[Could infant euthanasia be ever acceptable?]. / ¿Podría ser aceptable la eutanasia infantil?

The recent enactment of a law that allows infant euthanasia in Belgium raises questions with varied answers. To contribute to a better understanding of the topic, euthanasia and legislation concepts are described. After a bioethical analysis, we propose as conclusion that children euthanasia could only be acceptable in very exceptional situations in which palliative measures have failed. The answer should be that it is not acceptable in our setting, not until we have public policies, protocols and palliative care services for terminally ill children.

[Maternal brain death during pregnancy]. / Muerte cerebral materna durante el embarazo.

The case of a pregnant patient who had a massive intracraneal haemorrhage at 18 weeks of gestation is presented. Patient's neurological damage evolved to brain death, but the fetus continued in good condition. The decision of withdrawing life support or to continue supporting the mother's life to allow fetal development aroused difficult ethical questions, both to relatives and professionals. This is an exceptional situation of a heart beating cadaver and a non viable fetus whose life depends on the continuation of treatments that are considered as experimental. A good decision should be based on the respect to a body in brain death, the fetal right to life, family's wishes and values, the use of experimental treatments, and the rational use of a public hospital's resources. The conclusion was that the continuation of life support treatments was not an ethical obligation. Withdrawing life support to allow fetal death in this case means foregoing an experimental treatment and to respect family's autonomy and the right of the patient's death with dignity. Similar cases need to be discussed with a multidisciplinary analysis in their own particularity.

Do not resuscitate orders and pediatric patients: the role of a clinical ethics committee in a developing country.

No published information is currently available about formal "do not resuscitate" (DNR) orders for pediatric patients in developing countries, even though there has been extensive discussion of how to determine who should be involved. This article reports the experience of a clinical ethics committee that recommended DNR orders at a pediatric public hospital in Chile. The committee consisted of four permanent physician members and temporary members including clergymen, nurses, the head of the patient's hospital unit, and the attending physician. Attending physicians submitted cases to the committee on a voluntary basis, and the committee's recommendations were not binding. During the 1990-1993 study period the committee recommended issuing DNR orders for 16 of the 34 patients it evaluated. The hospital records of these 16 patients were retrospectively reviewed for information about the patient's age and diagnosis, the committee's specific recommendations, and the outcome of the case. It was found that the committee typically recommended specific measures to help the child's parents and attending staff in addition to the DNR order. The average patient age was 2 years and 2 months. Nearly all of the patients had chronic and multiple pathologies. In all cases the committee recommendations (taken by consensus) were followed by the attending physician with the consent of the patient's parents. Eleven of the 16 patients for whom DNR orders were issued died during the study period. The five others remained alive despite respiratory insufficiency, severe neurologic damage, or hepatic failure. In general the committee's recommendations appeared useful, providing stronger arguments for DNR decisions and suggesting further support measures for patients, their families, and the attending professionals. This finding supports the idea that clinical ethics committees can provide both valuable support and an opportunity to arrive at better decisions in the public hospitals of developing countries.

[Diagnosis of neonatal femoral thrombosis following umbilical arterial catheterization by ultrasonic flow detection]. / Diagnóstico por Doppler de la trombosis arterial causada por cateterismo umbilical.

At her second day of life, a 2,200 g, 34 weeks gestational age female newborn infant with idiopathic respiratory distress syndrome, under treatment with mechanical ventilation and monitored through an umbilical arterial catheter (UAC), had severe clinical signs of arterial obstruction of her left limb. Signs of occlusion at the common femoral artery level were evident at Doppler ultrasonography. Doppler determinations showed early arterial blood flow improvement before amelioration of skin coloration and arterial pulses, that allowed close observation and withholding of surgical treatment which was finally not necessary. Eighteen newborn babies with an umbilical arterial catheter were then prospectively followed by Doppler ultrasound flow determinations. No further cases with clinical signs of arterial occlusion were found and Doppler studies performed in these late cases showed normal results in all of them. Doppler ultrasound flow determination is helpful for the diagnosis and management of lower limb arterial obstruction in newborn infants with umbilical arterial catheters.

[Home oxygen therapy in children with bronchopulmonary dysplasia]. / Oxigenoterapia domiciliaria en niños con displasia broncopulmonar.

Eight babies with severe bronchopulmonary dysplasia (BPD) were discharged from a private hospital at Santiago, Chile, on a program that provided oxygen therapy at home. Mean gestational age was 27 +/- 2 weeks and mean birth weight was 1,181 +/- 353 g. Discharge was decided after stabilization of arterial PO2 or O2 Sat, PCO2 less than 50 mmHg and adequate weight gain. Prior to discharge parents were trained in O2 administration and cardiopulmonary resuscitation. Oxygen was given at home for a mean of 71 days (range 7 to 339). There were no complications secondary to oxygen therapy. At follow up in only two cases additional hospitalizations were needed, in both instances because of intercurrent respiratory infections. Weight gain between 3d and 50th percentile were seen in all cases. Oxygen therapy at home appears to be a good alternative in the treatment of infants with BPD, and it reduces significantly hospital stay and costs. Both optimal family conditions and adequate support at home are needed.

[Mortality by birth weight and survival by gestational age and route of delivery in premature infants]. / Mortalidad por peso de nacimiento y sobrevida por edad gestacional y vía de parto en recién nacidos de pretérmino.

Specific mortality rates for birthweight (BW) and survival for gestational age were determined in babies under 1500 g and less than 34 weeks gestational age (GA), which were born in a private hospital at Santiago, Chile, between 1983 and 1988. Mortality rates were 875/1,000 in babies under 750 g, 391/1,000 for BW between 750 and 999 g, 185/1,000 for BW 1,000 to 1,249 g, and 125/1,000 in newborns who weighed 1,250 to 1,499 g. Survival increased with gestational age from 39% under 26 weeks to 57% at 26 and 27 weeks, reaching 83% at 28 and 29 weeks, 90% at 30 and 31 and 87% at 32 and 33 weeks. No significant difference was found neither in mortality nor in intracranial hemorrhage (ICH) incidence between newborns delivered by cesarean section or vaginal way. Survival of babies born after 26 weeks GA and weighing over 750 g was comparable with that reported by others. The type of delivery is not likely to play a role by itself in mortality or in incidence of severe ICH.

[Height, weight and head circumference according to gestational age in newborn infants born before 35 weeks]. / Talla, peso y perímetro craneano según edad gestacional en recién nacidos de menos de 35 semanas.

A retrospective and collaborative study was done in Santiago, Chile, in order to obtain national data on birth-weight, height and head circumference of babies born at 24 to 34 weeks of gestation: 370 babies with reliable gestational age, single pregnancies and no maternal nor fetal morbidity were included in the study. Babies were born in three government and one private hospitals from 1982 to 1987. Mean birthweight, height and head circumference for each gestational age from 24 to 34 weeks are presented in tables with their S.D. and charts +/- 1.5 S.D. The national use of these tables and curves is recommended.