Bonnie H. Arzuaga

National variability in neonatal resuscitation practices at the limit of viability.

OBJECTIVEnDelivery room management of extremely premature infants is not subjected to professional regulations. In the United States, legal definitions of human viability and statutes regulating elective abortions vary by state, placing providers in an often difficult position regarding whether to attempt resuscitation when faced with the delivery of an infant of 22 to 25 weeks gestation. The objective of this study was to delineate variations in delivery room resuscitation practices of periviable infants in the United States in 2012.nnnSTUDY DESIGNnElectronic survey was sent to the members of American Academy of Pediatrics Section of Perinatal Medicine. Chi-square, Fisher exact test, and multivariate logistic regression were performed.nnnRESULTSnA total of 758 surveys returned out of which 637 were complete. Overall 68% of providers consider 23-week gestation to be the youngest age that should be resuscitated at parental request, while 25-week gestation is considered by 51% to be the youngest age of obligatory resuscitation even with parental refusal. Responses varied when providers were separated into geographical regions based on the U.S. Census Bureau (pu2009<u20090.05). When provided with delivery room scenarios, parental preference significantly affected resuscitation attempts of 22 to 25 weeks, but not 26-week infants. In scenarios of periviable elective terminations, providers personal belief systems influenced management of aborted fetuses.nnnCONCLUSIONSnRegional practice variation exists independent of specific state laws. Parental request is the most important factor to providers resuscitating 22 to 25-week infants. Providers personal belief systems influence infant management infrequently.

Limits of Human Viability in the United States: A Medicolegal Review

Throughout American history, medical and legal definitions of human viability have evolved on interrelated but slightly different trajectories. In the early 19th century, although common law did not consider abortion to be a criminal offense, it was discouraged after the onset of quickening, which connected the initial delineation of viability to the sensation of fetal movement within the womb. When post–Civil War physicians campaigned to outlaw abortion, it was transformed into a criminal act, because societal attitudes had redefined human life as beginning at conception.1nnIn 1935, the American Academy of Pediatrics defined a premature infant as one who weighed <2500 g at birth regardless of gestational age,2 a standard first adopted in Europe in 1919.3 Although no minimum weight for viability was established, 1250 g was frequently used and corresponded to an estimated gestational age (EGA) of 28 weeks.2,4 In the mid-20th century, the addition of gestational age and crown-to-heel length to assist with the definition of viability was advocated.5,6nnIn the 1950s, infantile respiratory distress syndrome was described to the Royal College of Obstetricians and Gynaecologists of the United Kingdom7 and identified as a principal cause of death in infants younger than 37 weeks EGA. This led to a landmark distinction between “premature” and “growth-restricted” infants who weighed <2500 g at birth.8 In the ensuing decades, neonatal mechanical ventilation and parenteral nutrition became established as contemporary cornerstones of neonatal medicine. Although the mortality rate of infants born at <1800 g was not significantly altered by initial intermittent positive-pressure ventilator strategies,9 the … nnAddress correspondence to Bonnie Hope Arzuaga, MD, Comer Childrens Hospital at University of Chicago, 5721 S Maryland Ave, Chicago, IL 60637. E-mail: bonniehope{at}gmail.com

Attitudes towards the resuscitation of periviable infants: a national survey of American Muslim physicians

To examine the associations between American Muslim physicians characteristics and intended behaviours towards resuscitation of 22‐ and 23‐week gestation infants.

Utilization of extracorporeal membrane oxygenation in congenital hypertrophic cardiomyopathy caused by maternal diabetes

Extracorporeal membrane oxygenation (ECMO) is an advanced strategy utilized in many neonatal intensive care units for a specific list of indications. This case illustrates a rare but effective use of this therapy for a newborn infant with severe hypertrophic cardiomyopathy induced by maternal diabetes. Such infants who are unresponsive to conventional therapies may benefit from ECMO support, if it is used in conjunction with management strategies that optimize cardiac output.

Practices and education surrounding anticipated periviable deliveries among neonatal-perinatal medicine and maternal-fetal medicine fellowship programs

Objectives:To explore national practices of periviable decision-making and care, and to determine and compare trainee education in this domain, within neonatal-perinatal medicine (NPP) and maternal-fetal medicine (MFMP) fellowship programs.Study Design:A 75-item survey was sent to NPP and MFMP program directors in the United States.Results:In all, 79 of 168 surveys were completed (47%). MFMPs reported offering active interventions for bigger or more mature fetuses (versus NPPs). Variability exists in estimated frequency of simultaneous antenatal counseling by both specialties (range 0 to 90%) and of inter-specialty communication before consultation (range 5 to 100%). One-quarter of MFMPs reported no fellow education regarding periviable deliveries, versus 2% of NPPs (P=0.002); 40% of MFMPs teach fellows about periviable ethics, versus 63% of NPPs (P=0.05). NPPs more frequently utilize role modeling (P=0.01) and simulation (P=0.01) as learning methods.Conclusion:NPPs and MFMPs report different, often asynchronous, practices and fellow education regarding antenatal counseling and resuscitation at periviability.

Clinical Challenges in Parental Expression of Hope and Miracles

The concepts of hope and the medical miracle are ubiquitous in modern medical practice and can often become central aspects of a critically ill patient’s or his family’s hospital experience.1–3 Cases where these beliefs are especially strong even make their way into mainstream media, as in the 2013 case of the California teen who became brain dead after a complication from a tonsillectomy. In this case, her family fought a widely publicized court battle to be able to keep her on mechanical support and move her out of state to another facility. They believed that, despite what was explained to them regarding the diagnosis of brain death, their daughter would one day recover.4 A high prevalence of spirituality within the American population serves as a foundation for expectations in miracles5 and pediatricians may frequently encounter similar ideas in conversations with families.nnDespite all of the limitations in contemporary practice, physicians are acutely aware of the popular confidence in medical technology and the tendency for families to hope for outcomes that are medically unattainable. The unprecedented explosion of rapid medical advancement through the 20th century has helped to perpetuate the belief that technology has the ability to repair any affliction. With the advent of the mechanical ventilator and proliferation in its use from the 1960s to 1970s, it was suddenly possible to even prevent death. The new technology mandated the medical community to outline technical definitions of cardiac death and brain death, which is a debate that continues … nnAddress correspondence to Bonnie H. Arzuaga, MD, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Rose-3, Boston, MA 02215. E-mail: barzuaga{at}bidmc.harvard.edu

Antenatal calcium channel blocker exposure and subsequent patent ductus arteriosus in extremely low-birth-weight infants.

This study aimed to assess whether tocolytic fetal exposure to antenatal calcium channel blockers (aCCB) increases the risk for hemodynamically significant patent ductus arterioses (hsPDA) in extremely low-birth-weight (ELBW) infants. This case-control study investigated ELBW infants (<1,000xa0g) without cardiac defects in a level 3 neonatal intensive care unit who had survived at least 7xa0days. Nifedipine was the only aCCB used for this study population. The measurements included the history of aCCB exposure, selected maternal data, hsPDA diagnosis, gestational age at birth, birth weight, mode of delivery, sex, maternal race, location of birth, Apgar scores, and selected neonatal morbidities. The end point of the study was hsPDA, defined as an echocardiographically confirmed PDA with clinical symptoms. A total of 180 infants met the study criteria. The diagnosis was hsPDA for 56% of these patients, 20% of whom had aCCB exposure. Of the infants without hsPDA, 11% had aCCB exposure (pxa0=xa00.09). No statistically significant associations were found between aCCB exposure and hsPDA after adjustment for gestational age (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.6–3.7) or for gestational age and cumulative aCCB exposure of 100xa0mg or more (OR, 2.0; 95% CI, 0.6–6.5). A history of aCCB exposure does not appear to increase hsPDA risk in ELBW infants. Studies using neonatal serum nifedipine concentrations after antenatal exposure should be performed to confirm this conclusion.

Concern for mortality in the neonatal intensive care unit (NICU): parent and physician perspectives

OBJECTIVE:The objectives of this study are as follows: (1) to determine the incidence of parental concern for mortality (PCM) and any potential predictors for it among parents of infants admitted to the Neonatal Intensive Care Unit (NICU), and (2) to explore physicians’ perspectives with respect to PCM in the NICU and to examine current practices of addressing it.STUDY DESIGN:Separate questionnaires were distributed to members of the AAP Section on Perinatal–Neonatal Medicine District I and to NICU parents post discharge, to gather perspectives from each group. A χ2-analysis and linear regression were performed.RESULTS:Response rate was 29% for the physician survey and 63% for the parent survey. Physician respondents believed that PCM increased with decreasing gestational age (GA) and reported having fewer discussions with parents of older infants about PCM. Parental report of PCM incidence was 48% overall. PCM was not associated with GA. PCM was associated with infant length of stay and occurrence of at least one discussion about PCM with physicians. Fifty-three percent of parents reported never having a discussion regarding PCM.CONCLUSION:Although physicians believe that PCM increases with decreasing GA, parental report suggests that PCM is not associated with GA. Parents of full-term infants in particular may experience more PCM and desire for discussion than is currently recognized.

Beyond the avoidance of waste: the ethical imperative to focus on value in the NICU

In the neonatal intensive care unit (NICU), like in all intensive care units (ICUs), concern over the cost of a needed intervention should never come into consideration to the individual physician. In reality, if the question of potential waste is suggested in an ICU, the therapy or intervention under consideration is not likely to be in the best interests of the patient. In life and death, life-saving measures should never be deemed too expensive or too resource intensive. The Choosing Wisely campaign, which launched in 2012, tasked specialty societies with the creation of five-item – ‘Top Five’ – lists of therapies or interventions which could be easily identified as ‘wasteful’ in an effort to eliminate the proverbial low-hanging fruit of medical overuse. The campaign focuses almost exclusively on ‘not doing’ unnecessary tests or procedures, thereby avoiding waste, cutting costs, and theoretically providing more efficient patient care. To date, over 70 societies have produced such lists (http://www.choosingwisely.org/clinician-lists/) and in 2015, the American Academy of Pediatrics’ Section on Neonatal-Perinatal Medicine (SONPM) added its contribution. This list, like its predecessors, identifies five commonly utilized diagnostics and therapies in the NICU with little or no appreciable benefit to patient outcomes and suggests that these not be routinely used. This initial step at reducing ineffective medical practices serves as a solid foundation for further discourse on waste reduction in the NICU, but it also raises some important ethical considerations. Specifically, it lends the questions of how physicians can simultaneously balance the utilitarian model of medicine which the Choosing Wisely framework instills with the contemporary emphasis on parental autonomy and shared decision-making and, consequently, how does the individual doctor-patient/doctorfamily relationship fit within the framework? The type of waste avoidance advocated by Choosing Wisely is fundamentally utilitarian: by reducing unnecessary (including marginally unnecessary) treatments and procedures on individual patients, the patient population as a whole will benefit—the greatest good for the greatest number. A prime example of this, taken from the SONPM list, is the elimination of the practice of obtaining routine term-equivalent or pre-discharge brain magnetic resonance imaging (MRI) studies on premature infants. Routine MRIs, it is argued, are expensive and, while they correlate with neurodevelopmental outcomes of former premature infants at 2 and 5 years of age, they do nothing to improve those outcomes. On the surface, this seems appropriate. If we cannot improve the neurodevelopmental outcome for a particular patient by doing a test, then why do it at all? However, this conclusion ignores another notable measurable outcome that obtaining a pre-discharge MRI may affect: parental anxiety. Consider what a provider should do when a patient’s parents, who may have read about the use of MRIs on the internet, strongly request one as hospital discharge approaches? Should the physician accede to their request? Would the decision change if the infant has a history of normal head ultrasounds versus abnormal scans? Should head ultrasound results, which are usually, at best, a crude method of risk-assessment, even matter in the face of parental request rooted in worry over their child’s future? Our duty to our individual patients and families can only be fully upheld within the idea of overuse reduction if the primary focus is shifted from Choosing Wisely’s emphasis on pure waste avoidance toward one on value-optimization in the medical care provided to critically-ill newborns. If value can be defined as achieving the best outcome as efficiently as possible, then examining the impact of specific practices on monetary costs alone not only falls short of helping to define what our actual patient-centered value-based goals should be, but will also become more difficult as more units move towards a system of bundled payments. Instead, in order to optimize value, one must take a multifaceted approach which includes (1) avoiding procedures and treatments with no value; (2) avoiding procedures and treatments with little or marginal value; (3) shifting focus to procedures and treatments with the most benefit, and most importantly; (4) structuring the system in such a way that the money and resources saved by the first and second components are allocated to the patient population from which they were taken. The Choosing Wisely framework tackles the first and second facets of value-optimization with its ‘Top Five’ lists but does not address the last two, which may well lead to the campaign being ignored by providers who feel a primary duty to their individual patients in day-to-day practice. Alternatively, a medical association supported shift from a culture of waste avoidance to an environment focused on interventions that provide a patient with the most benefit would invariably succeed in attaining individual providers’ acceptance as it falls directly in-line with physicians’ fundamental fiduciary roles to their patients. Such a shift is possible by paying attention to what should be done for a patient, rather than what should not. Focusing energies on ways to strengthen the partnership found in successful doctor-family relationships will, in turn, promote shared decision-making, family engagement in medical care, and maybe even increased usage of underutilized resources like neonatal palliative care. For example, actively engaging families in the understanding and consequential management of gastroesophageal reflux will naturally lead to parental adherence to long-term plans. After all, what good is avoiding an anti-reflux medication in the NICU (item #1 on SONPM’s ‘Top Five’ list) if the family pediatrician will prescribe it on the first post-discharge follow-up visit?