were given 24 hours to come to a decision. spectroscopy: comparison between arterial and
families are in turmoil and may have dif- Figure 1 shows that, of 28 eligible babies, venous occlusion methods. Early Hum Dev
ficulty in coming to terms with a small baby only five were recruited. Eight out of nine 2000;57:211–24.
in intensive care. We recently had to abandon mothers approached antenatally gave consent, 3 NHS Executive West Midlands Regional Office.
an observational, non-invasive study because but only two of their babies were studied, Report of a review of the research framework in
North Staffordshire Hospital NHS Trust [Griffiths
of practical difficulties arising from the new as three did not meet the entry criteria and
report]. Leeds: NHS Executive, 2000.
Research Governance Framework,1 and we the other three were born elsewhere. [Link].
would like to share this experience, and its What went wrong? Since the Griffiths
implications, with the research community. report,3 the emphasis has been on obtaining
We needed parental consent for the study, fully informed parental consent, and the Gestational age in the literature
which had local research ethics committee research team has to ensure that the parents In neonatology, the correct gestational age
approval. Babies had to be ( 1500 g birth thoroughly understand the research and its (GA) is extremely important, as the viability
weight, . 25 weeks gestation, , 48 hours implications. Research where parents signed and survival of the premature baby depend
old, ventilated, with an arterial line, and no consent forms, but later claimed that they did on it. A difference of a few hours or a day can
prior intervention for circulatory compro- not understand the research, was heavily criti- have a substantial impact on the survival and
mise. The last two requirements meant that, cised.3 Consequently researchers are reluctant long term morbidity of premature babies.
in reality, babies had to be recruited within to approach parents who are in any way Doctors are trained to report the GA of a
the first 12 hours. A non-invasive measure- distressed, because of the difficulty in ensur- premature baby in exact days—for example,
ment of peripheral oxygen consumption2 was ing valid consent. If it is important for early 26+4 (GA = 26 completed weeks and
to be made regularly over 24 hours. We neonatal research to continue, we urgently 4 days). Reporting the GA in this format
aimed to recruit 50 babies over two years. need agreement on a sensitive, humane, and helps in understanding and assessing the
When an eligible baby was admitted, the realistic framework that is acceptable to both postnatal and maturational age of premature
parent(s) were given further information before parents and clinical researchers alike. babies. One would therefore expect GA to be
consent was sought a minimum of four hours reported exactly in the literature, especially in
S Nicklin, S A Spencer
later. Postnatal recruitment proved difficult. articles, studies, and trials dealing with
Neonatal Unit, University Hospital North Staffordshire
The need to give parents time to consider (NHS) Trust, Newcastle Road, Stoke on Trent ST4 survival and morbidity in premature babies.
their decision meant that the opportunity for 6QG, UK; [Link]@[Link] In fact, descriptions of GA are extremely
starting the study was often missed because ambiguous in most articles. An example of
of changes in the baby’s clinical condition. doi: 10.1136/adc.2003.043711 this ambiguity is survival at 26 weeks GA is

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26%.1 This description of GA is open to be wise and safe? These are the questions we ‘‘training’’ session (equipment use and advice
interpretation. It could mean 25+1 to 26+1 or should be struggling to answer. on feeding, skin care, and temperature con-
26+1 to 26+6. Every extra day improves the I have reservations about the authors’ trol) and were given written advice. Tayside
survival of the premature baby by 2%. ‘‘standard work up protocol’’. A cerebrospinal Committee on Medical Research Ethics
Therefore, for the above GA, survival could fluid analysis on asymptomatic, otherwise advised that ethical approval for the progra-
change by 12% on either side of 26%. This healthy neonates with fever is probably mme and written consent were not required,
could have a large effect not only on survival unwarranted. I think it is unwise to perform as the treatment being offered was not novel.
but also on long term morbidity. a spinal tap on a baby with suspicion of Between February and August 2002, 28
Many large studies and articles published dehydration fever. In other words, if one families were offered home phototherapy in
on survival, viability, and ethical issues of suspects meningitis in a neonate, it is not fair Tayside: six refused (difficulties with feeding,
resuscitation in extremely premature babies to withhold antibiotics. About the treatment distance from home to hospital, and parental
have used this ambiguous description of GA. protocol, the authors treated 107 infants with choice). The mean birth weight was 3245 g
The EPICure study is a good example of a antibiotics unnecessarily; only one had a (range 2240–4220), with a median gestation
large, important study that uses the ambig- positive culture. This approach of empiric of 38 weeks (range 35–41). Mean maternal
uous description GA.1 Such large studies have antibiotic use needs critical appraisal in the age was 30 years (range 17–41). Twenty
a major impact on doctors and parents, as the protocol of the institution. (91%) infants were breast fed. Ten were first
results and interpretation are used by neona- Fever without symptoms is not uncommon born. Seven families lived in affluent areas
tologist for counselling, teaching, and research. in healthy, full term babies in the postnatal and two in areas of high deprivation.4
For those dealing with ethical issues, especia- ward. To carry out a prospective study on Phototherapy started at a median age of
lly resuscitation in extremely premature babies, these babies would be feasible. There are two 5.5 days (range 1–13). Eight infants received
exact GA can be of immense help.2 3 As the issues that need clarification, how to inves- all their phototherapy at home. Mean treat-
limits of viability and survival are stretched, tigate and how to treat. I do not think that ment duration was 47.3 hours (range 17.5–
doctors need to be very clear in their minds there is much controversy about investigating 97.0) with a median decrease in SBR of
about the exact age of the premature baby. a febrile neonate. With our present knowl- 16.6 mmol/l per day (ranging from a fall of
In view of the above, we propose that the edge, any febrile neonate with fever, irre- 50 mmol/l to a rise of 53 mmol/l in one case).
reporting of GA in the literature should be spective of symptoms, should be investigated Community midwives spent about 60 min-
uniform. It should be described in exact appropriately with full blood count and blood utes on the first home visit. Subsequent
days—that is, weeks+extra days. and urine cultures. It is the treatment that is visits were shorter. Poor compliance, with-
the root of the controversy and needs further out compromise to either infant, was identi-
B V Pai, V A Pai evaluation. However, in view of the present fied in two families and rectified quickly. No
Royal Sussex Count Hospital, Brighton, Sussex, UK; study, in spite of a promising conclusion, fever other adverse incidents were reported, and
binapai@[Link] in healthy neonates should not be treated as there was no equipment failure. All parents
something benign and dealt with casually. preferred home phototherapy to inpatient
doi: 10.1136/adc.2003.040899 treatment. Community midwives have been
Having said all this, I appreciate the
methodology of the study and the authors’ happy to continue the programme.
References We believe this is the first report of a home
endeavour to look further into the issue of
1 Costeloe K, Hennesey E, Gibson AT, et al. fever in neonates. I hope my suggestion will phototherapy programme in the United King-
EPICure study: outcomes to discharge from generate intense discussion and not just be dom. With appropriate training and enthu-
hospital for infants born at threshold of viability. taken as a critical review of the paper. Lastly, siastic community support, it appears to be
Paediatrics 2000;106:659–71. in my view after reviewing the above paper in feasible, safe, and well accepted by families
2 Rennie JM. Perinatal management at lower and staff. We would encourage others to
margin of viability. Arch Dis Child Fetal Neonatal
detail, dehydration still remains a diagnosis
Ed 1996;77:F214–18. of exclusion, just as we take transient tachy- consider establishing such programmes.
3 Whitelaw A, Yu HYV. Ethics of selective pnoea of the newborn as a diagnosis of exclu- We are grateful to the rest of the Tayside
nontreatment in extremely tiny babies. Semin sion in cases of respiratory distress in neonates. Home Phototherapy Project Team (J Dalzell,
Neonatol 1996;1:297–304. A Jarvis, M Meldrum, V Samson) and the
S Manzar community midwives who contributed to the
Special Care Baby Unit, Royal Hospital, PO Box success of the project. This project was
Fever in the neonatal period 1331, Muscat 111, Sultanate of Oman; supported by a grant from the Scottish
shabihman@[Link] Executive Health Department – Innovative
This is in reference to the recent article by
Maayan-Metzger et al.1 The clinical implica- Fund for Children’s Services.
doi: 10.1136/adc.2003.039735
tion of the study is questionable. It is difficult
to make a prospective decision on retro- M Walls, A Wright, P Fowlie
Reference Neonatal Intensive Care Unit, Ninewells Hospital and
spective data. What should a clinician do if
Medical School, Dundee DD1 9SY, Scotland, UK
a healthy asymptomatic 3 day old baby has a 1 Maayan-Metzger A, Mazkereth R, Kuint J. Fever
fever of 37.9˚C? There is no problem in in healthy asymptomatic newborn during the first
days of life. Arch Dis Child Fetal Neonatal Ed
L Irvine
labelling the infant as having non-specific Department of Epidemiology, University of Dundee,
2003;88:F312–14.
fever, which may be due to dehydration. The Ninewells Hospital and Medical School
problem is to decide on the treatment.
Unfortunately, the study in question not only Home phototherapy in the United R Hume
lacks that information but also supports Maternal and Child Health Sciences, University of
treatment with antibiotics. This inference is Kingdom Dundee, Ninewells Hospital and Medical School
drawn from the results of the study, stating Although successful home treatment of neo-
natal jaundice using fibre-optic phototherapy Correspondence to: Dr Fowlie; [Link]@
that 108 of 122 healthy asymptomatic babies
[Link]
(that is, 88%) were treated with antibiotics. units has been reported elsewhere,1 2 we are
In five years (January 1997 to December not aware of any such provision in the United doi: 10.1136/adc.2003.034868
2001), 122 cases were identified with fever Kingdom. We have introduced a regional
giving a rough figure of 25 febrile cases in one home phototherapy programme in Tayside,
year—that is, about two cases a month. A Scotland and wonder if our initial experience References
prospective follow up of these febrile neo- would be of interest to others.
1 Grabert BE, Wardwell C, Harburg SK. Home
nates after separating them into two groups, Before introducing the service, hospital and phototherapy, an alternative to prolonged
one receiving antibiotics (treatment group) community midwives undertook training cover- hospitalization of the full-term, well newborn. Clin
and the other not (observation group) carried ing inclusion criteria (physiological jaun- Pediatr (Phila) 1986;25:291–4.
out in an ethical way, would be more dice in well, term infants), the treatment 2 Jackson CL, Tudehope D, Willis L, et al. Home
informative for clinical decision making. protocol, equipment use (Biliblanket, Ohmeda), phototherapy for neonatal jaundice: technology
Merely adding the risk factors in the list of and the assessment of parental competence. and teamwork meeting consumer and service
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very little clinical worth. It would be very results with a paediatrician; basing treat- hyperbilirubinaemia. J Pediatr 1979;95:281–5.
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Thickening milk feeds may cause necrotising

enterocolitis
P Clarke and M J Robinson

Arch Dis Child Fetal Neonatal Ed 2004 89: F280

doi: 10.1136/adc.2003.036392

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