Recent discussions
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Silvia Heloisa Moscatel Loffredo
The available evidence does not indicate optimal rewarming rates yet, but I believe that with the constantly evolving strategies in neonatal monitoring, there will be suitable opportunities for further research
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Silvia Heloisa Moscatel Loffredo
There is clarity regarding the presented interventions, valuing the inherent peculiarities of gestational age, as well as the need for more data for the umbilical cord management strategies in preterm infants. The aim is to find a balance between effective resuscitation at birth and avoiding invasive procedures, minimizing complications in the short and long term.
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Nádia Sandra Orozco Vargas
I agree nevertheless We have to study and research more on this topic.
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Kaustabh Chaudhuri
Our unit observation is increase in number of polycythemia and neonatal jaundice in few subjects. Any comments?
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Susan Niermeyer
As noted in several comments, the choice of wording in the recommendation exerts strong influence on uptake and implementation. Treatment recommendations continue to suggest that deferred cord clamping be offered only to preterm infants “who are deemed not to require immediate resuscitation at birth”. This is open to widely divergent interpretation, and often results in extremely preterm infants being assumed a priori to need immediate resuscitation. Unless the assumption is positive, that a very preterm infant can be given an opportunity to breathe spontaneously, and appropriate monitoring by delivery room staff and thermal support are routinely in place, many preterm infants will continue to miss the mortality benefit of deferred cord clamping. This tendency may be reinforced by suggesting that cord milking (often perceived as faster and easier) is a reasonable alternative for preterm infants >28 weeks ”who do not receive deferred cord clamping".
The supporting statement to part B, “There is no evidence of increased rates of adverse effects in preterm infants <37 weeks’ gestation or their mothers after umbilical cord milking compared to immediate cord clamping.” appears on the surface to contradict to the recommendation against cord milking for infants <28 weeks. Although technically accurate regarding the studies included, this statement may lead to confusion.
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Steven Gelfand
Agree with update regarding UCM in preterms when DCC not possible. Reassured by Katheria et al 2023 in Pediatrics and appreciate the simplicity of using the 28 week cutoff for our obstetric providers.
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Dr Ashwini R C
In LMICs, the issues that need to be highlighted are
1.Therapeutic hypothermia is to be done in only level III NICU with trained neonatogist so that only eligible neonates need to be cooled(criteria to be clearly defined) and only those NICU with hemodynamic monitors, adequate nursing ratio,Neurosonogram, Echo facilities can cool. Also when cooling mandatory hemodynamic, haematological, neurological monitoring to be mentioned.
Clarification is required regarding
1.Servo controlled vs Non servo controlled cooling devices results…. Servo would ensure more consistent mattress temperatures so the results mentioned here are contradictory
2.Guidelines regarding feeding regimen while being cooled
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Viraraghavan Vadakkencherry Ramaswamy
1. The control group event rate for mortality is 8.1%.. For a control group event rate of even 10%, we require at least total events of 350 - 400 for a RRR of 25%. (Figure 2 A). Could the evidence have been downrated for imprecision. I agree that OIS criterion varies for CPGs and SRs. But most of the ILCOR SRs and CPGs use the later. May be we should have a threshold set for critical and important outcomes a priori
2. In the supplementary file of NMA, pg 302, Table 1, for comparison, ICC:long DCC, the CoE is upgraded by one level. We rarely upgrade the evidence certainty in meta-analysis of RCTs. GRADE quotes “Indeed, although it is theoretically possible to rate up results from randomized control trials (RCTs), we have yet to find a compelling example of such an instance.”
page 278 Table 2 (League Table, outcome: death): ICC vs long DCC: 0.75 (0.41-1.43). ?qualifies for large effect
3. In the node splitting analysis for inconsistency evaluation for the outcome death (page 287, Table 19), there is inconsistency in the model for the comparison short deferral vs. ICC (p=0.038). This is the most difficult part for an author of an NMA. When inconsistency creeps in, it's not only the particular comparison that is suspect but all of the NMA effect estimates in the model. There is no proven way to deal with inconsistency. But an optimal way might be to downgrade the NMA evidence certainty by one level (even this is only a suggestion by some experts).
4. For many comparisons (Table 1, pg 302), imprecision is downrated by two levels. GRADE specifies circumstances where imprecision may be downrated by two levels. IGRADE “When there are very few events and CIs around both relative and absolute estimates of effect that include both appreciable benefit and appreciable harm, systematic reviewers and guideline developers should consider rating down the quality of evidence by two levels. For example, a systematic review of the use of probiotics for induction of remission in Crohn’s disease found a single randomized trial that included 11 patients. Of the treated patients, four of five achieved remission; this was true of five of six of the control patients. The point estimate of the risk ratio (0.96) suggests no difference, but the CI includes a reduction in likelihood of remission of almost half, or an increase in the likelihood of over 50%.”
My compliments to the team for the great work done.
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Shaimaa Ibrahim
I agree on recommendations, Knowledge gaps identified on long-term development and need for further evidence generation on long term outcome for development.
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Judith Finn
Useful scoping review - highlighting the need for further research in this field. Thanks, Judith