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Limitations of Care for Very-low-birthweight Infants
1257
1981, 54 % of infants of birth weight less than 1250 g in one series had poor neurodevelopmental status at follow-up,6 whereas a more recent report claimed an incidence of severe handicap of only 12 % in infants of 23-28 weeks’ gestation.2 Schechner was not alone in wondering whether this approach to perinatal care, particularly in very preterm babies, might mean that some infants undergo prolonged treatment only to die eventually, with concomitant heavy financial and emotional burdens for the family and neonatal staff.7 She also
morbidity.
Limitations of Care for Very-low-birthweight Infants MANY neonatologists now adopt a dynamic approach, including full resuscitation and artificial respiration,l for even the smallest infants. Very-lowbirthweight (VLBW) babies may be ventilated either electively from birth because of size or during the acute stage of their illness before severe respiratory failure intervenes.1 VLBW strictly describes an infant of birthweight less than 1500 g, but is used here for infants who are born preterm rather than for those who are mature but extremely small for gestational age, since these two groups have different problems and
outcomes.
The active approach to the management of such infants has been adopted because many paediatricians feel that "benign neglect" may lead to severe handicap in those who survive.2 As a result of this vigorous attitude to treatment more VLBW infants receive intensive care -3 there has also been a dramatic improvement in survival. Among infants ventilated for respiratory distress syndrome, mortality declined from 79 % in 19654 to 17 % in 1983.1 One study reported 79% survival of VLBW infants5 and another documented only 25 % mortality even in those born at 28 weeks’ gestation.2 This decrease in mortality has been mirrored by an equally important reduction in 1. Greenough 2
3 4
5
A, Roberton NRC. Morbidity and survival m neonates ventilated for the respiratory distress syndrome. Br Med J 1985; 290: 597-600. Yu VYH, Loke HL, Bajuk B, Szymonowica W, Orgill AA, Astbury J. Prognosis for infants born at 23 to 28 weeks’ gestation. Br Med J 1986; 293: 1200-03. Field DJ, Milner AD, Hopkin IE, Madeley RJ Changing patterns in neonatal respiratory diseases. Pediatr Pulmonol 1987; 3: 231-35 Delivora-Papadopoulos M, Levison H, Swyer PR. Intermittent positive pressure respiration as a treatment in severe respiratory distress Arch Dis Child 1965, 40: 474-79. Yu VYH, Zhao SM, Bajuk B. Results of intensive care for 375 very low birth weight infants Aust Paediatr J 1982; 18: 188-92.
In
asked "When does appropriate care end and abuse of very small infants begin?" and made the suggestion that the goal for the 1980s should be to recognise and accept the limitations of neonatal care and to guarantee the humane approach to medicine. Some evidence suggests that, despite a vigorous approach to the management of VLBW infants, paediatricians do not prolong life unnecessarily. Support for this conjecture comes from cost-benefit analyses of neonatal care. Many of these studies have documented a difference in the "economic" cost of a non-survivor compared with that of a survivor of neonatal intensive care:"-10 in one series a survivor "cost" six times more than a non-survivor.9 This calculation suggests a difference in attitude to the duration of treatment for infants with a poor prognosis. Review of the timing of most neonatal deaths also confirms that intensive therapy is not prolonged without good reason. In two series, 66 % and 56 % of deaths, respectively, were within the first 24 hours and in a third reports 50% occurred within 48 hours. If the active
approach is to be adopted but prolonged unnecessary suffering prevented, accurate guidelines are required to indicate when continuance of intensive care is no longer appropriate. However, in studies of newborn babies reasons for discontinuing therapy have seldom been reported. Persisting severe neurological abnormality following an intraventricular haemorrhage (IVH) was the criterion used in one study,12 and another cited severe bronchopulmonary dysplasia, hydrocephalus, renal necrosis, or unresponsiveness to neonatal intensive care." Guidelines for the withdrawal of therapy could be developed from knowledge of the causes of death or severe handicap. In many series, large IVHs have been associated with a high mortality (65% -86%of neonatal deaths), and they are also an important cause 6. Rothberg AD, Maisels MJ, Bagnato S, Murphy J, Gifford K, McKinley K, Palmer EA, Bannucci RC. Outcome for survivors of mechanical ventilation weighing less than 1259 gins at birth.J Pediatr 1981, 98: 106-11 7 Schechner S For the 1980s How small is too small? Clin Perinatol 1980, 7: 135-43. 8. Sandhu B, Stevenson RC, Cooke RWI, Pharoah POD Cost of neonatal intensive care for very-low-birthweight infants. Lancet 1986; i: 600-03 9 Nerons B, Drummond MF, Durbin GM, Culley P Costs and outcomes in a regional neonatal intensive care unit Arch Dis Child 1984, 59: 1064-67 10 Pomerance JJ, Ukrainski CT, Ukra T, Henderson DH, Nash AH, Meredith JL. Cost of living for infants weighing 1000 grams or less at birth. Pediatrics 1978; 61: 908-10 11. Saigal S, Rosenbaum P, Stroskopf B, Sinclair JC. Outcome in infants 501-1000 gm birth weight delivered to residents of McMaster Health Region. J Pediatr 1984; 105: 969-76
1258
of serious morbidity.13.14 Nevertheless, such infants do not have a uniformly poor prognosis.15 Although babies with the worst disease-ie, those who require high peak inspiratory pressures and oxygen concentrationsl6 or who have severe acidosis5-are the most likely to die, some survive." Thus none of the abnormalities mentioned above is found only in infants with very little hope of intact survival. In contrast, Lantos et al have lately suggested that the need for cardiopulmonary resuscitation (CPR) among VLBW infants accurately reflects a poor chance of survival;18 none of the 38 infants who received cardiopulmonary resuscitation in the first few days of life survived. These workers propose that CPR for small infants should be considered not as routine but as an experimental therapy to be embarked upon only as part of a clinical trial after obtaining informed
establish clear criteria from which paediatricians can predict whether vigorous intensive care is likely to result in the survival of a normal infant. For now, appropriate therapy must consist of evaluation of the infant at birth by an experienced paediatrician followed by intensive monitoring and treatment until full recovery is guaranteed or the likelihood of survival approaches zero. True cardiopulmonary arrest in a VLBW infant receiving full intensive care dramatically declares a very poor outcome. In critically ill babies such sudden deterioration may be anticipated and discussion and counselling should have already taken place between the parents and medical and nursing staff. At the time of the cardiopulmonary arrest, the infant may then be allowed to die with dignity.
parental consent. If CPR is to be withheld from VLBW infants in the belief that the necessity for such measures indicates a very poor progosis, then the definition of CPR merits careful attention. Lantos et all’ collectively describe as CPR the use of adrenaline, bicarbonate, atropine, chest-wall compression, vasopressor infusions, and emergency intubation. Such therapeutic manoeuvres are also used in combination after cardiac arrest or in infants with bradycardia and apnoea. In a VLBW infant who is already receiving intensive therapy, either of these events would certainly reflect a deterioration in an already critically ill baby which, if not fatal, would probably lead to serious neurodevelopmental damage as a result of haemorrhage or hypoxia. However, these six therapeutic interventions, if used separately, are not necessarily reserved for infants in extremis. Bicarbonate is used for the correction of acidosis; in one series, 86% of VLBW infants who had received sodium bicarbonate survived.5 Intubation is frequently carried out for 1,5 apnoea and survivors in such series are reported. Vasopressor infusions are now used more routinely by paediatricians as part of a more intensive approach to blood pressure support, in an attempt to limit
hypotensive episodes. VLBW infants will survive, and survive neurologically intact, if offered appropriate therapy. The objective for the 1990s must be to In
12. 13.
14.
15.
16. 17. 18
1988,
most
Yu VYH, Hollingsworth E. Improving prognosis for infants weighing 1000 g or less at birth. Arch Dis Child 1979; 55: 422-26. Bozynski MEA, Nelson MN, Matalon TAS, et al. Prolonged mechanical ventilation and intracranial hemorrhage: impact on developmental progress through 18 months in infants weighing 1200 gms or less at birth. Pediatrics 1987; 79: 670-76. Guzzetta F, Shackelford GD, Volpe S, Perlman JM, Volpe JJ Periventricular intraparenchymal echodensites in the premature newborn, critical determinant of neurologic outcome. Pediatrics 1986, 78: 95-1006 Stewart AL, Thorburn RJ, Hope PL, Goldsmith M, Lipscomb AP, Reynolds EOR. Ultrasound appearance of the brain in very preterm infants and neurodevelopmental outcome at 18 months of age Arch Dis Child 1983; 58: 598-604. Bhat R, Zikos-Labropoulou E. Resuscitation and respiratory management of infants weighing less than 1000 gms. Clin Perinatol 1986; 13: 285-97 Booth P, Nicolaides KH, Greenough A, Gamsu HR. Pleuroamniotic shunting for fetal chylothorax. Early Hum Dev 1987; 15: 365-67. Lantos JD, Miles SH, Silverstein MD, Stocking CB. Survival after cardiopulmonary resuscitation in babies of very low birth weight. is CPR futile therapy? N Engl J Med 1988; 318: 91-95
Direction of Postgraduate Medical Education in the UK THE system of postgraduate medical education in the UK could hardly be more fragmented. Universities, Royal Colleges, the General Medical Council (GMC), postgraduate deans, clinical tutors-where do they all fit into the scheme? The Medical Act 1978 provided for the establishment of the Education Committee of the GMC to promote high standards and coordinate all stages of medical education. The efforts of the committee, headed by Prof Arthur Crisp, who has just completed a five-year term of office, culminated in the issue of two booklets on general clinical training1 (the pre-registration year) and on the training of specialists.2 Last week the GMC convened a conference in London to discuss the principles of postgraduate medical education and the roles of the numerous bodies who contribute to it. As the GMC sees it, Professor Crisp explained, the lynchpin of the system is the educational supervisor-the person responsible for seeing that the trainee’s educational needs are met. In general practice this system is already well established: the trainer, a practice principal, supervises the work of his trainee. Many participants returned to the GP model-general practice had "got its act together" with the assessment of both trainees and trainers (and the mechanism of removing the training status of trainers who do not make the grade). In other specialties the educational supervisor is the consultant with whom the trainee works (or if several consultants, one could be assigned this task); the committee’s recommendations do not envisage another tier in the medical staffing system. 1. General Medical Council Recommendations
on
general clinical training London
GMC, 1987. 2. General Medical Council Education Committee. Recommendations on the training of specialists. London: GMC, 1987
1981, 54 % of infants of birth weight less than 1250 g in one series had poor neurodevelopmental status at follow-up,6 whereas a more recent report claimed an incidence of severe handicap of only 12 % in infants of 23-28 weeks’ gestation.2 Schechner was not alone in wondering whether this approach to perinatal care, particularly in very preterm babies, might mean that some infants undergo prolonged treatment only to die eventually, with concomitant heavy financial and emotional burdens for the family and neonatal staff.7 She also
morbidity.
Limitations of Care for Very-low-birthweight Infants MANY neonatologists now adopt a dynamic approach, including full resuscitation and artificial respiration,l for even the smallest infants. Very-lowbirthweight (VLBW) babies may be ventilated either electively from birth because of size or during the acute stage of their illness before severe respiratory failure intervenes.1 VLBW strictly describes an infant of birthweight less than 1500 g, but is used here for infants who are born preterm rather than for those who are mature but extremely small for gestational age, since these two groups have different problems and
outcomes.
The active approach to the management of such infants has been adopted because many paediatricians feel that "benign neglect" may lead to severe handicap in those who survive.2 As a result of this vigorous attitude to treatment more VLBW infants receive intensive care -3 there has also been a dramatic improvement in survival. Among infants ventilated for respiratory distress syndrome, mortality declined from 79 % in 19654 to 17 % in 1983.1 One study reported 79% survival of VLBW infants5 and another documented only 25 % mortality even in those born at 28 weeks’ gestation.2 This decrease in mortality has been mirrored by an equally important reduction in 1. Greenough 2
3 4
5
A, Roberton NRC. Morbidity and survival m neonates ventilated for the respiratory distress syndrome. Br Med J 1985; 290: 597-600. Yu VYH, Loke HL, Bajuk B, Szymonowica W, Orgill AA, Astbury J. Prognosis for infants born at 23 to 28 weeks’ gestation. Br Med J 1986; 293: 1200-03. Field DJ, Milner AD, Hopkin IE, Madeley RJ Changing patterns in neonatal respiratory diseases. Pediatr Pulmonol 1987; 3: 231-35 Delivora-Papadopoulos M, Levison H, Swyer PR. Intermittent positive pressure respiration as a treatment in severe respiratory distress Arch Dis Child 1965, 40: 474-79. Yu VYH, Zhao SM, Bajuk B. Results of intensive care for 375 very low birth weight infants Aust Paediatr J 1982; 18: 188-92.
In
asked "When does appropriate care end and abuse of very small infants begin?" and made the suggestion that the goal for the 1980s should be to recognise and accept the limitations of neonatal care and to guarantee the humane approach to medicine. Some evidence suggests that, despite a vigorous approach to the management of VLBW infants, paediatricians do not prolong life unnecessarily. Support for this conjecture comes from cost-benefit analyses of neonatal care. Many of these studies have documented a difference in the "economic" cost of a non-survivor compared with that of a survivor of neonatal intensive care:"-10 in one series a survivor "cost" six times more than a non-survivor.9 This calculation suggests a difference in attitude to the duration of treatment for infants with a poor prognosis. Review of the timing of most neonatal deaths also confirms that intensive therapy is not prolonged without good reason. In two series, 66 % and 56 % of deaths, respectively, were within the first 24 hours and in a third reports 50% occurred within 48 hours. If the active
approach is to be adopted but prolonged unnecessary suffering prevented, accurate guidelines are required to indicate when continuance of intensive care is no longer appropriate. However, in studies of newborn babies reasons for discontinuing therapy have seldom been reported. Persisting severe neurological abnormality following an intraventricular haemorrhage (IVH) was the criterion used in one study,12 and another cited severe bronchopulmonary dysplasia, hydrocephalus, renal necrosis, or unresponsiveness to neonatal intensive care." Guidelines for the withdrawal of therapy could be developed from knowledge of the causes of death or severe handicap. In many series, large IVHs have been associated with a high mortality (65% -86%of neonatal deaths), and they are also an important cause 6. Rothberg AD, Maisels MJ, Bagnato S, Murphy J, Gifford K, McKinley K, Palmer EA, Bannucci RC. Outcome for survivors of mechanical ventilation weighing less than 1259 gins at birth.J Pediatr 1981, 98: 106-11 7 Schechner S For the 1980s How small is too small? Clin Perinatol 1980, 7: 135-43. 8. Sandhu B, Stevenson RC, Cooke RWI, Pharoah POD Cost of neonatal intensive care for very-low-birthweight infants. Lancet 1986; i: 600-03 9 Nerons B, Drummond MF, Durbin GM, Culley P Costs and outcomes in a regional neonatal intensive care unit Arch Dis Child 1984, 59: 1064-67 10 Pomerance JJ, Ukrainski CT, Ukra T, Henderson DH, Nash AH, Meredith JL. Cost of living for infants weighing 1000 grams or less at birth. Pediatrics 1978; 61: 908-10 11. Saigal S, Rosenbaum P, Stroskopf B, Sinclair JC. Outcome in infants 501-1000 gm birth weight delivered to residents of McMaster Health Region. J Pediatr 1984; 105: 969-76
1258
of serious morbidity.13.14 Nevertheless, such infants do not have a uniformly poor prognosis.15 Although babies with the worst disease-ie, those who require high peak inspiratory pressures and oxygen concentrationsl6 or who have severe acidosis5-are the most likely to die, some survive." Thus none of the abnormalities mentioned above is found only in infants with very little hope of intact survival. In contrast, Lantos et al have lately suggested that the need for cardiopulmonary resuscitation (CPR) among VLBW infants accurately reflects a poor chance of survival;18 none of the 38 infants who received cardiopulmonary resuscitation in the first few days of life survived. These workers propose that CPR for small infants should be considered not as routine but as an experimental therapy to be embarked upon only as part of a clinical trial after obtaining informed
establish clear criteria from which paediatricians can predict whether vigorous intensive care is likely to result in the survival of a normal infant. For now, appropriate therapy must consist of evaluation of the infant at birth by an experienced paediatrician followed by intensive monitoring and treatment until full recovery is guaranteed or the likelihood of survival approaches zero. True cardiopulmonary arrest in a VLBW infant receiving full intensive care dramatically declares a very poor outcome. In critically ill babies such sudden deterioration may be anticipated and discussion and counselling should have already taken place between the parents and medical and nursing staff. At the time of the cardiopulmonary arrest, the infant may then be allowed to die with dignity.
parental consent. If CPR is to be withheld from VLBW infants in the belief that the necessity for such measures indicates a very poor progosis, then the definition of CPR merits careful attention. Lantos et all’ collectively describe as CPR the use of adrenaline, bicarbonate, atropine, chest-wall compression, vasopressor infusions, and emergency intubation. Such therapeutic manoeuvres are also used in combination after cardiac arrest or in infants with bradycardia and apnoea. In a VLBW infant who is already receiving intensive therapy, either of these events would certainly reflect a deterioration in an already critically ill baby which, if not fatal, would probably lead to serious neurodevelopmental damage as a result of haemorrhage or hypoxia. However, these six therapeutic interventions, if used separately, are not necessarily reserved for infants in extremis. Bicarbonate is used for the correction of acidosis; in one series, 86% of VLBW infants who had received sodium bicarbonate survived.5 Intubation is frequently carried out for 1,5 apnoea and survivors in such series are reported. Vasopressor infusions are now used more routinely by paediatricians as part of a more intensive approach to blood pressure support, in an attempt to limit
hypotensive episodes. VLBW infants will survive, and survive neurologically intact, if offered appropriate therapy. The objective for the 1990s must be to In
12. 13.
14.
15.
16. 17. 18
1988,
most
Yu VYH, Hollingsworth E. Improving prognosis for infants weighing 1000 g or less at birth. Arch Dis Child 1979; 55: 422-26. Bozynski MEA, Nelson MN, Matalon TAS, et al. Prolonged mechanical ventilation and intracranial hemorrhage: impact on developmental progress through 18 months in infants weighing 1200 gms or less at birth. Pediatrics 1987; 79: 670-76. Guzzetta F, Shackelford GD, Volpe S, Perlman JM, Volpe JJ Periventricular intraparenchymal echodensites in the premature newborn, critical determinant of neurologic outcome. Pediatrics 1986, 78: 95-1006 Stewart AL, Thorburn RJ, Hope PL, Goldsmith M, Lipscomb AP, Reynolds EOR. Ultrasound appearance of the brain in very preterm infants and neurodevelopmental outcome at 18 months of age Arch Dis Child 1983; 58: 598-604. Bhat R, Zikos-Labropoulou E. Resuscitation and respiratory management of infants weighing less than 1000 gms. Clin Perinatol 1986; 13: 285-97 Booth P, Nicolaides KH, Greenough A, Gamsu HR. Pleuroamniotic shunting for fetal chylothorax. Early Hum Dev 1987; 15: 365-67. Lantos JD, Miles SH, Silverstein MD, Stocking CB. Survival after cardiopulmonary resuscitation in babies of very low birth weight. is CPR futile therapy? N Engl J Med 1988; 318: 91-95
Direction of Postgraduate Medical Education in the UK THE system of postgraduate medical education in the UK could hardly be more fragmented. Universities, Royal Colleges, the General Medical Council (GMC), postgraduate deans, clinical tutors-where do they all fit into the scheme? The Medical Act 1978 provided for the establishment of the Education Committee of the GMC to promote high standards and coordinate all stages of medical education. The efforts of the committee, headed by Prof Arthur Crisp, who has just completed a five-year term of office, culminated in the issue of two booklets on general clinical training1 (the pre-registration year) and on the training of specialists.2 Last week the GMC convened a conference in London to discuss the principles of postgraduate medical education and the roles of the numerous bodies who contribute to it. As the GMC sees it, Professor Crisp explained, the lynchpin of the system is the educational supervisor-the person responsible for seeing that the trainee’s educational needs are met. In general practice this system is already well established: the trainer, a practice principal, supervises the work of his trainee. Many participants returned to the GP model-general practice had "got its act together" with the assessment of both trainees and trainers (and the mechanism of removing the training status of trainers who do not make the grade). In other specialties the educational supervisor is the consultant with whom the trainee works (or if several consultants, one could be assigned this task); the committee’s recommendations do not envisage another tier in the medical staffing system. 1. General Medical Council Recommendations
on
general clinical training London
GMC, 1987. 2. General Medical Council Education Committee. Recommendations on the training of specialists. London: GMC, 1987