[Very premature births: Dilemmas and management. Second part: Ethical aspects and recommendations]

In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

[Retinopathy of prematurity: 10-year retrospective study at the University Hospital of Strasbourg]

OBJECTIVES

This work was splitted in two parts: the first one was the study of retinopathy incidence in premature infants less than 33 weeks gestation, born between 1988 and 1997; the second one is the identification of severe retinopathy different risk factors.

PATIENTS AND METHODS

Our study was retrospective over ten years. All premature infants less than 33 weeks gestation born between January 1, 1988 and December 31 1997, admitted to the Strasbourg neonatal intensive care unit with retinopathy, were included (164 children). First we studied the incidence evolution of retinopathy over these ten years; then by a statistical study (univaried and multivaried) we looked for a significant difference for several factors between the infants with mild retinopathy and the group with severe ocular disease.

RESULTS

Retinopathy incidence decreased in ten years from 13.7 to 6.7% for the moderate forms (P < 0.001) and from 3.7 to 1.7% for severe stage (non significant). A significant difference was found for various factors after comparison between both groups. The birth weight (P = 5 x 10(-4)), the gestational age (P = 4 x 10(-6)), were weaker in the group with severe retinopathy. A maternofetal or nosocomial infection (P = 0.009; P = 0.002), hemodynamic shock (P = 10(-6)), patent ductus arteriosus (P = 10(-6)), bronchopulmonary dysplasia (P = 3 x 10(-6)), postnatal steroid treatment (P = 0.007), respiratory distress syndrome (P = 0.01), were all more frequent in the severe retinopathy sample. The number of days with oxygenotherapy (P = 10(-6)) and mechanical ventilation (P = 10(-6)) the number of blood transfusion (P = 10(-5)) were higher in this group than in the other. The logistic regression analysis showed that the hemodynamic parameters influence mostly on the risk of severe ocular disease, like an hemodynamic shock syndrome (OR = 16.94; CI = 2.12-135.77) or a patent ductus arteriosus (OR = 5.36; CI = 1.53-18.74).

CONCLUSION

A decrease of the retinopathy incidence in premature infants was observed in ten years, probably due to better care in the neonatal period. An unstable hemodynamic state would be one prominent risk factor in the genesis of severe retinopathy of prematurity.

[Ethical dilemmas in the perinatal period: guidelines for end-of-life decisions]

According to several recent surveys, around 50% of the deaths occurring nowadays in French neonatal intensive care units result from a medical decision. This has led French neonatologists to set up guidelines for end-of-life decisions and practice in the perinatal period, which are presented in this paper. It covers definitions, clinical situations, ethical principles, obligations of the medical and nursing staff, and specific conditions where dilemmas occur.

Temporary auxiliary liver transplantation for subacute liver failure in a child

A 4-year-old boy with subacute liver failure due to hepatitis A virus underwent temporary auxiliary liver transplantation. The graft, an adult reduced liver, was implanted othotopically after a left hepatectomy had been carried out on the recipient's liver. Good liver function was immediately restored. The remaining native liver, which was 90% necrotic at the time of transplantation, regained normal histological features within 3 months. The auxiliary graft was then removed and immunosuppressive therapy stopped.

[Clinical examination of children with urination disorder]

The management of a child with disorders of urination must begin with a high-quality clinical examination. Detailed questioning in an atmosphere of confidence yields information on the type of disorder (dysuria, frequencies, urgencies, burning sensation at voiding, enuresis, incontinence) either alone or in association. Physical examination aims to find signs pointing to the cause of the disorder. Particular attention must be paid to an inspection fo the external genitalia and to a search for possible abnormalities affecting the pinna of the ear and the extremities, since they are frequently found in association with deep malformations of the urinary tract. Collecting the urine provides an opportunity to observe the process of urination and possible abnormalities in the initial, middle and terminal voiding streams. The reagent dipstick is a minute but true laboratory test accessible to children, which makes it possible to detect glomerular, tubular and interstitial lesions. This clinical examination will lead to a precise diagnosis, inform on the need, if any, for additional explorations and enable the clinician to select the correct treatment.