Every now and then I come across an instance when I discover that something that I have known for some time truly is not as well appreciated as I might think.
Twice in my career I have come across the following situation which has been generalized to eliminate any specific details about a patient. In essence this is a fictional story but the conclusions are quite real.
Case of the Flat Baby
A mother arrives at the hospital with severe abdominal pain and in short order is diagnosed with a likely abruption at 26 weeks gestational age. Fetal monitors are attached and reveal a significant fetal bradycardia with a prolonged period of minutes below 100 and sometimes below 60 beats per minute. She is rushed to the OR where an emergency c-section is performed.
A live born infant is handed to the resuscitation team after cord clamping is stopped at 30 seconds due to significant cyanosis and no respirations. After placing the infant in a polyethylene wrap and performing the initial steps of ventilation there is no respiratory effort and the baby is given PPV. After no heart rate is noted chest compressions commence followed by intubation and then epinephrine when a heart rate while detected remains below 60. The team gives a bolus of saline followed by another round of epinephrine and by 10 minutes a pulse of 80 BPM is detected. While a pulse is present it remains borderline and the baby shows no sign of any respiratory efforts.
The care providers at this point have a decision to make about continuing resuscitative efforts or not. One of the team members performs a physical exam at this stage and notes that the pupils are unresponsive to light with a 3 mm pupillary diameter. The team questions whether based on this finding irreversible neurological damage has occurred.
Pupillary Reactions in Preterm Infants
It turns out that much like many organs in the body which have yet to fully mature the same applies to the eye or more specifically in this case the pupil. Robinson studied 50 preterm infants in 1990 and noted that none of the infants under 30 weeks gestational age demonstrated any reaction to light shone in the eye. After 30 weeks the infants gradually realized this function until by 35 weeks all infants had attained this pupillary reaction to light.
Isenberg in the same year when examining 30 preterm infants under 30 weeks noted that in addition to the lack of pupillary constriction to light, as the gestational age decreased the pupillary diameter enlarged. The youngest infants in this study at 26 weeks had a mean pupillary diameter of 4.7 mm while by 29 weeks this number decreased to 2.9 mm. This means that the smaller the infant the larger the pupillary size and given that these are also the highest risk infants one can see how the appearance of a “fixed and dilated pupil” could lead one down the wrong path.
Deciding when to stop a resuscitation is never an easy decision. Add to this as I recently wrote, even after 10 minutes of resuscitation outcomes may not be as bad as we have thought; Apgar score of 0 at 10 minutes: Why the new NRP recommendations missed the mark. What I can say and obviously was the main thrust of this piece is that at least when you are resuscitating an infant < 30 weeks gestational age, leave the eyes out of the decision. The eyes in this case “do not have it”.
In March 2015 the CPS Infectious Diseases and Immunization Committee released a new statement entitled Preventing Ophthalmia Neonatorum. This condition otherwise known as Neonatal Conjunctivitis is potentially vision threatening and therefore is not something to be taken lightly. This statement replaces the one from 2002 and is a significant departure from the previous version. The most striking difference were the following recommendations:
Neonatal ocular prophylaxis:
Neonatal ocular prophylaxis with erythromycin, the only agent currently available in Canada for this purpose, may no longer be useful and, therefore, should not be routinely recommended.
Paediatricians and other physicians caring for newborns, along with midwives and other health care providers, should become familiar with local legal requirements concerning ocular prophylaxis.
Paediatricians and other physicians caring for newborns should advocate to rescind ocular prophylaxis regulations in jurisdictions in which this is still legally mandated.
Jurisdictions in which ocular prophylaxis is still mandated should assess their current rates of neonatal ophthalmia and consider other, more effective preventive strategies, as outlined below.
So not only are they not recommending erythromycin any longer but they ask us as health advocates to lobby to have laws changed in order to enforce such change in practice.
It has been almost half a year since this recommendation came out and what has happened in Manitoba? Nothing. I don’t believe it is inertia but rather a visceral feeling by many that this might not be the right path. In Manitoba rates of chlamydia and gonorrhea are quite high in certain pockets of the province and the reliance on people observing for signs of eye discharge after leaving the hospital is anything but certain. Large segments of the population could be put at risk of blindness or corneal damage as a minimum if we rely on all families seeking medical attention in a timely fashion. Due to circumstance that is not always possible.
This August, Dr. C. Mulholland a Pediatric Ophthalmologist in Winnipeg and Dr. Gardiner the President of the Canadian Association of Pediatric Ophthalmology and Strabismus responded to the CPS statement with their own analysis of the literature. They found the CPS statement to be not just lacking in including all the relevant evidence but in some cases actually misrepresenting research that was being quoted. I would like to commend him for critically reviewing this statement and for his analysis. A full copy of his editorial can be found here. I would encourage you to read it as it is relatively short and to the point but perhaps the best comments from his analysis are:
“Darling and McDonald conclude that, although the randomised and quasi-randomised evidence in relation to ON is not of high quality, when additional evidence is also considered, it appears that prophylaxis does reduce the risks of both GON and CON.”
“The CPS statement claims that mild irritation produced by ocular prophylaxis has been perceived by some parents as “interfering with mother–infant bonding.” This is presented as an argument for cessation of prophylaxis. This risk is overstated. The article to which the statement refers,7 in fact, found that although eye openness was lower in those infants treated with prophylaxis, “eye openness in the new-born did not significantly alter the attention of the mother toward her baby.”
The CPS statement while intending to provide solid guidance for health practitioners I believe has missed the mark. I could not agree with Dr. Mulholland more in that any attempt to change such recommendations MUST include consultation with the speciality affected by such change and that did not happen here. As a comparison, imagine the outrage if the Fetus and Newborn committee made a recommendation on the management of inguinal hernia before discharge and did not consult with Pediatric Surgeons who ultimately would be impacted by such a recommendation.
The one battleground area may be in the situation in which a mother has screened negative for GC and insists on not treating. Previously this would cause some consternation among our health care team but if we know the result is negative, they appear to be reliable and are educated about the signs to watch for this may not be a battle worth having.
While I remain a tremendous proponent of the work being done by the CPS I believe they missed the mark on this one. All statements must include a comprehensive evaluation of the literature which includes all relevant studies. Cherry picking articles to help prove ones bias does not lead to good recommendations and for that reason at least in Manitoba I do not see us changing our practice.