Respiratory complications of preterm birth
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7472.962 (Published 21 October 2004) Cite this as: BMJ 2004;329:962All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
To all--greetings, peace, and grace--
In the most recent issue of BMJ one finds a brief review by Fraser,
et al. of
"Respiratory Complications of Preterm Birth" (BMJ 2004;329;962-965), a
useful primer on the topic for those uninitiated in the ongoing struggle
against respiratory distress syndrome and chronic lung disease of
prematurity (CLD). I would like to offer my praise for an article clearly
written
and objective about the topic, but with one proviso: The authors claim
near
the end of the article that "Parents can be reassured that infants with
chronic
lung disease have few clinically important respiratory problems in later
childhood." This is one area subject to both a significant paucity of
data on
which to base such reassurance, on one hand, and some potential trouble
about what constitutes a "clinically important" respiratory difficulty.
In fact,
Kilbride et al., in one of the very few long-term studies addressing the
topic,
found that ELBW babies developing CLD in fact suffered a significant
decrement in pulmonary function testing performed at 9-15 years of age
[Kilbride HW, Gelatt MC, Sabath RJ, J Pediatr 2003 Oct;143(4):488-93].
Whether such findings are clinically important I leave to the
determination by
the particular parent and child. This, of course, leaves to the side
consideration of neurodevelopmental sequelae associated with severe CLD.
Chronic lung disease of prematurity is one of the betes noirs of
neonatology,
seeming only slightly susceptible to any of our myriad machinations.
Because
of this and the above, despite often encouraging outcomes, it remains to
be
seen just how reassuring we can be to parents, children, and others about
this frustrating disease. I'm sure we all look forward to the day when we
can
with great confidence be very reassuring indeed about outcomes from this
disease--unfortunately, we seem not to be there yet.
Cordially,
Perry L Clark, MD,
Assistant Professor of Pediatrics,
Interim Chief, Section of Neonatology,
University of Kansas School of Medicine
Competing interests:
None declared
Competing interests: No competing interests
There is a certain tragic irony about the timing of publication of
this important article, coming in at the same time as the High Court
Family Division has decided that another premature baby should not have
the very treatments which this article discusses. In other words this
baby, Luke Winston-Jones should not be given the mechanical respiratory
support advocated.
The paper also makes an important contribution by setting out the
long known complications of prematurity, including higher risk of
mortality, respiratory distress syndrome, intraventricular haemorrhage and
of the side effects of corticosteroids given to treat such symptoms.
These side effects include gastro-intestinal bleeding and long term
complications including poor brain growth and adverse neuro-motor
outcomes, the latter including autism to my certain knowledge.
The effects of mercury (Thimerosal/Thiomersal) in vaccines given to
these premature infants (and smaller more medically vulnerable infants) is
an additional issue which I mention in my book (1) and was seen as
creating more problems than in the general population in an important
study involving US and Europe and reported on in 2000 in the US following
a meeting in Europe in 1999. The increased incidence of problems included
ADHD, Autism, Speech and Language Disorders and general learning
difficulties, depending on when and how much - cumulatively - thimerosal
was injected into the baby and on the size and medical status of the baby.
(2)
The long known `side effects` of prematurity and of side effects of
treatments for prematurity related conditions also feature strongly in
false cases of Munchausen Syndrome by Proxy across the world, in which
innocent mothers have been accused of causing these difficulties. To my
certain knowledge effects of vaccines leading to death and disorder have
also led to parental accusations of SBS or MSBP.
It is becoming clearer to all but the hugely cynical or the guilty,
that these allegations and opinions were premature and were validated in
the very same Courts in the UK which are now handing out the Death
certificates for the sick premature infants. Perhaps this disease du jour
will take off like MSBP did?
A few years ago, in these same Courts, these babies were called
`normal` by medics - the mothers accused of fabricating or inducing the
problems. Now medics tell the Courts that they are so ill/disabled, they
should be allowed to die.
Am I being terribly cynical when I suggest that requesting these same
Courts to `allow` premature babies to now die - by not giving them these
treatments - might have something to do with the demise of the main
proponents of MSBP and, at long last, a serious focus on exactly what was
wrong with the children, many of whom were taken and adopted?
I wonder how the workers in Dundee who have written this paper view
both the MSBP issue involving premature or vulnerable infants and the
recent Court issues in which hospitals apply to not apply the treatments
they discuss?
Are these Court cases also going to prove to have been unneccessary
and the opinions presented in them as premature?
1. Blakemore-Brown LC Reweaving the Autistic Tapestry. Jessica
Kingsley Publishers. 2001
2. Simpsonwood Meeting 2000 - http://www.momsonamissionforautism.org/
Competing interests:
Expert in Autism
Competing interests: No competing interests
Taking the antenatal corticosteroids (inhalational or oral) to the grass-root level for prevention of preterm respiratory complications
Intramuscular administration of antenatal corticosteroid in women expecting to deliver preterm is a robust and safe intervention. We suggest that instead of injectables they can be given by puff (in larger amount so as to be large enough to get absorbed in blood, but the dosage has to be decided) in the periphery in resource poor settings. Betamethasone as recommended by WHO is not available in India. So dexamethasone is to be given by i.m. injection as per current recommendations. We suggest, not only by inhalation (as said above), this drug is bioavailable as oral preparation which can be tried by peripheral health worker, in mothers at high risk of preterm labour.
Alternatively, all the expectant mothers can be given antenatal corticosteroids at 32 weeks (or whatever the experts decide) as there is no harm done.
Competing interests: No competing interests