Antenatal Phenobarbital Therapy and Neonatal Income

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To the Editor. Attempts to analyze methods of preventing intracranial hemorrhage (ICH) are difficult for a variety of reasons. ICH has a diverse pathophysiology, marked interinstitutional variance in occurrence, and there has been a progressive decline in the prevalence of ICH over the past decade. The efforts of Shankaran and colleagues1 to clarify this issue are appreciated. The authors might comment on the following points to provide further insight into their study: 1. There has been a marked decline in prevalence of severe ICH over the past decade, probably as a result of changing obstetric and neonatal care.2 It is puzzling that the study of Shankaran et al1 is published over ten years after it began. Why was there such a delay in publication? With regard to advances in perinatal care, is this study applicable to perinatal care in the 1990s? 2. Many different studies suggest that antenatal betamethasone dramatically reduces the incidence of ICH.2,3 The recent National Institutes of Health consensus of experts suggests that antenatal betamethasone is one of the most studied, efficacious, and underutilized interventions in obstetrics.3 In the study of Shankaran and colleagues,1 only 35% of their study population were given antenatal betamethasone. Is this study applicable to the 1990s when all these patients should be given antenatal betamethasone? Does the authors' institution routinely use antenatal betamethasone currently? 3. Why is ICH categorized as mild, moderate, and …