Dehydration: the main cause of fever during the first week of life.

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Dehydration: the main cause of
fever during the first week of life
We read with interest the findings of
Maayan-Metzger et al on fever in healthy
newborns during the first days of life.1
It is difficult to identify febrile neonates at
lowrisk ofserious bacterial infection.2
Although no consensus exists on the optimal
approach to diagnosis and treatment, current
guidelines recommend that febrile infants
less than 28 days of age be admitted to
hospital and given intravenous antibiotics
for 48–72 hours. However, as mentioned in
this report, dehydration is the primary cause
of fever especially during the first days of life.
We retrospectively reviewed the medical
charts of patients admitted to our neonatal
intensive care unit with fever between 1 May
1999 and 30 September 2003.
The inclusion criteria were gestational age
>37 weeks, 1–7 days of postnatal age exclud-
ing the first day of life, axillary or rectal
temperature >37.8˚C on admission, normal
physical examination with well appearance,
no signs of focal infection, and no history of
illness or antibiotics.
Overall, 46 febrile neonates were included
in the study. Most (90–95%) were exclusively
breast fed. Laboratory data included complete
blood count, C reactive protein, serum urea
and sodium concentrations, urinalysis, and
blood, urine, and cerebrospinal fluid cultures.
The mean (SD) age on admission was
3.4 (1.9) days. The mean (SD) duration of
fever was 2.8 (2.4) hours. Twenty seven
infants (59%) had lost 8–24.3% of their
birth weights. In 34 of the babies, white
blood cell counts were between 5000 and
15 000/mm3. Serum sodium concentrations
were obtained in 35 patients: mean (SD) was
147 (6.7) mmol/l, and in 14 (40%) the levels
wereequal to or higherthan 150 mmol/l.There
was a positive correlation between weight
loss and high serum sodium concentration
(p = 0.002). Mean (SD) serum urea nitrogen
concentration was 19.3 (11.1) mmol/l. In 22
(48%) babies, serum bilirubin concentration
was equal to or greater than 220 mmol/l.
Cultures were positive in seven babies.
Coagulase negative staphylococci were recov-
ered from five blood cultures and considered
PostScript ..............................................................................................
Newborn surgery, second edition
Edited by P Puri. London: Arnold, 2003, £195,
pp 976. ISBN 034076144X
Neonatologists
involved in the intensive care of neonates as
surgical patients. In my own case this has led
to a slightly blinkered approach. I am very
familiar with perinatal stabilisation of pro-
blems such as gastroschisis, with the inten-
sive care of infants with diaphragmatic
hernias, and with the referral of infants with
less acute problems. However, perioperative
management, particularly of uncomplicated
cases, and the mysteries of operative techni-
ques have been beyond my reach. A book,
with neonatologists within its scope, ideally
withstrong emphasis
embryology, and associations as well as
describing surgical options, would plug a
significant gap in my knowledge.
With 97 chapters, typically under 10 pages
each, this book certainly has breadth of
coverage. Chapters typically deal with a
problem such as chylothorax, subglottic
stenosis, or necrotising enterocolitis and
describe the authors’ perspective on manage-
ment. There are numerous photographs,
radiographs, and drawings in nice balance
with the text. Fascinating drawings, intended
to complement the ‘‘comprehensive descrip-
tion of operative techniques’’ left me wonder-
ing that such complicated operations could
be so simply described. The authors are
drawn from all over the world, but the book’s
style remains uniformly European.
The book begins with a series of chapters
dedicated to general and theoretical aspects
of the care of these high risk infants. These
areas of overlap with standard neonatal texts
are very variable and, from my perspective,
also very interesting. Some could have been
more up to date. It was also interesting for
example to see a chapter on neonatal trans-
port written by two paediatric surgeons
rather than by neonatologists.
Some overlap is inevitable in a book like
this. However, I would have preferred, for
example, that either there was more embry-
ology in each surgical chapter or a more
comprehensive introductory chapter. A well
written chapter on ethics, from a purely
North American perspective, occupies eight
pages, which is also the space given to
parenteral nutrition. The five sides dedicated
to respiratory management of the newborn
emphasised to me the potential rewards to be
reaped from closer integration of training and
practice in neonatology and newborn surgery.
The chapters on surgical problems are the
book’s strongest area. We have found the
book valuable in furthering our understand-
ing of the problems we see on a day to day
basis. Many of the lesions in question are
relatively rare, which makes the superspecia-
list multiauthor approach most valuable. The
inclusion of problems sometimes dealt with
by neurosurgeons and plastic surgery specia-
lists makes this an especially attractive
volume. Only the occasional chapter seemed
to focus too heavily on the authors’ own
are notalwaysdirectly
onpresentation,
Nestle nutrition workshop series:
pediatric program, Vol 52:
micronutrient deficiencies in the first
months of life
Edited by F M Delange, K P West Jr, S Karger.
2003, $198.25
3805575599
(hardcover).ISBN
Micronutrient deficiencies in the first few
months of life may not keep you awake at
night if you are working in the UK, and this
book may not grab your attention straight
away, but you should give it some considera-
tion whatever your branch or specialty in
paediatrics. The book is a collection of 16
papers, written by an international panel of
experts, which are the proceedings of a
workshop held in Dubai in October 2002.
Most of us will be familiar with the
problems of iron deficiency in early infancy
and the debate on the role of neonatal
vitamin K administration, and, if pushed,
many of us would be able to say something
about the public health implications of
maternal folic acid supplementation and
prevention of neural tube defects. This book
presents papers that provide thorough state
of the art reviews of these subjects. The
practice of most UK based paediatricians
won’t frequently encompass micronutrient
deficiencies outside of these aforementioned
areas, but this book reminds us that, from a
global perspective, nutritional deficiency pro-
blems are extremely prevalent. Vitamin A
deficiency probably affects over 40% of the
world’s children, and iodine deficiency affects
over 10%, with salt iodination theoretically
simple, but practically complicated. Iron
deficiency is a truly global problem which
affects at least one in three children world
wide.
Many of us might be surprised to learn that
over 50% of children in China and Tibet have
features of rickets (which is also a growing
(sic) problem among certain groups in the
UK), and the latest evidence on the benefits
of zinc supplementation in the prevention
and treatment of diarrhoea, and in promotion
of linear growth from field trials in develop-
ing countries, is truly compelling. Because
the book is really a series of presented papers,
it is genuinely more readable than a textbook
on the subject. A paper on the relation
between micronutrients in pregnancy and
early infancy and mental and psychomotor
development, and another on special micro-
nutrient concerns in premature infants were
of particular interest to my personal practice.
Discussions after the papers were presented
have been included and often highlight areas
of uncertainty or real practical importance.
Of course, in a book such as this there are
going to be areas that don’t get covered, and,
if you were looking for a comprehensive tome
on this subject, then spending your money on
a textbook might be better. But many of us
purchase textbooks and then allow them to
sit on the shelves collecting dust while we
only ‘‘dip into’’ them occasionally. The good
thing about this type of book is that you
might actually end up reading some of it!
N Embleton
Consultant in Neonatal Medicine, Royal
Victoria Infirmary, Newcastle upon Tyne, UK;
n.d.embleton@ncl.ac.uk
LETTERS
experience without consideration for the
variety of techniques in use.
I’m glad to say that this book is the one to
plug the gaps in my knowledge. I would
therefore recommend this book to fellow
paediatricians, much as I would encourage
surgeons andneonatologists
develop collaboration in practice and in
training.
to further
S Oddie
Royal Victoria Infirmary, Newcastle upon Tyne
NE2 2PU, UK; s.j.oddie@ncl.ac.uk
BOOK REVIEWS
Arch Dis Child Fetal Neonatal Ed 2004;89:F373–F376 F373
www.archdischild.com

Page 2

to be contaminated both clinically and in a
negative repeated culture. In one infant, blood
culture was positive for Staphylococcus aureus,
and Enterococcus grew from culture of the urine
in the other. Most admissions (83%) were
between June and early October, which are
the warmest months of the year in this area.
In this low risk group of infants, only two
patients had serious bacterial infection. Com-
patible with the findings of Maayan-Metzger
et al,1the results of our study support dehy-
dration as the main cause of fever during the
first week of life. As most of our cases
occurred during summer and early autumn,
environmental temperature may have an
additive effect in this population.
F Tiker, B Gurakan, H Kilicdag, A Tarcan
Faculty of Medicine, Baskent University, Ankara,
Turkey; filiztiker@yahoo.com
doi: 10.1136/adc.2003.047696
References
1 Maayan-Metzger A, Mazkereth R, Kuint J. Fever
in healthy asymptomatic newborns during the first
days of life. Arch Dis Child Fetal Neonatal Ed
2003;88:F312–14.
2 Baker MD, Bell LM. Unpredictability of serious
bacterial illness in febrile infants from birth to
1 month of age. Arch Pediatr Adolesc Med
1999;153:508–11.
Increasing incidence of moderate
neonatal hyperbilirubinaemia in
Wirral
Severe neonatal jaundice and bilirubin ence-
phalopathy have been reported with increas-
ing frequency from North America and
Europe.1–3There are no published reports of
similar trends in Britain. We therefore exam-
ined trends in moderate neonatal hyperbili-
rubinaemia in Wirral Hospital between 1991
and 2001. Neonates of > 34 weeks gestation
with a serum bilirubin of > 340 mmol/l were
identified from the laboratory database.
Trends in hyperbilirubinaemia were analysed
using the x2test for trend.
A total of 184 infants were identified; 122
presented before initial discharge, and 62 were
readmitted. Median (interquartile range) gesta-
tional age was 38 (37–39) weeks, and 69% of
affected infants were breast fed. The incidence
of moderate jaundice increased from 2.4/1000
live births in 1991 to 5.5/1000 in 2001
(p , 0.0001). Despite a progressive fall in
annual births, readmissions
increased from seven in the first six years of
studyto55inthesecondfiveyears(p,0.0001).
Five infants needed exchange transfusion; all
had haemolytic diseases. All were identified
before initial discharge. No infants developed
bilirubin encephalopathy, and none died.
Ours is the only report of recent trends in
neonatal jaundice in Britain. Whether our
experience is representative is not known,
nor is the national incidence of bilirubin
encephalopathy. These questions may be
answered by this continuing study, supported
by the British Paediatric Surveillance Unit, of
severe neonatal jaundice.
forjaundice
F Walston, D Manning
Department of Paediatrics, Wirral Hospital,
Merseyside CH49 5PE, UK; flossige@yahoo.com
W D Neithercut
Department of Biochemistry, Wirral Hospital
doi: 10.1136/adc.2003.037242
References
1 Seidman DS, Stevenson DK, Ergaz Z, et al.
Hospital readmission due to neonatal
hyperbilirubinaemia. Pediatrics
1995;96:727–9.
2 Maisels MJ, Newman TB. Kernicterus in otherwise
healthy, breast-fed term newborns. Pediatrics
1995;96:730–3.
3 Ebbesen F. Recurrence of kernicterus in term and
near-term infants in Denmark. Acta Paediatr
2000;89:1213–17.
Use of abbreviations in daily
progress notes
Errors in medication and documentation are
reported.1 2These errors, no matter how
minor, could have grave consequences for
the patient, especially in the paediatric
population. One can imagine the potential
threat to small neonates. Recently, Carroll et
al3described problems in residents’ progress
notes in a neonatal intensive care unit. Being
the busiest centre in the country, managing
the great majority of seriously sick neonates,
we are at a very high risk of these errors. In
view of this and as a screening audit, we
looked at a few progress notes written on our
inpatient neonates. One example of a pro-
gress note, written by a junior doctor, stated
‘‘Prem 32 WOG, F&G , Problems: RDS, IVH
II, S/P SVT, Stable on RA, TPR normal, PU,
BO. Chest, CVS & abdomen: NAD’’. This
excessive and inappropriate use of abbrevia-
tions is alarming and disturbing. The abbre-
viations used denoted the following (in order
of citation): weeks of gestation, feeder and
grower, respiratory distress syndrome, intra-
ventricular grade 2 haemorrhage, status post
supraventricular tachycardia, room air, tem-
perature pulse respiration, passed urine,
bowel open, cardiovascular system, and no
abnormality detected. This prompted us to
look further into the use of abbreviations in
the daily progress notes in our neonatal unit.
A cross section survey was carried out at
the Special Care Baby Unit (SCBU), Royal
Hospital, Muscat, on 7 October 2003. Thirty
consecutive charts were reviewed. The pro-
gress notes written by seven different doctors
(three registrars and four resident medical
officers) were analysed for use of abbrevia-
tions. The commonly used ones were: CP
(crystalline penicillin), RR (respiratory rate),
HR (heart rate), BP (blood pressure), PA (per
abdomen), O/E (on
(nasogastric tube), UE1 (urea and electrolyte
1), BGA (blood gas analysis), BBA (born
before arrival), TPN (total parenteral nutri-
tion), SLS (standard lipid solution), STS
(standard TPN solution), D/w (discussed
with), SBR (serum bilirubin), CTG (cardio-
tocograph), IUGR(intrauterine
restriction), BTshunt
shunt), TAT (trans-anastomotic tube), IVF
(intravenous fluid or in vitro fertilisation),
POD (postoperative day), ASD (atrial septum
defect), VSD (ventricular septum defect),
PDA (patent ductus arteriosus), TR (tricuspid
regurgitation), L-R shunt
shunt), TOF (tetralogy of Fallot), CRT (capil-
lary refill time). One interesting note that
needs separate mention was ‘‘Plan is to
start ABs after ABC’’ (ABs, antibiotics; ABC,
aerobic blood culture).
We noted a high frequency of the use
of abbreviations in our neonatal unit. This
was a single day observation; we would
expect much more in a longitudinal study.
Fortunately, none of the abbreviations had
resulted in erroneous interpretation, as most
examination),NGT
growth
(Blalock-Taussig
(left to right
of the staff were used to them. However, this
does not indicate that it is all right to use
abbreviations. Standard abbreviations, such
as VSD (ventricular septal defect) and PDA
(patent ductus arteriosus), are acceptable,
whereas others are not.
Documentation errors have been reported
to be an increasing problem in day to day care
of patients.4 5A recent report described the
same negligence in documentation by resi-
dents. Carroll et al3found discrepancies in the
daily progress notes written by a resident
doctor in the neonatal intensive care unit.
They also found that notes often contained
inaccurate information and lacked pertinent
information. We looked further into the
situation and found extensive use of abbre-
viations in progress notes.
Our observation is not unique and requires
rectification. The solution could be to stan-
dardise or eliminate the use of abbreviations
in the unit. Total elimination would be
difficult, as many of the abbreviations are
acceptable. Thus, the use of unacceptable
abbreviations should be discouraged. New
medical officers should be given brief instruc-
tion on the writing of appropriate progress
notes. An alternative is to use the electronic
information system for all medical transcrip-
tion including progress notes, as described
elsewhere.6 7
In conclusion, care of neonates requires
good documentation of day to day progress.
The use of unacceptable abbreviations should
be discouraged. A follow up audit is war-
ranted to look further into the effect and
success of our recommendations.
S Manzar, A K Nair, M Govind Pai,
S Al-Khusaiby
Special Care Baby Unit, Royal Hospital, PO Box
1331, Postal Code 111, Muscat, Sultanate of Oman;
shabihman@hotmail.com
doi: 10.1136/adc.2003.045591
References
1 Brennan TA, Leape LL, Laird NM, et al. Incidence
of adverse events and negligence in hospitalized
patients. Results of the Harvard Medical Practice
Study I. N Engl J Med 1991;324:370–6.
2 Cradock J, Young AS, Sullivan G. The accuracy
of medical record documentation in
schizophrenia. J Behav Health Serv Res
2001;28:456–65.
3 Carroll AE, Tarczy-Hornoch P, O’Reilly E, et al.
Resident documentation discrepancies in a
neonatal intensive care unit. Pediatrics
2003;111:976–80.
4 Bedell SE, Deitz DC, Leeman D, et al. Incidence
and characteristics of preventable iatrogenic
cardiac arrests. JAMA 1991;265:2815–20.
5 Lester H, Tritter JQ. Medical error: a discussion of
the medical construction of error and suggestions
for reforms of medical education to decrease
error. Med Educ 2001;35:855–61.
6 Kaushal R, Barker KN, Bates DW. How can
information technology improve patients’ safety
and reduce medication errors in child health
care. Arch Pediatr Adolesc Med
2001;155:1002–7.
7 Menke JA, Broner CN, Campbell DY, et al.
Computerized documentation system in pediatric
intensive care unit. BMC Med Inform Decis Mak
2001;1:3.
Use of nasal continuous positive
airway pressure during neonatal
transfer
Within neonatal intensive care units, nasal
continuous positive airway pressure (nCPAP)
F374 PostScript
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