Ethical Challenges in the Use of Therapeutic Hypothermia in Indian Neonatal Units.

Trials in developed countries have shown that therapeutic hypothermia reduces the risk of death or severe disability in infants with neonatal encephalopathy. Cooling has been adopted as a standard of care in some parts of the world. Some Indian neonatal units have considered or even embarked upon cooling encephalopathic term newborn infants. In this article we discuss some of the potential ethical questions that should be considered before introducing therapeutic hypothermia in an Indian setting. Evidence from previous trials may not be relevant given significant differences in the epidemiology of neonatal encephalopathy in countries like India. There is a possibility that hypothermia would be ineffective or harmful. The most appropriate way to answer these concerns would be to perform a large randomized controlled trial of cooling in India. However, such trials will also raise potential ethical challenges. Cooling may also affect decisions about treatment withdrawal, and may create uncertainty about prognosis. It may exacerbate ethical problems relating to lack of neonatal intensive care bed space.

The art, science and philosophy of child care.

Pediatrics deals with promotion of health and well being of children and not merely diagnosis and treatment of their diseases. Children are truly the foundation of a society because healthy children grow to become healthy and strong adults who can actively participate in the developmental activities of a nation. Health and well being of children is intimately linked with the health, nutrition, education and awareness of their mothers. In order to improve child health and survival, it is therefore important to provide a life-cycle approach for the care of girl children with focus on equal opportunities for their nutrition (from birth through infancy, childhood, adolescence, pregnancy and lactation), optimal health care, education, dignity, empowerment, status and say in society. Every child must be viewed in totality - body, mind, heart and soul, and not in isolation but in context with the dynamics of their ecology, family, friends, teachers and society. We should treat the child and not his disease or laboratory reports. And every contact with the family should be effectively harnessed to provide "holistic care" and not mere "cure". We must give advice regarding life style changes, importance of personal hygiene, promotion of breast feeding, provision of safe environment, personal hygiene, optimal nutrition, immunizations and prevention of accidents. We should try to establish a rapport with the child and his parents to provide them emotionai support and win their faith, trust and confidence. We should make sincere efforts to become knowledgeable, upto-date and a rational physician to practice evidence-based pediatrics. Above all, we must strive to master the sublime art of medicine and acquire the divine gift of healing. And we should not allow technology to further dehumanize medicine!

Essential fatty acids, DHA and human brain.

Essential fatty acids cannot be synthesized in the body but they are required for maintenance of optimal health. There are two classes of polyunsaturated fatty acids (PUFAs)--omega-6 and omega-3. The parent omega-6 fatty acid, linoleic acid (LA) is desaturated in the body to form arachidonic acid while parent omega-3 fatty acid alpha-linolenic acid (ALA) is desaturated by microsomal enzyme system through a series of metabolic steps to form eicosapentaenoic acid (EPA) and decosahexaenoic acid (DHA). But there is a limited metabolic capability during early life to metabolize PUFAs to more active long-chain fatty acids. There is a critical role of EFAs and their metabolic products for maintenance of structural and functional integrity of central nervous system and retina. Most of the brain growth is completed by 5-6 years of age. At birth brain weight is 70% of an adult, 15% brain growth occurs during infancy and remaining brain growth is completed during preschool years. DHA is the predominant structural fatty acid in the central nervous system and retina and its availability is crucial for brain development. It is recommended that the pregnant and nursing woman should take at least 2.6 g of omega-3 fatty acids and 100-300 mg of DHA daily to look after the needs of her fetus and suckling infant. The follow-up studies have shown that infants of mothers supplemented with EFAs and DHA had higher mental processing scores, psychomotor development, eye-hand coordination and stereo acuity at 4 years of age. Intake of EFAs and DHA during preschool years may also have a beneficial role in the prevention of attention deficit hyperactivity disorder (ADHD) and enhancing learning capability and academic performance.

Role of micronutrients for physical growth and mental development.

Due to control of florid and severe cases of protein-energy malnutrition, deficiencies of micronutrients in children have assumed public health importance. According to National Nutrition Monitoring Bureau of India, over 50% of apparently healthy looking children have subclinical or biochemical deficiencies of vitamin A, vitamins B2, B6, folate and vitamin C. Over two-third of children have clinical evidences of iron deficiency while deficiency of trace minerals like iodine and zinc is quite common in certain populations. Children have food preferences and they are quite fussy to take green leafy vegetables and fruits thus compromising their intake of micronutrients from dietary sources. The full genetic potential of the child for physical growth and mental development may be compromised due to subclinical deficiencies of micronutrients which are commonly referred to as "hidden hunger". Micronutrients are required for the integrity and optimal functioning of immune system. Children with subclinical deficiency of micronutrients are more vulnerable to develop frequent and more severe common day-to-day infections thus triggering a vicious cycle of undernutrition and recurrent infections. A number of micronutrients are required for optimal physical growth and neuromotor development. Isolated deficiencies of micronutrients are rare in clinical practice and usually deficiencies of multiple micronutrients co-exist. The first 3 years of life are most crucial and vulnerable to the hazards of undernutrition. All efforts should be made so that preschool children are given a balanced and nutritious home-based diet. However, it has been shown that it is not possible to meet 100% requirements of recommended dietary allowances (RDA's) of micronutrients from dietary sources alone and most preschool children need administration of nutritional supplements to optimize their genetic potential for physical growth and mental development.

Ethical and social issues in the care of the newborn.

Ethical and social issues are based upon a system of moral values that serve the best interests of the society in a humane and compassionate manner. The ethical decisions should be based upon the well-enunciated principles of beneficence, non-maleficence, parental autonomy, correct medical facts and justice. In view of our economic constraints, we should follow the philosophy of utilatarian ethics based on the concept of "value for money" and focus our resources and efforts for the care of salvageable babies. Nevertheless, we should try to ensure equitable development of health care of neonates at all levels, and NICU facilities should be developed in the country in a phased manner. In order to ensure justice and cost-effectiveness, the narrow principles of "best interest" of the child should be replaced by the concept of global beneficence to the family, society and the state. Neonatologists are often faced with a large number of ethical issues and dilemmas in the care of critically sick newborn babies and they should be resolved jointly by taking nurses, sub-speciality colleagues and family members into confidence. The technology should not be allowed to further dehumanize medicine and we must establish rapport and provide emotional support to the family members by showing our concern, sympathy and compassion in the care of their critically sick and extremely preterm babies. It is desirable that all the medical and nursing schools in the country should initiate regular education programs in the field of behavioural sciences, communication techniques and medical ethics for the benefit of graduate and postgraduate medical and nursing students.

Survival and morbidity in extremely low birth weight (ELBW) infants.

We report the morbidity and mortality in extremely low birth weight neonates (ELBW) from a tertiary care hospital over seven years (1994-2000). Data regarding maternal and neonatal details was obtained from old records, computer database and medical files. Of the 12,807 live births during this period, 137 (1.07%) were ELBW infants. All of them were managed without surfactant. Overall, 67 infants (48.7%) survived to discharge. The most commonly encountered morbidities were hyperbilirubinemia(65%), respiratory distress(65%), sepsis(52%), intraventricular hemorrhage(29%), pneumonia (25%) and retinopathy of prematurity(24%). Need for resuscitation, pulmonary hemorrhage, seizures, acute renal failure, sclerema and air leak syndromes were significantly associated with mortality. Sepsis accounted for 41% of all deaths while immaturity was the second most important cause, accounting for 24% deaths. The average length of stay for survivors was 49 days (SD +/- 15.9 days)

Microbiological study of neonatal conjunctivitis with special reference to Chlamydia trachomatis.

PURPOSE: To study the microbial agents, chiefly Chlamydia trachomatis and other bacteria, in neonatal conjunctivitis. METHODS: Conjunctival specimens from 70 newborns with conjunctivitis were subjected to bacterial culture and sensitivity testing, monoclonal antibody based C. trachomatis antigen detection test and species-specific Chlamydia antibody detection in the sera of babies and their mothers, by micro-immunofluorescence assay. RESULTS: Bacteria were isolated from 35 (50%) babies; the majority (20, 57.14%) were Staphylococcus epidermidis. C. trachomatis antigen was detected in conjunctival smears of 17 (24%) babies, and 6 (35.29%) of them were positive for other bacteria. Six babies and their mothers tested positive for C. trachomatis Ig G antibodies. At follow-up after 14 weeks, 6 (35.29%) of the Chlamydia antigen-positive babies were found to have developed recurrent conjunctivitis. CONCLUSION: C. trachomatis is responsible for almost a quarter of all cases of neonatal conjunctivitis, with recurrences in 35% of cases. Bacteria could be isolated from 50% of the patients though the exact role of Staphylococcus epidermidis, isolated from 28.65% of the neonatal conjunctivitis cases, remains unclear.