Substance abuse in pregnancy: a major ethical challenge for pediatricians.

This article has conceptualized substance abuse in pregnancy as a major ethical challenge for pediatricians. At the outset, it was suggested that ethics need not be a question of bad consequences, right or wrong, guilt, or fixed principles, but a question of information sought, faced, and taken into account in action. Hopefully the information contained in this issue of Pediatric Annals will shed new light on the present, thus enabling pediatricians to reconceptualize their downstream efforts on behalf of drug-exposed infants and their families as something other than futile and hopeless labor and encourage pediatricians to move further upstream and join in a public health effort to prevent substance abuse in the first place.

Teaching intubation skills using newly deceased infants.

This prospective study was designed to (1) test the hypothesis that the majority of families of newly dead infants in a tertiary neonatal intensive care unit would consent to their infants' being intubated for teaching purposes, (2) determine factors related to family consent, and (3) determine the effects of participation on resident physicians and respiratory therapists. Family consent for intubation was requested following 44 (80%) of the 55 deaths that occurred during the 10-month study period. Of these requests, 32 (73%) were granted. Proportionately more white than black families consented and consent was positively related to autopsy permission. Fifty-three (75%) of 71 trainees completed a mailed questionnaire after their first intubation experience. Although each respondent found the experience helpful, many reported mixed feelings categorized as doubt about participating, apprehension and discomfort, respect for the body, appreciation for the opportunity, a sense of achievement, and feelings of comfort knowing that consent had been obtained. These findings confirm our initial hypothesis and suggest that (1) newly dead infants can be a valuable resource for teaching intubation skills, and (2) others considering a similar approach need to be aware of and sensitive to trainees' feelings.

Effects of early intervention and stimulation on the preterm infant.

To test the hypothesis that early intervention can enhance the development of high-risk preterm infants, a prescribed multimodal sensory enrichment program, within a regional neonatal intensive care unit, was designed and implemented. Twenty-eight appropriate-for-gestational age infants with birth weights between 1,200 and 1,800 gm were selected for study. To prevent control group contamination by the enrichment procedure the first 14 infants were designated as the control group, and the next 14 as the treatment group. Treated infants had significantly higher developmental status than control infants, as measured by the Bayley Scales of Infant Development, at six months past the maternal expected date of confinement (F = 14.98, P < .001, and F = 16.46, P < .001 for the mental and motor scales, respectively). Mean infant weight gain per day and mean total weight gain during the hospitalization were not significantly different for the two groups although the treatment group received significantly less calories per kilogram per day than the control group (F = 9.02 P < .006). Our data suggest that a prescribed intervention program for high-risk preterm infants appears to enhance the quality of development as measured at six months past the expected date of confinement. Further studies are necessary to determine the long-term value of early intervention and the apparent ability of infants receiving an enrichment program to utilize calories more efficiently than control infants.

Iatrogenic prematurity due to elective termination of the uncomplicated pregnancy: a major perinatal health care problem.

In a series of 1,000 newborn infants referred to a regional neonatal center, 32 iatrogenically preterm infants were identified. All had been delivered following elective termination of uncomplicated, apparently term pregnancies, without prior documentation of fetal lung maturity or ultrasonic determination of fetal biparietal diameter. Associated acute morbidity included asphyxia neonatorum in 10, respiratory distress syndrome in 24, and pneumothorax or pneumomediastinum in nine patients. One infant died. Hospital costs totaled $150,643, for a mean of $4,701 per patient. The unexpected premature births were associated with major parental grief reactions and alterations in their daily activities, Iatrogenic prematurity is a major regional health care problem which, when viewed on a national basis, may affect thousands of newborn infants and their families annually. Our data suggest the need for more accurate assessment of fetal maturity, before elective termination of pregnancy, by well-established techniques.

Grief response of parents to neonatal death and parent participation in deciding care.

We determined the grief response to neonatal death of 50 mother-father pairs by administering a questionnaire and conducting a semistructured interview during the infant postmortem review. As measured by a parent grief score, maternal grief significantly exceeded paternal grief (t = 5.89, P less than .0001). Parent grief was not significantly related to birth weight, duration of life, extent of parent-infant contact, previous perinatal loss, parent age, or distance from the hospital of birth to the regional center (Pearson product-moment correlation coefficients). However, the attitudes and behavior of family, friends, and health care personnel in the hospital of birth often adversely influenced parent grieving. Of 39 mother-father pairs whose infants required respirator support, 18 participated in a group decision with their physician to withdraw respirator support when the prospects of infant survival seemed hopeless (limited respirator care group). No significant differences in parent grief scores were found (t tests) when the limited respirator care group was compared to those parents of infants who died despite uninterrupted respirator care. Our data suggest that informed parents can participate as partners with their physician in difficult infant care decision, even when death results, and adjust to their loss with healthy grieving.