John Colin Partridge

Maternal or neonatal infection: association with neonatal encephalopathy outcomes.

Background:Perinatal infection may potentiate brain injury among children born preterm. The objective of this study was to examine whether maternal and/or neonatal infection are associated with adverse outcomes among term neonates with encephalopathy.Methods:This study is a cohort study of 258 term newborns with encephalopathy whose clinical records were examined for signs of maternal infection (chorioamnionitis) and infant infection (sepsis). Multivariate regression was used to assess associations between infection, pattern, and severity of injury on neonatal magnetic resonance imaging, as well as neurodevelopment at 30 mo (neuromotor examination, or Bayley Scales of Infant Development, second edition mental development index <70 or Bayley Scales of Infant Development, third edition cognitive score <85).Results:Chorioamnionitis was associated with lower risk of moderate–severe brain injury (adjusted odds ratio: 0.3; 95% confidence interval: 0.1–0.7; P = 0.004) and adverse cognitive outcome in children when compared with no chorioamnionitis. Children with signs of neonatal sepsis were more likely to exhibit watershed predominant injury than those without (P = 0.007).Conclusion:Among neonates with encephalopathy, chorioamnionitis was associated with a lower risk of brain injury and adverse outcomes, whereas signs of neonatal sepsis carried an elevated risk. The etiology of encephalopathy and timing of infection and its associated inflammatory response may influence whether infection potentiates or mitigates injury in term newborns.

Antenatal Exposure to Magnesium Sulfate Is Associated with Reduced Cerebellar Hemorrhage in Preterm Newborns

OBJECTIVE To determine the association of antenatal magnesium sulfate with cerebellar hemorrhage in a prospective cohort of premature newborns evaluated by magnetic resonance imaging (MRI). STUDY DESIGN Cross-sectional analysis of baseline characteristics from a prospective cohort of preterm newborns (<33 weeks gestation) evaluated with 3T-MRI shortly after birth. Exclusion criteria were clinical evidence of a congenital syndrome, congenital infection, or clinical status too unstable for transport to MRI. Antenatal magnesium sulfate exposure was abstracted from the medical records and the indication was classified as obstetric or neuroprotection. Two pediatric neuroradiologists, blinded to the clinical history, scored axial T2-weighted and iron susceptibility MRI sequences for cerebellar hemorrhage. The association of antenatal magnesium sulfate with cerebellar hemorrhage was evaluated using multivariable logistic regression, adjusting for postmenstrual age at MRI and known predictors of cerebellar hemorrhage. RESULTS Cerebellar hemorrhage was present in 27 of 73 newborns (37%) imaged at a mean ± SD postmenstrual age of 32.4 ± 2 weeks. Antenatal magnesium sulfate exposure was associated with a significantly reduced risk of cerebellar hemorrhage. Adjusting for postmenstrual age at MRI, and predictors of cerebellar hemorrhage, antenatal magnesium sulfate was independently associated in our cohort with decreased cerebellar hemorrhage (OR, 0.18; 95% CI, 0.049-0.65; P = .009). CONCLUSION Antenatal magnesium sulfate exposure is independently associated with a decreased risk of MRI-detected cerebellar hemorrhage in premature newborns, which could explain some of the reported neuroprotective effects of magnesium sulfate.

When Life-Sustaining Treatment Is Withdrawn and the Patient Doesn’t Die

One of the most difficult decisions that doctors and parents must make is the decision to withdraw life-sustaining treatment. Doctors find it easier to withdraw treatments in situations where withdrawal will be rapidly fatal rather than in situations in which treatment withdrawal will lead to a prolonged dying process. Mechanical ventilation is usually such a treatment. Withdrawal of ventilation generally leads to the patient’s rapid demise. Doctors may tell parents that death will occur quickly after a ventilator is withdrawn. But what happens when the doctors are wrong and a patient survives without life support? What should doctors do next? We present a case in which that happened and asked 3 experts to comment on the case. Stefan Kutzsche is a senior consultant in neonatology at Oslo University Hospital Ulleval in Norway. John Colin Partridge is a neonatologist and professor of pediatrics at University of California, San Francisco. Steven R. Leuthner is a neonatologist and professor of pediatrics and bioethics at the Medical College of Wisconsin. They each recommend slightly different approaches to this dilemma.

Home‐use icterometry in neonatal hyperbilirubinaemia: Cluster‐randomised controlled trial in Vietnam

To determine whether home‐use icterometry improves parental recognition of neonatal jaundice, early care seeking and treatment to minimize risks of bilirubin encephalopathy.

Valuation of Quality of Life in Pediatric Disability in a Developing Country

This article assessed how Indian providers and mothers value quality of life in pediatric disabilities, hypothesizing lower values with increasing disability, lower values among providers than mothers, and lower values among mothers with versus mothers without a disabled child. We asked 175 participants: “If born tomorrow, how many years of a disabled life (y) would you trade to avoid life-long disability” for 4 hypothetical disabilities, calculating “utility” scores as: (life span – y) / life span, where death = 0 and full life without disability = 1. Providers’ utilities were 0.67 (mild), 0.18 (moderate), –0.70 (severe), and –0.60 (profound); 0.67, 0, –0.77, and –0.88 for mothers without and 0.38, –0.49, –0.86, and –0.87 for mothers with a disabled child. Mothers without reported lower utilities than providers (severe and profound disability [P ≤ .03]), and higher utilities than mothers (for mild and moderate disability [P < .001]). Major disability is valued as a fate worse than death in India.

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.

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.