Ethical issues in pediatric and neonatal resuscitation.

CPR in infants and children has a number of unique clinical, legal, and ethical aspects. The distinguishing clinical aspects relate to the circumstances of pediatric cardiopulmonary arrest and their prognostic implications. The relevant legal and ethical considerations derive from the special triadic physician-child-parent relationship, the standing of parents as surrogate decision makers, and the progressive development of decisional capacity in maturing children. This paper discusses the implications of guidelines and policies concerning decisions to provide, withhold, or withdraw CPR and life support systems.

Medical-legal aspects of immunization. Policy and practices.

The experience in the United States with the vaccine liability crisis demonstrates the vulnerability of public health policy and practice standards to independent developments in the legal arena. Scientific progress in the fields of immunology and molecular biology offer promise for the control of an increasing number of communicable diseases through immunization. Legal protections for pharmaceutical laboratories, manufacturers, and providers are appropriate incentives to continued development, supply, and administration of effective, affordable vaccines. At the same time, potential recourse to litigation in the courts in the event of vaccine-related injury provides society with desirable assurances of enforceable industrial and professional standards, as well as financial support for those who sustain serious adverse reactions to licensed vaccines. The National Childhood Vaccine Injury Act of 1986 is an attempt to construct an equitable solution to this dilemma. Interested physicians and lawyers will have a role to play in the search for an appropriate balance between these important but competing values. Progress in science and the law in the field of public health generally, and vaccine development specifically, should be a collaborative enterprise. Familiarity with, and respect for, the basic principles and theories of both fields will be essential to this endeavor.

Children as witnesses in child sexual abuse trials.

When alleged child sexual abusers are prosecuted and brought to trial, child witnesses are often exposed to procedural requirements of the criminal justice system that may cause further psychologic trauma. These procedures are driven by the dual interests of pursuing the truth and protecting the constitutional rights of the accused to a fair trial with a presumption of innocence. Proposals for judicial reforms designed to balance both interests while shielding children from potential adverse effects of the process are discussed.

Fetal abuse and neglect: an emerging controversy.

Advances in fetal medicine have expanded opportunities for protection of fetal health and intrauterine management of an increasing number of fetal disorders. The legal rights and duties of parents to provide necessary medical treatment for the child may extend to the prenatal period. Resolution of the conflict between the rights of the fetus to be born healthy and the pregnant woman's right of privacy is difficult and controversial. It is suggested that intrusion into a woman's individual fundamental rights for the potential benefit of her fetus should be permissible only in narrowly defined circumstances.

A review of pediatric inpatient care.

Between 101 and 188 medical records of children hospitalized in each of three community hospitals and one major teaching hospital were examined to determine need for admission and quality of care administered. Two of the hospitals had been similarily studied two years before. Twenty-five percent of all admissions and 17% of all patient days were considered unnecessary. The smallest number of inappropriate admissions was found in the major teaching institution, but one of the community hospitals without any teaching affiliation was notably better than the other two. The teaching hospital and the same community hospital also achieved the lowest questionable management rates. Significant (P less than 0.5) but minimal reduction had occurred in number of unnecessary admissions when first and second utilization studies in these two hospitals were compared.

Failure to thrive-an analysis of 83 cases.

The case histories of 83 children admitted to the hospital with a diagnosis only of failure to thrive were examined. In twenty-six cases there was evidence of maternal deprivation as a factor. Forty patients were found to have significant organic diseases as a possible or probable cause or contributing influence.Twenty-six were found to have some degree of mental retardation, either documented or suspected, but in nearly all of them there were associated factors presumably responsible, at least in part, for failure to thrive.Several children had birth weight less than 2,500 grams, but no child was thought to grow poorly because of prematurity alone. Congenital anomalies such as cleft palate and other problems leading to feeding difficulties were not unusual.In any case of persistent failure of an infant to gain adequately in weight and length, in which the cause is not evident, the child should be admitted to a hospital to determine response in a new environment. Also an adequate social history should be sought and siblings more closely evaluated; and careful study should be made of the renal, gastro-intestinal, cardiac, pulmonary and central nervous systems, even if there are no symptoms or signs referable to these systems.