Pediatric Annals

EDITORIAL 

A Pediatrician's View: How Low Can You Go? Making Tough Decisions

Robert A Hoekelman, MD

Abstract

This issue of Pediatric Annals, with Barry V. Kirkpatrick, MD, and Greg R. Elliot, MD, of the Medical College of Virginia, as its Guest Editors, addresses a variety of pulmonary diseases affecting infants, children, and adolescents.

As I read these articles, I kept thinking back to the early 1950s when I was a pediatric resident at Dartmouth's Mary Hitchcock Memorial Hospital in Hanover, New Hampshire, and at Columbia's Babies Hospital in New \brk City - thinking back to my teachers and what they taught me about neonatal intensive care, cystic fibrosis, tuberculosis, recurrent and persistent pneumonia, and asthma. Those teachers were among the best of their time - William Silverman (neonatology), Dorothy Anderson (cystic fibrosis), Hattie Alexander (tuberculosis), and Colin Stewart (asthma). I don't recall who was the expert on children having recurrent and persistent pneumonia, if there was one, but John Caffey sure knew how to read their chest x-rays. As a primary care practitioner during the 1950s and 1960s, 1 was able to use what these mentors taught me to good advantage. But things have changed considerably in each of these fields since then, as the articles in this issue clearly document.

The best example of this relates to the treatment of premature infants in our delivery rooms and our neonatal intensive care units. Only a few newborns weighing less than 1000 g survived in the early 1950s; most died from hyaline membrane disease, now known as respiratory distress syndrome. There wasn't much to do for them except to keep them warm in an isolette (newly on the market) and give them oxygen - too much oxygen for some who developed retinopathy of prematurity (then called retrolental fibroplasia) and blindness. If very tiny babies did not breathe spontaneously, there were no respirators to use, and they were left on their own, soon to die. Those who did live, did so without the aid of the high technology we have available to us today.

Bill Silverman relates his experience during that era with a 600-g baby girl who lived for 3 1Zz months.1 Prior to that, no baby that small had ever lived more than a few hours at Babies Hospital. He uses that example to make the point that he overtreated that baby - an example in which he invested much of his personal energies and emotions trying to keep the baby alive and one in which the parents were not grateful for his efforts to save their unplanned for, unwanted baby. In doing so, he went beyond the then-current expectations of his profession and of the baby's parents.

Professional and parental expectations have changed since then. Gradually, with the application of high technology and expanding knowledge and experience, we have raised those expectations while lowering the "cut off birthweight we term as viable to 500 g. But in 1988, a 345 -g infant born in Rochester, New York survived.2 She survived despite a 7-month stay in the neonatal intensive care unit, during which she experienced respiratory distress requiring intubation and ventilatory support, several bouts of staphylococcus sepsis, necrotizing enterocolitis, cholestatic liver disease, and bronchopulmonary dysplasia. She survived, with testing 4 years later that revealed normal gross-motor skills, somewhat delayed finemotor skills, moderately delayed receptive language, severely delayed expressive language, and moderately delayed cognitive development. She survived with parental consent for all that was done for her. She survived at huge financial costs, most of which have been and will be borne by the public.3

Much criticism has been leveled at neonatologists who save presumed nonviable babies. Silverman levels it at himself, retrospectively, and at those neonatologists who…

This issue of Pediatric Annals, with Barry V. Kirkpatrick, MD, and Greg R. Elliot, MD, of the Medical College of Virginia, as its Guest Editors, addresses a variety of pulmonary diseases affecting infants, children, and adolescents.

As I read these articles, I kept thinking back to the early 1950s when I was a pediatric resident at Dartmouth's Mary Hitchcock Memorial Hospital in Hanover, New Hampshire, and at Columbia's Babies Hospital in New \brk City - thinking back to my teachers and what they taught me about neonatal intensive care, cystic fibrosis, tuberculosis, recurrent and persistent pneumonia, and asthma. Those teachers were among the best of their time - William Silverman (neonatology), Dorothy Anderson (cystic fibrosis), Hattie Alexander (tuberculosis), and Colin Stewart (asthma). I don't recall who was the expert on children having recurrent and persistent pneumonia, if there was one, but John Caffey sure knew how to read their chest x-rays. As a primary care practitioner during the 1950s and 1960s, 1 was able to use what these mentors taught me to good advantage. But things have changed considerably in each of these fields since then, as the articles in this issue clearly document.

The best example of this relates to the treatment of premature infants in our delivery rooms and our neonatal intensive care units. Only a few newborns weighing less than 1000 g survived in the early 1950s; most died from hyaline membrane disease, now known as respiratory distress syndrome. There wasn't much to do for them except to keep them warm in an isolette (newly on the market) and give them oxygen - too much oxygen for some who developed retinopathy of prematurity (then called retrolental fibroplasia) and blindness. If very tiny babies did not breathe spontaneously, there were no respirators to use, and they were left on their own, soon to die. Those who did live, did so without the aid of the high technology we have available to us today.

Bill Silverman relates his experience during that era with a 600-g baby girl who lived for 3 1Zz months.1 Prior to that, no baby that small had ever lived more than a few hours at Babies Hospital. He uses that example to make the point that he overtreated that baby - an example in which he invested much of his personal energies and emotions trying to keep the baby alive and one in which the parents were not grateful for his efforts to save their unplanned for, unwanted baby. In doing so, he went beyond the then-current expectations of his profession and of the baby's parents.

Professional and parental expectations have changed since then. Gradually, with the application of high technology and expanding knowledge and experience, we have raised those expectations while lowering the "cut off birthweight we term as viable to 500 g. But in 1988, a 345 -g infant born in Rochester, New York survived.2 She survived despite a 7-month stay in the neonatal intensive care unit, during which she experienced respiratory distress requiring intubation and ventilatory support, several bouts of staphylococcus sepsis, necrotizing enterocolitis, cholestatic liver disease, and bronchopulmonary dysplasia. She survived, with testing 4 years later that revealed normal gross-motor skills, somewhat delayed finemotor skills, moderately delayed receptive language, severely delayed expressive language, and moderately delayed cognitive development. She survived with parental consent for all that was done for her. She survived at huge financial costs, most of which have been and will be borne by the public.3

Much criticism has been leveled at neonatologists who save presumed nonviable babies. Silverman levels it at himself, retrospectively, and at those neonatologists who succeeded him.1 Four editorialists (an epidemiologist,4 a sociologist,5 a premature baby's parent,6 and a neonatologist7) leveled criticism at the Rochester team and others who would save these tiny babies. Their criticism is compelling - poor quality-oflife for these babies and their parents, much suffering along the way, and enormous expenditures of medical resources that are in short supply for so many persons who have infinitely better prognoses than babies with birthweights under 500 g. Compelling criticism, yes, but not convincing to many, some of whom say it is an extremely difficult choice to make - to treat or not to treat - when individual babies are "staring you in the face" and parents, who want you to do everything possible to save their baby, are looking over your shoulder.8

It is a tough decision that goes beyond the interests of individual babies and their parents. It is a decision that should consider, in its making, our country's debt-laden, failing economy - an economy that cannot support the health-care needs of a large portion of its citizens, many of whom will die or suffer severe morbidity for our lack of providing them with routine immunizations and with programs for preventing substance abuse, teenage pregnancy, sexually transmitted diseases, accidents, homicide, and suicide.

I'm glad I am not a neonatologist.

REFERENCES

1. Silverman WA. Overtreatment of neonates.' A personal retrospective. Pediatrics. 1992;90:971-976.

2. Sherer DM, Abramowicj JS, Bennett SLt et al. Case report: survival of an infant with a birthweight of 345 g. Birth. 1992;19:151-153.

3. Mercier CE. Reply to editorial comments. Brrm. 1992;19:160-161.

4. Panetti N. Tiny babies- enormous costs. BnA. 1991;19:154-155.

5. Guillemin J. The problem of probable outcome. BrrtA. 1992;19:155-156.

6. Harrison H. Medical miracle or Pyrrhic victory. Btrm. 1992;19:157-158.

7. Campbell N. Neonatologists versus the rest - the need for new rules. BfrrA. 1992;19:158-160.

8. Phoon CK. Parents often urge overtreatment. Ratones. 1993;92:187-188.

10.3928/0090-4481-19930901-04

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