Hungarian paediatricians' attitudes regarding the treatment and non-treatment of defective newborns: a comparative study

Conclusion: The four compared surveys clearly show that paediatricians from different backgrounds encounter these moral dilemmas in their everyday practice. Hungarian paediatricians facing morally significant decisions of discontinuation of treatment in defective newborns were permissive toward passive euthanasia like their Australian and Canadian colleagues, but were almost unanimously against active euthanasia like their Polish colleagues. The results of our study revealed a strong paternalistic attitude among Hungarian doctors, unwillingness to include other professionals in a discussion of moral problems and neglect of the nurses' views in these matters. Many physicians in the Hungarian study group were not aware of the legal ramifications in such cases. These findings were similar to the results of the Polish study. It is plausible that the paternalistic attitude and ignorance of the relevant law is common in all 'former' socialist countries. The Australian, Canadian and Hungarian doctors displayed more understanding and tolerance towards passive euthanasia. Many physicians in all study groups seemed to be not familiar with the legal regulations of their own country. The paediatricians of the four studies showed the greatest difference in their attitudes towards active euthanasia, with the Australian community being more permissive, the Canadian, Polish and Hungarian community rejecting it.     

A survey of Calgary paediatricians' attitudes regarding the treatment of defective newborns: a report from Canada

... Premature infants and those born with severe abnormalities have stimulated the creation of neonatal units, but advances in medicine have created the dilemma of whether to sustain life in neonates who would otherwise die from their abnormalities. Often these methods are sophisticated and costly, and carry their own share of iatrogenic complications... It is crucial that the infant -- unable to be directly involved -- have an advocate, whose role it is to act in the best interests of the patient in determinations of the latter's treatment. Under most circumstances that role is occupied by the child's physician and family... For this reason, it is imperative to discern physicians' -- and specifically pediatricians' -- attitudes towards the treatment of defective newborns. To accomplish this, a survey was taken in Calgary... It is the purpose of this paper to provide information regarding local physicians' views and how they compare with the opinions of their colleagues from other countries.     

A REPORT FROM AUSTRALIA: WHICH BABIES ARE TOO EXPENSIVE TO TREAT?

The author examines current practices and attitudes of Australian neonatologists regarding the treatment of low birth weight infants. One intensive care unit adheres to criteria of treatment based on weight and its perceived connection with prognosis even when there are available beds and equipment. Another unit treats infants of much lower weight with poorer prognoses. A survey of Australian neonatologists revealed that although most knew of varying practices, over half were opposed to disclosing this knowledge to parents. The physicians were also queried on allocation of resources among infants of varying weights in the units, and on prevention of prematurity. Singer discusses the QALY (quality adjusted life year) and its application in comparing the benefits of resource allocation to neonatal intensive care and to adult care.     

Proximate personhood as a standard for making difficult treatment decisions: imperiled newborns as a case study

... The standard of personhood is gaining increased attention and prominence. The essential claim is that only individuals with capacities for significant cerebral functioning possess a morally unique claim to existence. Persons are defined as individuals who are self-aware and capable of self-direction (Engelhardt), able to enter meaningful relationships (McCormick), capable of minimal independent existence (Shelp), and in possession of a minimal 20-40 I.Q. (Joseph Fletcher). These are "high standard" personhood positions (those holding higher-brain related criteria). It is a commonplace with most such positions that newborns -- all newborns -- are not, strictly speaking, persons. That is, newborns are not self-aware, intentionally choosing individuals.... The thesis of this essay is that a developing individual's right to life increases as he or she approaches the threshold of personal life. That is, the more a newborn approximates -- or is proximate to -- undisputed personhood (e.g. the status of readers of this essay), the greater his or her claim to life. The two pivotal criteria for determining personhood are the potentiality for and development toward becoming an undisputed personal being. I am presupposing, for purposes of argument, that the handicapped infant would not be an excessive familial burden or an inordinate financial load for society, one an ancient and the other a modern criterion. That condition granted, this essay contends that if an imperiled newborn is reasonably projected to reach at least minimal personal capacity, treatment should be given.     

Urinary Screening Tests in the Prevention of Mental Deficiency

A substantial number of genetically determined biochemical disorders in infants and young children produce mental deficiency and serious ill health in early life. If these diseases are detected promptly, effective therapy can be instituted to prevent the development of mental defect, or, where no treatment is presently available, the parents can be given appropriate genetic counselling so that the birth of further affected children can be prevented.Eight simple urine screening tests are described which have proved useful in the early detection of metabolic disorders in apparently healthy infants. These tests can easily be performed by a physician or nurse without special training or elaborate equipment. The attention of general practitioners, pediatricians and public health physicians is directed to the real possibilities for preventing some forms of mental deficiency through the routine use of screening tests on urine and on blood.     

Participation of Colorado pediatricians and family physicians in the Medicaid program.

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients.     

Streptococcus group B in meningitis and infection of newborn infants

Streptococci were isolated from the liquor or blood of 102 newborn infants and 16 infants in the first month of their life, suspected of having purulent meningitis, in 22 cases (18,5%). 5 isolated streptococcal strains were classified with group B on the basis of their cultural, biochemical and serological features. All of these strains were isolated from newborn infants during the first 3-4 days of their life. The occurrence of group B streptococci among all examined newborn infants was 4.8%; among the newborns with the positive results of bacteriological examination (73 infants) this figure was as high as 6.8%. The authors emphasize the necessity of producing, on an industrial scale, diagnostic preparations for the identification of group B streptococci playing a significant role in septic diseases and meningitides in newborns.     

Discussion: pre-zygotic rights

Silverman uses Warnock's article "Do human cells have rights?" (Bioethics 1987 Jan; 1(1): 1-14) as the springboard for a brief discussion of decision making in the care of handicapped newborns. He argues that the parents of these children should have a major role in deciding for or against life-prolonging treatment, because they must live with the consequences. Silverman does not find it surprising that, in reaching their decision, parents are inclined to weigh the competing interests of family members, including those of children not yet conceived whose rights are foreclosed by the drain on the family of an existing handicapped child.     

Hormone synthesis and storage in the thyroid of human preterm and term newborns: effect of thyroxine treatment.

Iodine and thyroglobulin concentrations, as well as iodine, T3, T4 and sialic acid contents of thyroglobulin, were measured in thyroid glands collected postmortem from 42 human premature or term newborns and infants. Three groups were considered: very preterm newborns (24-32 postmenstrual weeks, < 5 days postnatal life), preterm and term newborns (34-41 postmenstrual weeks, < 5 days postnatal life) and infants (born at term, postnatal age 1-8 months). Five very preterm and seven preterm newborns received a daily dose of 10 microg/kg L-T4 for at least 3 days. Thyroid weight and sialic acid content of thyroglobulin progressed with maturation. Intrathyroidal concentrations of iodine and thyroglobulin did not increase significantly before the 42nd week of postmenstrual age. The level of thyroglobulin iodination increased during the postnatal life, except in the very preterm neonates. T4 and T3 content of thyroglobulin was directly proportional to its degree of iodination and positively related to its sialic acid content. L-T4 treatment of preterm newborns increased thyroglobulin iodination and T4-T3 content, without increasing thyroglobulin concentration in the thyroid. It was concluded that the storage of thyroglobulin and iodine in the thyroid develops around term birth. This, associated with the resulting rapid theoretical turnover of the intrathyroidal pool of T4 in Tg, could be an important factor of increased risk of neonatal hypothyroxinemia in the premature infants. The L-T4 treatment of preterm newborns does not accelerate the maturational process of the thyroid gland.     

NARRATIVES OF ‘TERMINAL SEDATION’, AND THE IMPORTANCE OF THE INTENTION‐FORESIGHT DISTINCTION IN PALLIATIVE CARE PRACTICE

The moral importance of the ‘intention–foresight’ distinction has long been a matter of philosophical controversy, particularly in the context of end‐of‐life care. Previous empirical research in Australia has suggested that general physicians and surgeons may use analgesic or sedative infusions with ambiguous intentions, their actions sometimes approximating ‘slow euthanasia’. In this paper, we report findings from a qualitative study of 18 Australian palliative care medical specialists, using in‐depth interviews to address the use of sedation at the end of life. The majority of subjects were agnostic or atheistic. In contrast to their colleagues in acute medical practice, these Australian palliative care specialists were almost unanimously committed to distinguishing their actions from euthanasia. This commitment appeared to arise principally from the need to maintain a clear professional role, and not obviously from an ideological opposition to euthanasia. While some respondents acknowledged that there are difficult cases that require considered reflection upon one's intention, and where there may be some ‘mental gymnastics,’ the nearly unanimous view was that it is important, even in these difficult cases, to cultivate an intention that focuses exclusively on the relief of symptoms. We present four narratives of ‘terminal’ sedation – cases where sedation was administered in significant doses just before death, and may well have hastened death. Considerable ambiguities of intention were evident in some instances, but the discussion around these clearly exceptional cases illustrates the importance of intention to palliative care specialists in maintaining their professional roles.     

Premature babies and pharmacology.

In his research on the action of various drugs in newborns, Dr. Jacob Aranda of the Centre for Perinatal and Developmental Pharmacology Research in Montreal draws upon his expertise in both neonatology and pharmacology. His work has led to the acceptance of caffeine as a standard treatment of apnea in premature infants, and his current studies of ibuprofen as a possible treatment of cerebral intraventricular hemorrhage, a serious problem in some premature babies, have yielded promising results. Other areas being tackled by Aranda and his colleagues include pain control for newborns and the elusive pathology of sudden infant death syndrome. By shedding more light on neonatal development and the principles of drug action in newborns, these research projects will help to improve the odds for many babies who suffer the setback of being born too soon.     

Predicting the future for newborns requiring intensive care

When intensive care for newborns was introduced thirty years ago its primary goal was to improve the rates of survival of sick and premature infants. Medicine has been successful in attaining this goal; however, as more infants survive, the cost of intensive care and the additional cost of services and care for handicapped survivors continue to escalate. In order to curb the increasing cost of newborn intensive care, heightened initiatives directed at the prevention of premature births will be necessary.     

Infants, pain and what health care professionals should want to know -- a response to Cunningham Butler

A neonatologist responds to an article by Nance Cunningham Butler, in the same issue of Bioethics, that is critical of current attitudes toward management of pain in infants. Campbell mentions briefly three matters relating to pain in newborns that he believes Butler could have emphasized more: (1) the wider phenomenon of distress in babies, of which pain is a part; (2) health personnel's failure to recognize unnecessary distress in all patients, not just infants; and (3) the fact that pain control measures vary from place to place and have changed recently. Campbell then discusses alternative viewpoints to Butler's in three areas: (a) do newborns feel pain as older patients do; (b) the technicalities of pain relief in newborns; and (c) the special problems of premature infants. He argues that the onus of proof is on advocates of drug administration to control pain in infants.     

Sex differences in infant integration in a semifree-ranging group of Barbary macaques (Macaca sylvanus,L. 1758) at Salem,Germany

Sixteen multiparous Barbary macaque females with newborns were studied over a 16 month period within the context of their naturally formed group. Analysis of their social behavior revealed 1) triadic interactions involving focal females, their newborns, and other group members occurred mainly with other females; and 2) mothers with female newborns interacted mainly with females of their own matriline, while mothers with male newborns interacted mainly with nonmatriline females. Observed in two successive birth seasons, this pattern indicates that partners of maternal interactions chose each other according to the sex of the newborn. Measures of distance from the mother also reflected differences between infants of different sex. At about five months of age, female infants were observed close to their mothers significantly more often than males. This finding follows the pattern of a sex-specific infant socialization process which integrates female infants into the network of their matrilines and male infants into the broader group. This sex-specific integration pattern is interpreted as supporting female philopatry and male dispersal. © 1995 Wiley-Liss, Inc.     

Retinal vasculitis--a primer.

Retinal vasculitis is a diagnosis that is generally suggested by an ophthalmologist. Frequently patients with the disorder are referred to nonophthalmologists for further diagnostic evaluation or treatment. The criteria for defining vasculitis differ greatly between ophthalmologists and other physicians. To facilitate collaboration between ophthalmologists and their colleagues, we have sought to clarify the term "retinal vasculitis" by discussing its subcategories, the potential role of antiphospholipid antibodies, and the etiology of retinal vasculitis. We offer guidelines for evaluating the disorder and treating patients.     

Normative data for total and free acid-labile subunit of the human insulin-like growth factor-binding protein complex in pre- and full-term newborns and healthy boys and girls throughout postnatal development

Insulin-like growth factors (IGFs) circulate in plasma as part of a 150-kD complex that also contains IGF-binding protein-3 (IGFBP-3), a protein that binds IGF-I and IGF-II with high affinity, and an acid-labile subunit (ALS) that does not directly bind IGFs. Because the ALS assay methods currently being used are relatively new, there is a need for updated normative reference data. We report the normative data in 17 preterm infants (10 males and 7 females), 30 normal full-term newborns (15 males and 15 females) and 150 normal children who where divided into 5 groups according to their Tanner stage (15 males and 15 females per group). Serum levels of total and free ALS were significantly lower in premature infants than in full-term newborns, but all newborns had significantly lower levels than Tanner stage-I children (p<0.001, ANOVA). A significant increase was seen between Tanner stages I-III in both sexes (p<0.001, ANOVA). No differences were found between sexes at any developmental age studied. Significant correlations (p<0.001) were seen between total and free ALS concentrations and IGF-I (r = 0.50 and 0.60, respectively), free IGF-I (r = 0.37 and 0.36), IGF-II (r = 0.37 and 0.27), IGFBP-1 (r = -0.48 and -0.49), IGFBP-2 (r = -0.44 and -0.51) and IGFBP-3 (r = 0.67 and 0.59) at all Tanner stages. However, no correlation was found with IGFBP-1, -2 or -3 levels at birth. This study shows normal values in a population of preterm infants and healthy Spanish newborns and subjects of both sexes at all stages of pubertal development and indicate the different relationships between the components of the IGF system during intra- and extrauterine life.     

Microbial colonization and succession on the faucial mucosa in newborn infants rooming in with their mothers in a maternity hospital]

The formation of microflora on the laryngeal mucosa in newborn infants during the first 5 days of their life was studied in one of the maternity hospitals of Moscow. In this work modern methods of the isolation and identification of aerobic and anaerobic microorganisms were used, and the results thus obtained were computer-processed. In the maternity hospital of the "mother-child" type the microbial colonization of the laryngeal mucosa by normal and opportunistic microorganisms was noted in newborn infants. A wave-like course of the formation of laryngeal microflora, indicative of microbial succession occurring in the child, was revealed. The attempt to establish the cases of microbial interference between the species colonizing the laryngeal mucosa revealed that it was very rarely observed in 5-day-old newborns. This feature was seemingly the cause of low resistance of the larynx to colonization in newborn infants, which determined frequent colonization of their laryngeal mucosa with Staphylococcus aureus and Klebsiella.     

Pediatricians’ Own Weight: Self‐perception,Misclassification, and Ease of Counseling

Objectives: Pediatricians underdiagnose overweight and feel ineffective at counseling. Given the relationship between physicians’ health and health habits and counseling behaviors, we sought to determine the 1) percentage of pediatricians who are overweight; 2) accuracy of pediatricians’ own weight status classification; and 3) relationship between weight self‐perception and perceived ease of obesity counseling. Research Methods and Procedures: This study was a cross‐sectional, mail survey of North Carolina pediatricians that queried about their weight status and ease of counseling. Accuracy of pediatricians’ self‐classification of weight status was compared with BMIs derived from self‐reported height and weight. Using logistic regression, controlling for potential confounding variables, we examined the association between weight perception and ease of counseling. Results: The unadjusted response rate was 62%, and the adjusted response rate was 71% (n = 355). Nearly one‐half (49%) of overweight pediatricians did not identify themselves as such. Men had greater adjusted odds of misclassifying overweight than women [odds ratio (OR), 3.61; 95% confidence interval (CI) = 1.81, 7.21]. Self‐classified “thin” pediatricians had nearly six times the odds of reporting more counseling difficulty as a result of their weight than “average” weight pediatricians (OR = 5.69; 95% CI = 2.30, 14.1), and self‐identified “overweight” pediatricians reported nearly four times as great counseling difficulty as “average” weight physicians (OR = 3.84; 95% CI = 1.11, 13.3), after adjustment for self‐reported BMI weight status and other potential confounders. Discussion: The roles that physician weight misclassification and self‐perception potentially play in influencing rates of obesity counseling warrant further research.     

The pediatric walk-in clinic: competition for the private practitioner.

In an affluent city with many pediatricians a 20% increase in patients seen in a hospital-based walk-in clinic in 1982 prompted a study to determine the characteristics of clinic users and their reasons for using the clinic. It was found that users of the clinic were middle-class, that they had a higher employment rate than the average for the region, and that in 54% of the families both parents worked outside the home. The children of 85% of the families were patients of pediatricians in private practice; most of the others were patients of a family physician in private practice. Most of the children seen at the clinic had had symptoms for more than 24 hours, but few parents had attempted to contact their own physicians. In the previous 12 months 95% of the children had been seen at the clinic, 43% in the month preceding the study. They came to the clinic for two main reasons: the broad range of services offered --laboratory, radiology and pharmacy as well as medical--and the convenient hours, with 71% coming outside of their physicians'' office hours. Given the reality of social trends pediatricians will either have to share their patients with facilities that offer services outside of regular office hours or devise another system for the treatment of their patients.