Staff attitudes towards continuation of life-support in newborns with major congenital anomalies

This study was conducted to gain insight into the attitudes of medical staff towards life-support of newborns with life-threatening problems, seen against the background of these children's expected morbidity and quality of life. The opinions about the mode of life-support were determined by questionnaires and the demographic characteristics of the respondents were noted. Each patient's risk of mortality was scored by means of the standardized Paediatric Risk of Mortality Score (PRISM). Attitudes towards support were unanimous for 39 of the 46 patients. For the other 7 patients at least one of the respondents preferred a different support mode than that given at the time. The attitudes were influenced by the patient's risk of mortality.

CONCLUSION

Decisions about life-support of newborns with life-threatening problems should include all the disciplines involved in patient care and should be made at an early stage.

Management of antebrachial deformity and shortening secondary to a synostosis in a dog

A nine-week-old labrador was presented with a deformed left forelimb causing obvious lameness. Radiographs suggested that the dog had suffered a fracture involving the radius and ulna which had healed resulting in a synostosis. There was a concurrent radial physeal injury. The dog was treated initially by osteotomy of the radius and ulna stabilised using a static external skeletal fixator. At a subsequent surgery lengthening of the limb was achieved by using an Ilizarov apparatus. Worsening carpal hyperflexion was managed by bandaging in forced extension. A successful outcome was achieved with a final result of a 24 per cent discrepancy in length between the two radii at 17 months of age. An increase in length of the ipsilateral humerus was seen in association with the shortened forelimb.

Ethical issues in the application of medical technology to paediatric intensive care: two views of the newborn

Recent advances in medical technology have led to a marked improvement in the chances of survival of sick or preterm infants, thereby stimulating renewed ethical debate on the status of the newborn. Two contradictory attitudes to the medical care of preterm or congenitally malformed newborn infants can be discerned in our pluralistic society. The two attitudes have their historical roots in the classical Graeco-Roman and Judaeo-Christian ethical traditions respectively. The former views newborn infants as of potential value only whereas the latter emphasises the intrinsic worth and dignity of the individual made in God's image. Recent secular philosophical reflection has provided a rationale for infanticide of the sick or abnormal newborn. A Christian approach to the care of the newborn prohibits intentional killing yet may encompass the withdrawal of treatment that is inappropriate or unduly burdensome. Medical care should be based upon respect for the value of the individual, protection of the defenceless from abuse or exploitation, and wise stewardship of limited health-care resources.

Congenital limb anomalies and amputees Tayside, Scotland 1965-1994

The purpose of this study was to review the 68 patients who had been referred to Dundee Limb Fitting Centre during the period 1965-1994, with a congenital anomaly of a major limb requiring prosthetic replacement. A profile of the incidence of congenital anomalies, amputation levels and prosthetic fitting was obtained. During the period only 68 cases with 80 congenital anomalies were referred. During these 29 years, 20 cases required surgical amputation and overall 35 surgical procedures were performed in these cases, only 3 were in the upper limb. The incidence of upper and lower limb deficiency was similar. The patients represented a small proportion (1.6%) of the patients who were reported to have congenital anomalies. Figures indicated that about 8% of all live/still births have some form of anomaly. Prosthetic fitting and use was successful in all 68 cases but long term life follow-up is necessary to ensure continued prosthetic use.

Gastroschisis: 13 years' experience at RCH Melbourne

OBJECTIVE

To review recent experience of gastroschisis at the Royal Children's Hospital, Melbourne.

METHODOLOGY

Retrospective review of admissions over a 13 year period, June 1980-June 1993 inclusive, including an analysis of those factors influencing mortality, morbidity and complications.

RESULTS

There were 49 infants, of whom two died (4%), both having an associated bowel atresia. Mode of delivery, age at operative repair, birthweight centile and silo repair had no significant effect on the duration of total parenteral nutrition (TPN) or hospital stay. The presence of short gut and/or gut resection and localized bowel narrowing or bowel atresia resulted in a significant increase in the duration of TPN and hospital stay. The presence of a central venous line was a highly significant risk factor for the development of systemic sepsis.

CONCLUSION

Currently gastroschisis has a good outlook with a low mortality. Infants with short gut/resection and bowel atresia have a long duration of TPN and hospitalization, with significant morbidity and complications.

Prolonging life and allowing death: infants

Dilemmas about resuscitation and life-prolonging treatment for severely compromised infants have become increasingly complex as skills in neonatal care have developed. Quality of life and resource issues necessarily influence management. Our Institute of Medical Ethics working party, on whose behalf this paper is written, recognises that the ultimate responsibility for the final decision rests with the doctor in clinical charge of the infant. However, we advocate a team approach to decision-making, emphasising the important role of parents and nurses in the process. Assessing the relative burdens and benefits can be troubling, but doctors and parents need to retain a measure of discretion; legislation which would determine action in all cases is inappropriate. Caution should be exercised in involving committees in decision-making and, where they exist, their remit should remain to advise rather than to decide. Support for families who bear the consequences of their decisions is often inadequate, and facilitating access to such services is part of the wider responsibilities of the intensive care team. The authors believe that allowing death by withholding or withdrawing treatment is legitimate, where those closely involved in the care of the infant together deem the burdens to be unacceptable without compensating benefits for the infant. As part of the process accurate and careful recording is essential.

Fetal malformations diagnosed antenatally. 2: Ultrasound diagnosis of fetal structural anomalies

Paediatricians should be consulted about the significance of abnormalities seen on antenatal ultrasound scans. Good teamwork and communication is necessary between the obstetrician, paediatrician and ultrasonographer to explain the significance of any abnormality to a pregnant woman. Follow-up is important both for the parents and for audit purposes.

The treatment of non-HIV-related conditions in newborns at risk for HIV: a survey of neonatologists

OBJECTIVES

The purpose of this study was to examine attitudes of neonatologists about treatment of conditions unrelated to the human immunodeficiency virus (HIV) for critically ill newborns at risk for HIV.

METHODS

Questionnaires were mailed to the 1508 members of the Section on Perinatal Medicine of the American Academy of Pediatrics; 63% completed the survey (n = 951). The survey included structured questions about treatment for hypothetical cases and open-ended questions eliciting reasons for decisions.

RESULTS

Differences in recommendations for treatment by both maternal and infant HIV status were substantial and statistically reliable. For example, 98% of respondents recommended life-saving cardiac surgery for a neonate with no risk for HIV, but only 93% recommended such surgery for a child of an HIV-positive mother; only 50% recommended the same surgery for a newborn known to be infected. The corresponding figures for chronic dialysis were 91%, 61%, and 26%. Most expected diminished quality of life for both infected and uninfected children of HIV-positive mothers.

CONCLUSIONS

Recommendations about life-sustaining treatment for non-HIV-related conditions varied by HIV status. These data on physician attitudes raise the possibility that infants labeled as HIV positive, whether infected or not, may suffer discrimination.

Intralesional laser photocoagulation-steroids as an adjunct to surgery for massive hemangiomas and vascular malformations

Massive hemangiomas and vascular malformations have been treated with lasers and adjunctive measures. Intralesional laser photocoagulation involves the direct penetration of a tumor by a yttrium-aluminum-garnet laser fiber with photocoagulation at various depths and levels to produce thromboses and controlled coagulation necrosis, thus shrinking and blanching the malformation. Seven children have benefited from intralesional laser photocoagulation as well as steroids, embolization, and excisional surgery. Intralesional laser photocoagulation has contributed to the initial shrinkage and fibrosis of these massive vascular tumors in preparation for surgery or as the only treatment in some cases.

Significant hemangiomas and vascular malformations of the head and neck: clinical management and treatment outcomes

The treatment dilemmas and our institutional experience with head and neck hemangiomas and vascular malformations are reviewed. Fifty-eight patients (38 with hemangiomas, 20 with vascular malformations) aged from newborn to 78 years were treated from 1975 to 1993. Eighty-seven percent of patients provided up-to-date follow-up, yielding a median follow-up interval of 7.18 years from intervention. Only significantly sized tumors (minimum diameter > 4 cm) were studied. Sodium tetradecyl sulfate sclerotherapy (SDS) was a sole therapy in 12 patients (all with hemangiomas) and was used in combination with surgical ablation in 22 patients (16 with hemangiomas, 6 with vascular malformations). The minority of tumors from both categories were completely removed with ablative surgery (six hemangiomas [23%], eight vascular malformations [44%]). Significantly debilitating tumor postsurgical recurrence, which led to mortality in some patients, was unique to vascular malformations with high flow on the basis of increased arterial to venous shunting. Less alarming but significant functional and cosmetic challenges are created in primarily postadolescent patients with incompletely involuted hemangiomas and low-flow vascular malformations of the head and neck. We have had a favorable experience with the combined application of sclerotherapy and conservative ablative surgery in this group. Patient survey implied satisfaction with treatment in the majority: Nine indicated they benefited significantly (17%); 37 indicated they were generally improved (71%); and 6 stated they did not benefit (12%). Tumor-specific philosophy on ablative therapy, recurrence patterns, and associated complications are presented.

Double patella syndrome with a form of multiple epiphyseal dysplasia

OBJECTIVE

To present an interesting and unusual case of double patella syndrome in a patient with multiple epiphyseal dysplasia. The pertinent clinical and radiographic findings and a brief review of the literature are discussed.

CLINICAL FEATURES

An 11-yr-old male patient suffered from occasional right hip pain and limited range of motion, as well as a nontender soft tissue mass in the right knee. Radiographic examination of the hips and knees demonstrated double-layered patellae and bilateral coxa magna deformity.

INTERVENTION AND OUTCOME

Although surgery was initially recommended, conservative chiropractic management was employed and resulted in complete resolution of the patient's presenting hip symptoms.

CONCLUSION

This case is the first reported of double patella seen on MRI and demonstrates the value of this technology in the noninvasive preoperative assessment of double patella syndrome. The patient's clinical and radiographic features led to the correct diagnosis.

Congenital absence of the vagina--results of conservative treatment

OBJECTIVE

To assess the efficacy of a combination of Frank's mold therapy with intercourse as a treatment for congenital vaginal aplasia.

STUDY DESIGN

From 1973-1993, thirty-three patients with congenital aplasia of vagina and uterus were seen by one gynecologist. Patients with a partner were instructed how to create a functional vagina by a modified form of coitus ('interfemoral intercourse'). Mold therapy (using modified molds) was used as a primary treatment when patients had no partner (n = 9) or added to the treatment of nine patients in whom interfemoral intercourse alone had failed. In case of failure of conservative treatment, the surgical creation of a neovagina (McIndoe procedure) was offered.

RESULTS

Conservative therapy in patients with a stable sexual relationship (n = 24) gave significantly better (p = 0.0104) results than when patients were single. In the former, a vaginal depth of > 8 cm was reached within six months at most with intercourse alone and four months if combined with mold therapy. With molds alone, 3 out of 9 obtained a satisfactory vagina. Treatment failures occurred (with one exception) only in patients who had no or unstable sexual relationships.

CONCLUSION

Intercourse as a treatment of vaginal atresia can be very successful, especially if practised together with modified mold therapy. A stable sexual relationship--implying a healthy self-concept--appears to be an important determinant of treatment outcome.

Intestinal malrotation and midgut volvulus: a 15-year review

The records of 54 pediatric patients with symptomatic malrotation of the intestine seen over a 15-year period from 1978 to 1992 were reviewed. Bilious vomiting and bloody stools were the two most common clinical presentations in neonates, while bilious vomiting, recurrent abdominal pain and failure to thrive were the most common symptoms after the newborn period. Obscure symptoms, usually of appreciable duration, were common in many patients beyond infancy. Upper gastrointestinal radiologic examination is the preferred and more accurate method of diagnosing malrotation as it has greater sensitivity than barium enema study. Laparotomy showed 24 cases with midgut volvulus. The incidence of midgut volvulus in symptomatic malrotation was 42.1% in the neonatal period, and 50% beyond the neonatal period. The majority of patients were treated by Ladd's operation. Massive gangrene of the small bowel due to volvulus was noted in five neonatal cases. Three patients subsequently died of this complication. Four patients developed a bowel obstruction secondary to adhesions, which was relieved by enterolysis. This study reiterates that newborns with symptomatic malrotation require emergency laparotomy in order to prevent catastrophic massive bowel resection.

Unilateral renal agenesis

Unilateral renal agenesis is a relatively common congenital urinary malformation that is usually diagnosed during fetal ultrasonography. Some cases of URA may represent involution of a previous MCDK. Unilateral renal agenesis may be an isolated congenital malformation or may be associated with chromosomal abnormalities or a variety of nonchromosomal syndromes including the VACTERL and MURCS associations. Congenital cardiac malformations are the most common malformations associated with URA. Girls with URA should have a pelvic ultrasound to look for abnormalities in the müllerian structures. Vesicoureteral reflux is the most common abnormality noted in the contralateral kidney. The prognosis of individuals with isolated URA is good. There are reports of hypertension and renal insufficiency in long-term studies of patients with a single kidney, and lifetime follow-up is recommended.