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Death in the neonatal intensive care unit
The death of a baby still occurs many times a year in most neonatal units, often as a result of the withdrawal of intensive care. Although much has been written on this topic this month's contributions bring a wealth of common sense and experience to bear. Malcolm Chiswick has pointed out before that there are dangers in making assumptions about a baby's chances of survival from its appearance after weeks of intensive care.1 In this issue, Professor Chiswick thoughtfully discusses the articles on lingering death and consent for autopsy from McHaffie and her colleagues (pages 4and 8), adding much new material of his own (page 1). There can be few neonatologists who do not recognise at least one of his “unspoken signals” of staff distress, and most of us could probably add more. His honest approach to the need for analgesia and support during the dying process is helpful and refreshing. Withdrawal of intensive care based on a value judgement about a baby's future quality of life remains one of the most difficult and sensitive areas in neonatal medicine. Hazel McHaffie has already written on the enormous variation in practice between individual units, and individual doctors.2 Her new contributions address the reasons behind parents agreeing (or not) to a necropsy being carried out on their dead baby, and lingering death. Because the survey was done before the publicity surrounding the Bristol and Liverpool cases these data are uniquely valuable. Once again, huge interpersonal differences were apparent with a difference of 60% in the necropsy rate between two neonatologists working in the same unit. Clearly a target would be completely inappropriate in this area, but we can all learn from the comments and experiences of parents. Protracted death was more common (22%) than might have been predicted after withdrawal of intensive care, and it was not surprising that parents found it difficult to bear the process of death when it took many hours. McHaffie did not interview any parents whose baby survived after intensive care was withdrawn, but this certainly happens and it would be interesting to know how different units cope with this experience.
Risk factors for intraventricular haemorrhage in preterm babies
Just when you thought that there was no more to be said on the topic of intraventricular haemorrhage (IVH), because it was vanishing anyway, workers from Israel report a reduction in the risk of IVH in babies whose mothers were given ritodrine tocolysis (page 13). Magnesium sulphate and indomethacin did not exert any protective effect. All the old favourite risk factors are still there too; no antenatal steroids, RDS, PDA, low five minute Apgar score, pneumothorax and low gestational age.
Clotbusting in babies
Indwelling intravascular lines carry with them a risk of vascular occlusion due to thrombus formation, and babies are not exempt from this complication. Fortunately the need to dissolve a clot in a baby is quite rare, but the advice contained in the article by Hartmann and his colleagues will be invaluable should the event arise (page 18). Complete clot dissolution was achieved with tissue plasminogen activator (t-PA) in a dose of 0.7 mg/kg as a bolus, followed by 0.2 mg/kg/hour for a maximum of 5 days. These authors recommend choosing t-PA first, with heparin prophylaxis as an adjunct to treatment and continuing as long as intravascular lines were required. Elsewhere in this month's issue Ferrari et al, writing from Modena, also report success with t-PA at a dose of 0.4 mg/kg followed by 0.1 mg/kg/hour for only three hours (page66). More work is required to establish the most appropriate dose and duration of treatment for this promising, albeit expensive, agent.
Neurodevelopmental outcome of babies born at 32–35 weeks' gestation
So much of our time and energy is focused on the extremely preterm baby that we sometimes forget to consider the outcome for the relatively trouble free, more mature group. Information about their long term prospects is lacking, as is information about term babies who are ill enough to require intensive care. Huddy and her colleagues in Oxford confirm our worst fears, reporting that up to a third of a cohort of 176 babies born at 32–35 weeks' gestation in 1990 had school problems (page 23). Although there were a number of non-responders to the questionnaire survey, these results are sufficiently concerning to require urgent confirmation elsewhere.
Ketamine as an analgesic for newborns
The search for a suitable pain relieving agent continues, and Saarenmaa et al report that ketamine in a dose of 2 mg/kg provided effective short term pain relief for procedures without side effects (page 53). Ketamine has waxed and waned in popularity in my experience, and of course no one can ask babies about their experiences with this agent.
Elsewhere in ADC
In the June issue of ADC, McEwan et alcared for three infants with bacterial sepsis and very high ammonia levels who died. The babies did not have inborn errors of metabolism, but they did have infection with urea-splitting organisms. The authors hypothesise that the increased protein load resulting from these infections were responsible for the excessive ammonia levels seen, and this information may be of value to those who see similar cases in future (Arch Dis Child2001;84:512–13).
In the main journal this month is an editorial containing the welcome news that ADC will be made freely available, full text via the Web, to those countries defined as poor under the human development index of the World Bank and the United Nations. Special software will enable those logging on from these countries to be identified and allowed free access. Hopefully this new facility will encourage contributions to the journal and the rapid response facility from all countries of the world.
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