Alma M Martinez

Pain During Mogen or PlastiBell Circumcision

Routine neonatal circumcision can be a painful procedure. Although analgesia for circumcision has been studied extensively, there are few studies comparing which surgical technique may be associated with the least pain and discomfort when carried out by pediatric trainees.OBJECTIVE: We studied two commonly used techniques for circumcision to determine which was associated with less pain and discomfort.STUDY DESIGN: In a randomized, prospective, but not blinded study, newborns were circumcised either by Mogen clamp or by PlastiBell. All received dorsal nerve blocks with lidocaine. Fifty-nine well, term, newborn infants at San Francisco General Hospital were studied from 1997 to 1998. Circumcisions were carried out mostly by interns and residents in family practice and pediatrics. Pain was assessed by measuring duration of the procedure and by a simple behavioral score done sequentially.RESULTS: Dorsal nerve blocks were judged to be fully effective in over 70% of cases. Neither Mogen nor PlastiBell was associated with greater pain per 3-minute time period, but the PlastiBell technique on average took nearly twice as long as the Mogen procedure (20 vs 12 minutes). We judged that 60% of the infants had pain or discomfort associated with the procedure that was excessive. Residents and interns universally preferred the Mogen technique over the PlastiBell because of the formers simplicity.CONCLUSION: During the procedure, Mogen circumcision is associated with less pain and discomfort, takes less time, and is preferred by trainees when compared with the PlastiBell.

Antenatal counselling, resuscitation practices and attitudes among Australian neonatologists towards life support in extreme prematurity

Summary: A questionnaire survey of Australian neonatologists was conducted to ascertain their antenatal counselling and resuscitation practices, and attitudes towards life support in the extremely preterm infant. This study showed that in antenatal parental counselling, whether a paediatrician was given the opportunity to participate depends on the gestation at the time of the threatened preterm delivery. The counselling employed almost invariably covered mortality and morbidity. The obstetricians opinion was considered to be of utmost importance. Both financial and moral obligations were found to be of little importance in counselling and resuscitation. Only one‐third of institutions had guidelines for limiting resuscitation. The onus remained on the neonatologists concerning which infant to resuscitate, and the level of the resuscitation to be conducted.

Hyperphagia in neonates withdrawing from methadone

AIMS To examine whether hyperphagia is a clinically significant problem in infants born to women receiving methadone maintenance. METHODS The volume of feeds, changes in infant body weight, as well as occurrence of adverse clinical effects in infants withdrawing from methadone were studied during the first month of life. A retrospective chart review was conducted for all infants at San Francisco General between 1992 and 1995, born to women receiving methadone maintenance during their pregnancy. Forty four infants were identified and the data obtained from hospital medical records. The daily oral intake of these infants was recorded during the first month of life. The incidence of hyperphagia (oral intake > 190 cc/kg/day) was measured. Associations between infant oral intake and maternal methadone dose were studied using correlation analysis as well as Anova for repeated measures. Adverse clinical symptoms were also recorded. A subset of premature infants was studied separately. RESULTS The incidence of hyperphagia was 26% by day 8 and 56% by day 16 of life in the infants. Hyperphagia was not associated with maternal methadone dose or with infant withdrawal scores. Infants who were hyperphagic lost significantly more weight during the first week of life than those who were not. Despite significantly greater intake, the hyperphagic infants did not gain weight more rapidly during the first month of life compared with those infants with lower oral intake. Infants who were hyperphagic (maximum intake of 290 cc/kg/day) did not experience increased vomiting, aspiration, diarrhoea, or abdominal distention. CONCLUSIONS Hyperphagia is commonly found in infants withdrawing from methadone and can be persistent in a significant number. Hyperphagia was not associated with either increased neonatal weight gain or with adverse gastrointestinal consequences. Hyperphagia may occur in infants withdrawing from methadone who have high metabolic demands due to clinical signs not controlled by opiate treatment.

Variation in mortality and intraventricular haemorrhage in occupants of Pacific Rim nurseries

Objective:  A network of neonatal intensive care units in Pacific Rim countries was formed to compare infant risk factors, clinical practices, and outcomes for very low birthweight infants.

OBSTETRIC MANAGEMENT OF ELBW INFANTS: PERCEPTIONS OF INFANT VIABILITY AND PARENTAL COUNSELING PRACTICE. |[bull]| 162

Obstetricians (OBs) frequently counsel parents antenatally regarding pregnancy outcomes. We surveyed their perceptions of the limits of viability for ELBW infants and their current clinical and counseling practices. We obtained 163 responses from 411 practicing OBs in California. Most respondents were Caucasian (63%), male (58%), in private practice (55%) at a Level III hospital (66%). Their mean age was 45 ± 1 yrs (SEM), with a mean of 13± 1 yrs of practice. Resuscitation is discussed antenatally with parents by 48% of OBs at 22 wks, and by 82% at 26 wks. Almost 40% of OBs do not discuss resuscitation at 22 wks; this decreases to 5% by 25 wks. At 22 wks, OBs are evenly divided (40 vs 41%) whether they consult with pediatrics when counseling parents. By 25 wks, 80% of OBs consult with pediatrics. In counseling parents of 90%. In considering whether to resuscitate infants between 23-26 wks, OBs feel future quality of life (44%) and severe congenital anomalies (80%) are important. Factors less frequently used in decision-making are: perceived health resource allocations and costs(27%), family resources (26%), parental ethnicity (16%), and insurance status(18%). There are important variations in family counseling practices and in the role physicians allow parents in decision-making regarding ELBW resuscitation.

Opinions of paediatricians who teach neonatal resuscitation about resuscitation practices on extremely preterm infants in the delivery room

Objective To describe the opinions of paediatricians who teach resuscitation in Brazil regarding resuscitation practices in the delivery room (DR) of preterm infants with gestational ages of 23–26 weeks. Methods Cross-sectional study with an internationally validated electronic questionnaire (December 2011–September 2013) sent to the instructors of the Neonatal Resuscitation Program of the Brazilian Society of Paediatrics on parental counselling practices, medical limits for resuscitation of extremely preterm infants and medical considerations for decision-making in this group of infants. The analysis was descriptive. Results Among 685 instructors, 560 (82%) agreed to participate. Only 5%–13% reported having opportunity for antenatal counselling parents: if called, 22% reported discussing with the family about the possibility not to resuscitate in the DR; 63% about the possibility of death in the DR and 89% about the possibility of death in the neonatal unit. If the parents did not agree with the advice of the paediatrician, 30%–50% of the respondents would follow the procedures they advised regardless of the opinion of the parents. The higher the gestational age, the lower is the percentage of paediatricians who believed that parents should participate in decision-making. Only 9% participants reported the existence of written guidelines at their hospital on initiation of resuscitation in the DR at limits of viability, but 80% paediatricians reported using some criteria for limiting resuscitation in the DR. Conclusion The picture obtained in this study of Brazilian paediatricians indicates that resuscitation of extremely preterm infants is permeated by ambivalence and contradictions.

Obstetricians' attitudes and practices of life support for extremely premature low birth weight infants in El Salvador

Background: The increasing availability of costly life-support technologies in developing countries raises questions about the utility of resuscitation and intensive care for extremely premature infants. Objective: To characterize obstetricians’ attitudes and resuscitation practices for preterm infants in El Salvador. Design/Methods: Surveys (n = 214) were mailed to Salvadoran perinatal providers in 2000, and 100 more were distributed at a Latin American obstetrics and gynecology conference in December 2000. Survey questions covered counseling practices, resuscitation thresholds for prematurity, attitudes on life support, and demographics. Results: Of 111 Salvadoran respondents, more providers counsel parents antenatally (41% at 25 wks to 58% at 29 wks) as gestational age increased. Median thresholds for resuscitation were 26 weeks for intubation and ventilation and 27 weeks for cardiac massage or pharmacologic resuscitation, and 1000 grams for each of these interventions. Seventy-two percent of respondents would use all interventions to save life regardless of anticipated outcome, a stance correlated with religious activity (p = 0.03). Decisions to limit resuscitation were influenced by congenital anomalies (62%) more than parental wishes (28%), infant pain (21%) and moral or religious considerations (27%). Older obstetricians were more likely to withdraw support from an extremely premature infant with perinatal HIV exposure (p = 0.006), but not with severe intraventricular hemorrhage or a major congenital anomaly. Fifty-five percent felt their institution was “not aggressive enough” in caring for infants < 26 wks gestation. Less religious obstetricians were more likely to perceive their unit as “too aggressive.” Over 80% believed that physicians (44%), rather than parents (15%), should make final resuscitation decisions when consensus cannot be reached. Conclusions: In El Salvador, the obstetric management of extreme prematurity is influenced by providers’ level of religious activity. The majority of obstetricians regard care in their unit as not aggressive enough, despite using higher resuscitation thresholds than in other developing countries. Local economic constraints influence resuscitation options available to obstetricians and parents of extremely premature infants.

Elevated plasma Met-enkephalin levels in the human newborn are a poor indicator of perinatal stress

OBJECTIVE This study was designed to investigate whether plasma Met-enkephalin peptides could serve as markers of physiologic stress in the neonate. STUDY DESIGN Infants (n = 115) between 1.2 and 4.7 kg and 28 and 42 weeks of gestation were studied at birth. Seventy-four infants were delivered by the vaginal route, 31 by cesarean section after labor, and 10 by cesarean section before labor. Correlations were sought between plasma enkephalin peptides and epinephrine, norepinephrine, and arterial blood gases with linear regression analysis. Various clinical data were also analyzed. RESULTS Plasma Met-enkephalin levels were significantly greater in infants exposed to labor (440 +/- 36 vs 260 +/- 30 pg/ml, p less than 0.05). The large-molecular-weight forms of enkephalin peptides were also greater in these infants (approximately 50 +/- 4 vs 23 +/- 2 ng/ml). There was no correlation between plasma enkephalin peptides and catecholamines, arterial pH, or Apgar scores. There was a significant but weak correlation between plasma Met-enkephalin levels and birth weight (r = 0.34, p = 0.03) and PaO2 (r = -0.28, p less than 0.05). CONCLUSION The lack of correlation between Met-enkephalin plasma levels and umbilical plasma catecholamine concentrations, acid-base status, or Apgar scores suggests that circulating Met-enkephalin is a poor indicator of stress in the newborn.

132 RESUSCITATION OF NONVIABLE INFANTS: WILL NEONATOLOGISTS' PRACTICE CHANGE AFTER THE BORN-ALIVE INFANT PROTECTION ACT?

Background The Born-Alive Infant Protection Act of 2002 (BAIPA) defined the legal status of infants showing any sign of life; it did not mandate resuscitation. In April 2005, the federal government issued guidelines on enforcement of BAIPA, obligating treatment of all live-born infants without regard to gestational age (GA) or birth weight (BW). Methods We surveyed all neonatologists in California (n = 360). The mailed questionnaire asked physicians how their current resuscitation and neonatal intensive care practices for likely nonviable infants (20-24 wks GA) would change in response to enforcement of BAIPA. Results We received 87 completed questionnaires (response rate = 20%, to date); 8 physicians refused participation. Most respondents had not heard of BAIPA (64%) or enforcement guidelines (81%). Only 7% believed these guidelines should be enforced. Most respondents agreed that BAIPA clarified the definition of born-alive infants (68%) but criticized the guidelines as inappropriate governmental regulation of medical care (93%), not standard of care (93%), and not evidence based (95%). Respondents felt that enforcement of BAIPA would increase number of 20 to 23 6/7wk GA infants being resuscitated (89%), prompt overly aggressive treatment of nonsurvivors (89%), and restrict options to withhold or withdraw life support (79%). Regarding personal practices, respondents would not lower their current minimum GA or BW thresholds for routine resuscitation if BAIPA were enforced, but they would lower the maximum GA and BW at which they would allow only palliative care (Table). Conclusions Although most California neonatologists regard BAIPA as inappropriate governmental intervention in perinatal care, their practices may change if this legislation is enforced. Since most 20-24 wk GA infants do not survive, government enforcement of BAIPA may motivate physicians to resuscitate nonviable infants. Government intervention in resuscitation decisions for likely nonviable extremely premature infants could increase health care costs, prolong suffering in children who die, or augment survival of children with major disabilities.

Maternal and Infant Risk Factors for Neonatal Sepsis: A Comparison between an Inner-City County Hospital and a Health Maintenance Organization

Maternal and Infant Risk Factors for Neonatal Sepsis: A Comparison between an Inner-City County Hospital and a Health Maintenance Organization