569
aztreonam, and imipenem. However, a few isolates of some species,
RESULTS OF NEONATAL INTENSIVE CARE UNIT QUESTIONNAIRE
especially Vparahaemolyticus and Valginolyticus, showed unusual and multiple resistance to some of these drugs, including resistance to chloramphenicol and tetracycline. 1 of the Vvulnificus strains was resistant to cefotaxime and 4 to aztreonam. Halophilic vibrios grew poorly or not at all on sensitivity-testing media incubated at 37°C without the addition of salt, but inocula of 10 colony-forming units grow well on unsupplemented MuellerHinton agar incubated at 30°C. Since these are unusual test conditions it is important to include Vibrio controls. We have published results for USA and UK standard strains to aid inter-laboratory comparisons.1 V vulnificus is the most common cause of fatal spreading necrotising lesions among the vibrios,2,3 but they have also been seen with V parahaemolyticus, V alginolyticus, and V damsela.3-f> Your editorial notes that adequate surgical debridement is important for soft tissue infections and we would strongly endorse this. No antibiotic will penetrate dead tissue and in these life-threatening conditions emergency debridement or amputation is essential. Blind therapy with reliable systemic drugs is also required, and, on the basis of our results and anecdotal clinical experience, the aminoglycosides, ceftazidime, imipenem, or the quinolones should be effective. Department of Microbiology, United Medical and Dental Schools,
Guy’s Hospital, London SE1 7RT, UK
G. L. FRENCH
1. French GL, Woo ML, Hui YW, Chan KY. Antimicrobial susceptibilities of halophilic vibrios. J Antimicrob Chemother 1989; 24: 183-94. 2. Woo ML, Patrick WGD, Simon MTP, French GL. Necrotising fasciitis caused by Vibrio vulnificus. J Clin Pathol 1984; 37: 1301-04. 3. Howard RJ, Pessa ME, Brennaman BH, Ramphal R. Necrotizing soft-tissue infections caused by marine vibrios. Surgery 1985; 98: 126-30. 4. Johnson DE, Weinberg L, Ciarkowski J, West P, Colewell RR. Wound infection caused by Kanagawa-negative Vibrio parahaemolyticus. J Clin Microbiol 1984; 20: 811-12. 5. Bonner JR, Coker AS, Berryman CR, Pollack HM. Spectrum of vibno infections in a Gulf Coast community. Ann Intern Med 1983; 99: 464-69. 6. Coffey JA, Hams RL, Rutledge MJ, Bradshaw MW, Williams TW. Vibrio damsela: another potentially virulent marine vibrio J Infect Dis 1986; 153: 800-01.
Pain relief in neonatal intensive care SIR,-We believe that the need for pain relief in sick babies has been insufficiently recognised.l,2 This is despite the fact that it is generally accepted that babies feel pain as much as older children or adults.3,4 To assess pain relief practice in neonatal intensive care units we sent questionnaires to 21 units in the UK and Ireland. The questionnaire was addressed to the "Sister in charge of the unit", asked to discuss it with all staff. Results from the 17 questionnaires returned are shown in the table. It appears that while all units in this survey accept that babies experience pain, alleviation of pain is given a low priority. Policies for pain relief are poorly defined, only 2 units having a written policy. In 75% or more of cases no analgesia was given for necrotising enterocolitis and meningitis. There was a strong feeling that analgesia is underprescribed by doctors and a significant minority felt that, even when prescribed, analgesics are underadministered by nurses. We feel that doctors and nurses should translate their awareness of pain in the newborn into concrete procedures for alleviation. The nurse delegated to care for the baby has an important role in looking for behavioural manifestations of distress. These are important observations and should not be dismissed by other staff making casual observations. There should be a written policy on every neonatal unit with regard to pain relief otherwise it will frequently not be administered. Doctors should not underprescribe and nurses should not be afraid to administer. While the provision of adequate analgesia may cause problems (eg, apnoea and abolition of helpful clinical signs), this should not preclude its use when warranted. After receiving a narcotic, babies should be observed closely, and a narcotic antagonist and oxygen should be near at hand. Traumatic procedures should not be undertaken without the use of analgesia, except in dire emergencies; for example, the chest wall should be infiltrated with lignocaine before insertion of a drain. Greater use can be made of local anaesthetic sprays and creams. Equally who
was
important is the comfort that can be given by non-pharmacological measures,though these cannot deal adequately with intense pain from traumatic procedures. The results from the fmal question in our survey point towards poor pain assessment. It is likely that improved training can overcome this problem. Finally, we should recall that the Latin infans, from which the word infant derives, means speechless, and strive to ensure that babies in our care do not suffer. This study was undertaken as a research project during the neonatal intensive care course at the National Maternity Hospital, Dublin. We would like to thank the staff of the neonatal units in the Republic of Ireland and UK who made this study possible.
JANE TOHILL
National Maternity Hospital, Hollis Street, Dublin, Ireland
OLIVE MCMORROW
1. Owens ME. Pain in infancy. Conceptual and methodological issues. Pain 1984; 20: 213-30. 2. Owens ME, Todd EM. Pain in infancy. Neo-natal reaction to heel lance. Pain 1984;
20: 77-86. 3. Hatch DJ. Analgesia in the neonate. Br Med J 1987; 294: 920. 4. Bray RJ. Management of preoperative pain. Child Hosp Up-date 1988; May: 1565-72. 5. Allingham L. Pain in the neonate. Midwives Chronicle 1989; Feb: 54-56.
Growth and nutrition in children with cerebral palsy SiR,—Your May 26 editorial prompted us to look more closely at data on a total population (n 897) of low-birthweight infants (less than 1750 g) born in Scotland in 1984.’ Of the surviving cohort, =
our
611 (96%) have been reviewed at the age of 4i years, with Amiel Tison and Stewart’s2 standardised neuromotor assessment, and including measures of growth and cognitive function which will be reported in full shortly. The distributions of height, head circumference, and, in particular, weight centiles showed pronounced shifts to the left; the distribution of weight centiles was related to birthweight (figure). Patients were classified in three groups according to neuromotor impairment: those with neuromotor signs only; those with a moderate disability; and those with severe disability. Among the children whose motor deficit was accompanied by severe disability there was a U-shaped distribution in head circumference; the distribution of height showed a striking shift to the left, and more than 30% were below the 3rd centile. There was a slight shift to the left in weight, with no children at or above the 90th centile at 4z years
(figure).
aztreonam, and imipenem. However, a few isolates of some species,
RESULTS OF NEONATAL INTENSIVE CARE UNIT QUESTIONNAIRE
especially Vparahaemolyticus and Valginolyticus, showed unusual and multiple resistance to some of these drugs, including resistance to chloramphenicol and tetracycline. 1 of the Vvulnificus strains was resistant to cefotaxime and 4 to aztreonam. Halophilic vibrios grew poorly or not at all on sensitivity-testing media incubated at 37°C without the addition of salt, but inocula of 10 colony-forming units grow well on unsupplemented MuellerHinton agar incubated at 30°C. Since these are unusual test conditions it is important to include Vibrio controls. We have published results for USA and UK standard strains to aid inter-laboratory comparisons.1 V vulnificus is the most common cause of fatal spreading necrotising lesions among the vibrios,2,3 but they have also been seen with V parahaemolyticus, V alginolyticus, and V damsela.3-f> Your editorial notes that adequate surgical debridement is important for soft tissue infections and we would strongly endorse this. No antibiotic will penetrate dead tissue and in these life-threatening conditions emergency debridement or amputation is essential. Blind therapy with reliable systemic drugs is also required, and, on the basis of our results and anecdotal clinical experience, the aminoglycosides, ceftazidime, imipenem, or the quinolones should be effective. Department of Microbiology, United Medical and Dental Schools,
Guy’s Hospital, London SE1 7RT, UK
G. L. FRENCH
1. French GL, Woo ML, Hui YW, Chan KY. Antimicrobial susceptibilities of halophilic vibrios. J Antimicrob Chemother 1989; 24: 183-94. 2. Woo ML, Patrick WGD, Simon MTP, French GL. Necrotising fasciitis caused by Vibrio vulnificus. J Clin Pathol 1984; 37: 1301-04. 3. Howard RJ, Pessa ME, Brennaman BH, Ramphal R. Necrotizing soft-tissue infections caused by marine vibrios. Surgery 1985; 98: 126-30. 4. Johnson DE, Weinberg L, Ciarkowski J, West P, Colewell RR. Wound infection caused by Kanagawa-negative Vibrio parahaemolyticus. J Clin Microbiol 1984; 20: 811-12. 5. Bonner JR, Coker AS, Berryman CR, Pollack HM. Spectrum of vibno infections in a Gulf Coast community. Ann Intern Med 1983; 99: 464-69. 6. Coffey JA, Hams RL, Rutledge MJ, Bradshaw MW, Williams TW. Vibrio damsela: another potentially virulent marine vibrio J Infect Dis 1986; 153: 800-01.
Pain relief in neonatal intensive care SIR,-We believe that the need for pain relief in sick babies has been insufficiently recognised.l,2 This is despite the fact that it is generally accepted that babies feel pain as much as older children or adults.3,4 To assess pain relief practice in neonatal intensive care units we sent questionnaires to 21 units in the UK and Ireland. The questionnaire was addressed to the "Sister in charge of the unit", asked to discuss it with all staff. Results from the 17 questionnaires returned are shown in the table. It appears that while all units in this survey accept that babies experience pain, alleviation of pain is given a low priority. Policies for pain relief are poorly defined, only 2 units having a written policy. In 75% or more of cases no analgesia was given for necrotising enterocolitis and meningitis. There was a strong feeling that analgesia is underprescribed by doctors and a significant minority felt that, even when prescribed, analgesics are underadministered by nurses. We feel that doctors and nurses should translate their awareness of pain in the newborn into concrete procedures for alleviation. The nurse delegated to care for the baby has an important role in looking for behavioural manifestations of distress. These are important observations and should not be dismissed by other staff making casual observations. There should be a written policy on every neonatal unit with regard to pain relief otherwise it will frequently not be administered. Doctors should not underprescribe and nurses should not be afraid to administer. While the provision of adequate analgesia may cause problems (eg, apnoea and abolition of helpful clinical signs), this should not preclude its use when warranted. After receiving a narcotic, babies should be observed closely, and a narcotic antagonist and oxygen should be near at hand. Traumatic procedures should not be undertaken without the use of analgesia, except in dire emergencies; for example, the chest wall should be infiltrated with lignocaine before insertion of a drain. Greater use can be made of local anaesthetic sprays and creams. Equally who
was
important is the comfort that can be given by non-pharmacological measures,though these cannot deal adequately with intense pain from traumatic procedures. The results from the fmal question in our survey point towards poor pain assessment. It is likely that improved training can overcome this problem. Finally, we should recall that the Latin infans, from which the word infant derives, means speechless, and strive to ensure that babies in our care do not suffer. This study was undertaken as a research project during the neonatal intensive care course at the National Maternity Hospital, Dublin. We would like to thank the staff of the neonatal units in the Republic of Ireland and UK who made this study possible.
JANE TOHILL
National Maternity Hospital, Hollis Street, Dublin, Ireland
OLIVE MCMORROW
1. Owens ME. Pain in infancy. Conceptual and methodological issues. Pain 1984; 20: 213-30. 2. Owens ME, Todd EM. Pain in infancy. Neo-natal reaction to heel lance. Pain 1984;
20: 77-86. 3. Hatch DJ. Analgesia in the neonate. Br Med J 1987; 294: 920. 4. Bray RJ. Management of preoperative pain. Child Hosp Up-date 1988; May: 1565-72. 5. Allingham L. Pain in the neonate. Midwives Chronicle 1989; Feb: 54-56.
Growth and nutrition in children with cerebral palsy SiR,—Your May 26 editorial prompted us to look more closely at data on a total population (n 897) of low-birthweight infants (less than 1750 g) born in Scotland in 1984.’ Of the surviving cohort, =
our
611 (96%) have been reviewed at the age of 4i years, with Amiel Tison and Stewart’s2 standardised neuromotor assessment, and including measures of growth and cognitive function which will be reported in full shortly. The distributions of height, head circumference, and, in particular, weight centiles showed pronounced shifts to the left; the distribution of weight centiles was related to birthweight (figure). Patients were classified in three groups according to neuromotor impairment: those with neuromotor signs only; those with a moderate disability; and those with severe disability. Among the children whose motor deficit was accompanied by severe disability there was a U-shaped distribution in head circumference; the distribution of height showed a striking shift to the left, and more than 30% were below the 3rd centile. There was a slight shift to the left in weight, with no children at or above the 90th centile at 4z years
(figure).
