Ethical concerns in the management of pain in the neonate

The debate about the management of pain in the neonate has continued to evolve over the past 30 years. This controversy can be understood as evolving through now three eras of thought about the effect of pain and its management in newborns and infants. The first generation was characterized by a widespread belief that newborns lacked the complete development of the neuroanatomical and neuroendocrine components necessary to perceive pain. During this period, newborns often received inadequate anesthesia and analgesia for painful procedures, if not no treatment at all. The second generation was heralded by research that demonstrated that newborns did demonstrate similar or even exaggerated physiological and hormonal responses to pain compared with those observed in older children and adults and that exposure to prolonged or severe pain may increase neonatal morbidity. Controversy in this generation focused around the dosage of analgesia to newborns as well as the risks and benefits of pain management techniques. We are now in a third generation of thought about pain in the neonate, defined by intense debate over the significance of a growing number of studies in immature animal models that demonstrate degenerative effects of several anesthetics on neuronal structure. The challenge of this era is to integrate the advances in diagnosis and treatment achieved in previous generations with ongoing adaptation of clinical practice as dictated by research advances in the field. In this review, we examine the evolution of medical thought and ethical concerns regarding pain treatment in the neonate.     

PEER REVIEW OF UTILISATION OF MEDICAL BEDS AT FLINDERS MEDICAL CENTRE

A clinical audit of all medical inpatients was undertaken and the appropriateness of admissions and of length of stay was assessed from a clinical viewpoint on 4 separate days within an 11 day period. In addition, the mode of entry to hospital, length of stay of patients, occupancy rate, and the vacancy interval were analysed for all medical patients during the preceding three months. The mean length of stay of medical patients in hospital during this 3 month period was 5.6 days, with an occupancy rate of 93% and a vacancy interval of 0.43 days. Seventy-four percent of all medical inpatients were admitted through the Accident and Emergency Department (A&E). The short length of stay, high occupancy rate and low vacancy interval indicated that bed usage in the medical wards was efficient. A total of 493 reviews was carried out on 294 individual patients. In 87% of cases, both admission to hospital and length of stay were appropriate on clinical grounds alone. The number of patients whose admission to hospital (11), or length of stay (27) was not justified on medical grounds alone was 38 (13% of total patients). These patients were elderly, or had complex social and psychological problems contributing to their illness. It was concluded that stricter control of admissions or length of stay was unlikely to make a significant number of beds available for other admissions.     

Prevalence and aetiology of neurological impairment in extremely low birthweight infants

Objective : To determine the prevalence and perinatal predictors of cerebral palsy, intellectual impairment, visual impairment and deafness in a cohort of extremely low birthweight (ELBW) infants at two years of age.
Methodology : The study population comprised 199 of the 224 (89%) ELBW infants managed at the Mater's Mothers Hospital, Brisbane, between July 1977 and February 1990 and who survived to two years. The prevalence of cerebral palsy, intellectual impairment, blindness and deafness was measured by clinical, psychometric and audiological assessment and the association with 24 risk factors examined.
Results : Cerebral palsy occurred in 20 children (10%). Risk of cerebral palsy was associated with ventricular dilatation, intraventricular haemorrhage, necrotizing enterocolitis and multiple birth, though only ventricular dilatation (OR 4.41; 95% Cl 1.32-14.8) remained significant in the adjusted analysis. Intellectual impairment occurred in 20 children (10%) and was independently associated with ventricular dilatation (OR 15.0; 95% Cl 2.2-102.8), ventilation F _iO₂ >80% (OR 3.4; 95% Cl 1.01-11.5), vaginal delivery (OR 3.5; 95% Cl 1.09-11.4) and male sex (OR 6.1; 95% Cl 1.67-22.3). No perinatal predictor was statistically associated with risk of deafness. Retinopathy of prematurity (OR 36.9; 95% Cl 2.8-495.5) was associated with risk of later visual impairment.
Conclusions : Intellectual impairment was associated with a broad range of perinatal variables. Cerebral palsy was associated with fewer variables, all of which were also associated with intellectual impairment. Neurologic injury was associated with male sex and multiple birth, which are not biological insults themselves, but may be markers of susceptibility to injury.     

Dietary manipulation in childhood atopic dermatitis

The dietary habits of 73 children seen consecutively in a dermatology out-patient department were studied to ascertain the nature and frequency of dietary manipulation and to assess any potential hazards. Although most children had only mild flexural dermatitis, 71% had had significant alterations made to their diet before attendance at hospital. Almost all diets were unsupervised and only six children had seen a dietitian. Over half had been started on diets before any professional advice had been sought. Information on diet had come from media, books or magazines (51%), friends (32%), general practitioners (27%) and district nurses or health visitors (18%). The major dietary alterations included the exclusion of eggs, dairy products and food additives, and the use of soya and goat's milk. Under 10% of patients claimed benefit from these largely unsupervised diets. Harmful practices included the frequent use of unboiled, unpasteurized goat's milk, unmodified goat's milk in a baby of 4 months and the use of severely restricted diets. Three children (6%) in the diet group had been on diets which were considered by a hospital dietitian to be particularly dangerous. However, there was no evidence of growth retardation, failure to thrive or specific deficiency syndromes in the group we studied. Uncontrolled, unsupervised and often prolonged dietary alterations are commonplace in children with atopic dermatitis. This is a potentially serious health problem.