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Rationing in child health services
  1. Department of Paediatrics
  2. Southern General Hospital
  3. 1345 Govan Road
  4. Glasgow GSI 4TF, UK

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Editor—Aidan MacFarlane argues that further funding for neonatal and paediatric intensive care should not be provided unless funding for the long term needs of severely handicapped children is guaranteed.1 His comments imply that neonatal intensive care produces more neurologically impaired survivors, which in turn leads to greater cost in the long term.

In fact, improved survival in very low birthweight (VLBW) infants has been accompanied by a fall in intracranial haemorrhage and cerebral palsy, probably owing to a combination of antenatal steroids and postnatal surfactant replacement treatment. Cooke studied 1722 VLBW infants born between 1982 and 1993 and showed an increase in survival rates (from 69.2% to 79.7%) with a decrease in intracranial haemorrhage (from 14.9% to 10.5%) and cerebral palsy (from 10.9% to 7.3%).2

Although some technological advances, such as surfactant, high frequency oscillation ventilation, and extracorporeal membrane oxygenation are expensive, their impact on mortality has been shown in well conducted randomised controlled trials with either a decrease or no increase in neurological morbidity.3-5

Dr MacFarlane's view is an oversimplified one. A baby born at 28 weeks' gestation who is denied intensive care may well still survive but is then more likely to be neurologically damaged. Survival rates may be lower and disability rates higher with diminishing maturity, but a considerable number of infants born at 24 weeks' gestation survive neurologically intact. We note that Dr MacFarlane avoids specifying a gestational age below which resuscitation should not be offered.


Dr MacFarlane responds: Louise Grant and Peter MacDonald quite rightly point out the improvements that can be obtained in neurological outcomes by intensive care and I would not have expected them to do less. Yes, I over simplified to make my point, but most severely handicapped children do not survive as a result of neonatal intensive care but rather from other causes. However, these children (as well as those who do survive as a result of neonatal intensive care) and their families desperately need full support over a lifetime (and I doubt whether Louise Grant or Peter MacDonald would disagree). Given that there is and always will be limited funding for health services as a whole, my argument is that it is time to readdress the balance as to what is provided for severely handicapped children and their families and what is provided for highly technological and expensive medical innovations. This is the reality and needs to be debated publicly (as the subject is far too important to leave to doctors) as well as the gestational age below which resuscitation should not be offered.