Since that post, an incredible shift has occurred in the way that we as a team view attempts at resuscitation at 23 weeks. It took a great deal of dialogue among all health care providers and a deeper understanding of concerns of both Obstetrical and Neonatal colleagues to come to a mutual understanding that could yield a path to move forward. Through dialogue, the damage that had been done by the development of a “broken telephone” was repaired and trust emerged across disciplines which was the only way forward from the beginning.
Why not 22 weeks?
Yes, gestational age is so much more than just a number and must include estimates of fetal size, certainty of dates, parental wishes and several other factors to arrive at a decision that incorporates the wishes of the family. There are certainly significant challenges to informing families during a time of incredible stress as to the options that lay before them but we have to do our best in the time that we have.
When you are crossing that barrier of 24 weeks gestation, despite the caution above about the uncertainty surrounding gestational age dating there is a significant mental leap to move to 23 weeks. The leap to consider 22 weeks is even larger and I would suggest several fold. Is it possible that we would resuscitate such an infant? Absolutely if the dating was uncertain, the family had strong wishes and the team was on board with such a decision but for now this will not be advocated for at all in our city. I suspect similar discussions are happening all over North America and it will be fascinating to see where we land in 5, 10 and more years into the future.
What was the most important change to practice to enable progress?
Prior to 2015 we had one survivor at 23 weeks in a five year period. This year out of five actively resuscitated 3 have survived and at early assessments seem to be doing well. The overwhelming consensus was that skin care needed to be of paramount importance in this process. To that end we began a new process for cleaning the umbilical cord for line insertion with the goal to minimize skin burns on the abdomen. I am proud to report that since we change our technique there have been no skin burns found where once this was commonplace.
The process can be found in this short video here.
For now though, we are about to embark on a new journey in our city and I look forward to the continued collaboration with Obstetricians, Ethicists and all members of the Neonatal team as we explore this new frontier together.
I thought you may find it useful to see how this journey began and where we think it may go by watching this video of myself, Dr. Craig Burym (Obstetrics) and Dr. Aviva Goldberg (Ethics) presenting the approach to resuscitation at 23 weeks from the Neonatal, Obstetrical and Ethical standpoints. The video is about 50 minutes in length but truly addresses issues from multiple vantage points so if you missed it or are interested in how these issues were dealt with please have a look.
(If you are watching this on an Apple computer please use Safari to view)
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.
Last night’s Republican debate featured many challenges and criticisms of the front runners by contenders as is typical of most such televised features. Among the many topics discussed was the following exchange between Ben Carson a retired Neurosurgeon and Donald Trump. While I am not an American, I believe both of them should be ashamed for putting children’s lives at risk by taking the “political road” and trying to play both sides. Are the votes really worth it? For a glimpse into the exchange see the following link.
The response by Ben Carson should have been much stronger and in giving a tepid answer (no doubt to appease the masses on the opposite side of the discussion) he let the medical establishment down. Perhaps if Ben had read the following discussion on the topic he would have answered differently.
The Story of MMR and Autism
Children with autism may be healthy but life may be anything but easy. WIth the receipt of any bad news comes different phases of emotion but one common reaction is search for answers. Today I experienced an exchange of comments on Twitter from someone who disagreed with some comments I made with respect to giving the MMR vaccine. The gist of it was that they had been the responsible parent, listened to the doctors of the world and given the MMR vaccine only to find out some time later that their child was diagnosed with autism. I feel for this person and every other parent touched by this diagnosis. It is devastating and life changing although with time and a lot of work such children can make great strides but sadly not all.
I understand then the fear of receiving such a diagnosis is a compelling reason to avoid getting vaccinated if there is even a chance that your child could develop autism. You are wanting to protect your child and I commend you for that. Unfortunately while trying to protect them you are in fact leaving them unprotected and for that matter the rest of the children in your community. The aruguments against vaccinating with MMR centre around three major arguments. The first is that parents often recall receiving the vaccine shortly before the diagnosis of autism was given, the second that the literature supports that autism is caused by vaccines and the last that when the MMR vaccine was brought into existence autism rates started to rise. Below I will address each point with factual information that I hope in some way will make an impact on those who hold onto the beliefs which is all they are that their child developed autism due to the vaccine.
Under a year of age language is fairly limited. Social interaction, language and repetitive behaviours are typically noted after the first year of life. Given the timing of the diagnosis and the provision of MMR at a year of age it is no wonder that parents will attribute the vaccine to the diagnosis. Let’s think about this though for a minute. What is happening here is confirmation bias. As a parent you have heard that MMR can cause autism although thankfully it is quite rare but when you get the diagnosis you immediately jump to the conclusion that this is the true cause. What you have is an association and nothing more but your mind has convinced you otherwise. It equally could have been the new cookie you gave your child that month, the fumes from the car in a traffic jam or any other possible influence or it could be that it was always going to happen but as humans we need to make sense of things. Its in our genes but it causes us to make a dangerous link that to be frank just doesn’t exist.
Autism is caused by the MMR vaccine
This argument centres around a extremely well cited paper that has been refuted. Andrew Wakefield published a link between autism and the MMR vaccine that set the world on fire. The paper though was shown to be fraudulent and has been the subject of many publications since. retraction: http://bit.ly/1wb3Xjn
Let’s think about this for a second. What if this paper had never been published in the first place? A link between vaccines and autism would not have been put in the minds of people such as Jenny McCarthy and other people outspoken against vaccines (she has since softened her stance). In fact most people would not have even thought of such a link. In essence the argument would not have even been present in pop culture and the wave of anti-vax literature would not exist. Those young people who weren’t alive in the 1970s which is the time of our last point would not even be aware of the argument. So the question is, if the lie had never been told would we even need to write pieces like this today? Hard to believe people stand on an argument that was never meant to be in the first place. To put it another way, if I published a paper that I confirmed a sample from the moon contained cheese and it spread throughout the media outlets of the world, if it was refuted would anyone actually cite it? The fact is these people who are either scared of vaccines or have a child with autism need something to hang onto and this is it.
Autism rates increased after MMR came along
Again this is an association that people have attributed to be causative. For a wonderful explanation of this phenomenon in the 1970s please read the article at this link: http://1.usa.gov/1MajxDf
Autism diagnoses did in fact rise but that had more to do with a change in the way doctors classified autism than any external factor.
What all three points have in common is that we as parents need to find order where there is disorder. We also have the same drive as physicians to do no harm. It is compelling and strong in all of us. Each and every person who writes anti-vax literature I believe is not out to harm us but they truly believe that the reading they have done or the simple beliefs they have are the right ones.
What I ask is that people read a blog such as this and open themselves up to a paradigm shift. If you can read what I have written and convert your thinking to one where you realize that all you have believed was based on poor information and switch to one in which your drive is protect your child by immunizing them your children and our children will all be better for it.
First off I should state that while I generally love Apple products and have owned many, I have no financial interest in the company so this is not a plug with a hidden objective. Rather I was tipped off by a friend who is co-founder of Kindoma (a brilliant piece of software I would add that I also previously wrote about here). She was watching the Apple Keynote address and texted me after she saw something that she knew might pique my interest. No it wasn’t a bigger or faster iPhone, an iPad or even the Watch itself but rather a new capability using an Watch that I believe will revolutionize how we physicians and other health care providers interact with each other.
The short 4 minute presentation was by the founders of a piece of software called Airstrip and thankfully I was able to isolate just that presentation
I like others work in a busy NICU that at any given time has multiple babies receiving myriad blood and radiological tests. In tandem there are babies in need of physical exams, discharges to prepare, lectures to hear and paperwork to sign. After testing is ordered there is no way to predict exactly when results will be ready but when they are, we rely on our memory or the assistance of the bedside nurses to remind us that we need to follow-up. In the case of testing that is slow to come back, such as those that are only batched on certain days or sent to an outside laboratory the potential for missed follow-up is high.
Do Physicians Actually Miss Tests?
This was in fact the subject of a systematic review The safety implications of missed test results for hospitalised patients: a systematic review. This study examined the results of 12 studies, each of which sought to determine how commonly results were missed by staff physicians. One of the studies included found that 28.8% of the time results that were considered urgent were never accessed by the physician. Interestingly 5.1% of the time they did attempt to see them via a login terminal but before the results were ready so in other words were either too early or too late (not at all before the patient left). When looking at only emergency room settings, seven studies quantified the extent of failure to followup in EDs This ranged from 1.0% to 75% of tests and 0% to 16.5% of patients treated in the ED. Test types included: radiology with failure to follow-up ranging from none to 5.6%; microbiology with failed follow-up ranging from 3.0% to 75% and urgent biochemistry with 44.7% not followed up. One can see the comparison between a busy NICU and an ED so to think that so many tests can be missed due to lack of follow-up is frightening. Another concerning finding from the above analysis was that whether the hospital used paper, paper/electronic charting or purely electronic did not affect the rate of missed results.
Another question though is how quickly do physicians respond to a critical result.
This was the question that Kuperman GJ and colleagues tried to answer in their paper from 1998. In the chart review of a 9 day period, 99 test results were identified as being critical (CLR). Among these 99 CLRs, the median time interval until an appropriate treatment was ordered was 2.5 hours. This interval was 1.8 hours when the CLR met the laboratory’s criteria and a phone call was made, and 2.8 hours when the CLR met more complex criteria not requiring a phone call (p = 0.07). Shockingly, for 27 (27%) of the CLRs, an appropriate treatment was ordered only after five or more hours. The use of a phone call system does not seem to truly improve the reaction time even for these critical results.
You might be surprised by the minimal increase in efficiency with such a paging system but I can’t say I am shocked. Having a system that still requires the provider to call back or check a computer is great if the person is free at the time but what if they are with a patient or being pulled in three different directions in the ED. Will they still remember to answer the page? In many cases I imagine they might forget and then recall afterwards.
How Will Airstrip Resolve These Issues?
It is unclear to me whether the data from an electronic patient record needs to be pushed by a nurse or whether it can be automated but if not now I am certain the future will have this capability. Information can be pushed to the Watch as soon as it is reported so the clinician need only glance down at their watch to see the results. Guessing as to whether the results are ready is eliminated as are wasted minutes each time they sit down at a terminal to check if they are done. Imagine as well ordering an x-ray and a message appearing on the watch to inform you it is processed and ready for viewing. Then there is the ripple effect to consider. At some point perhaps even now the bedside nurse or unit clerk need to waste time finding the doctor to remind them to check. They could focus on the patient which is something they would rather do I imagine anyway!
In terms of privacy issues the technology is able to recognize when the physician is wearing the watch and push the data to them as long as it is on their wrist. Once removed (if taken off in a washroom and forgotten) it is disabled and in addition is HIPPA compliant with hospital compliance requirements.
There is additional functionality with being able to communicate with the nurse or family of a patient via the linked patient, family, nurse and lab results to the physician. Imagine getting the results of a head ultrasound and while walking from viewing the images sending the family a note via secure text letting them know you are coming to the unit if they want to hear the results. Embedded within this technology is also the ability to send orders to the EPR via a touch interface on the iWatch. Get an abnormal set of electrolytes that you believe is dilutional? Simply tap the electrolytes order on the Watch and the EPR notifies the bedside nurse or lab to recollect. I could go on with the many potential improvements to workflow that this technology may bring but thus far as you can tell I am quite impressed.
The chief problems that we face as providers in a busy NICU are failing to follow-up on results, and acting on these results. Airstrip on the iWatch would certainly go a long way to helping with these issues. I imagine a study to prove such efficiency will soon follow and if the results are as I expect I look forward to seeing an Watch on all of our medical staff in the near future. Better care is always our goal and this could be one efficient way to achieve it.
Nick is a tremendous advocate for premature infants and their families everywhere and as President and Co-Founder of Graham’s Foundation certainly puts himself front and centre. For more information on the incredible work he and his team are doing please see their website at and if you are in the New York area please consider attending their charity benefit to help raise some funds to continue the work that they do.
As it pertains to his question though it did get me thinking. How does a National body like the AAP determine best practice suggestions for a country with 50 states in which roughly 320 million people reside? Using 2013 USA census data ,showing 23.1% of it’s citizens are under 18 this equates to nearly 74 million children. This is a daunting task no doubt and due to regional variation in terms of expertise and available resources not all policies or guidelines are possible to implement equally or at all.
The article that is being addressed in his question of the day is from Med City News which addresses the latest statement from the AAP on managing an anticipated birth before 25 weeks. For the actual statement that the article refers to please see this link which will direct you to the actual paper.
When the Canadian Pediatric Society (CPS) reaffirmed their statement in January 2015 it drew a fair bit of criticism from Canadian Neonatologists and others from abroad due to it’s draconian approach to infants at 22 and 23 weeks gestation. In the CPS statement the following was written in the recommendations section with respect to these two gestational ages which also encompassed 24 weeks as well.
“At 22 weeks’ GA since survival is uncommon, a non-interventional approach is recommended with focus on comfort care”
“At 23 and 24 weeks’ GA active treatment is appropriate for some infants”
What drew the ire of these health care providers was the apparent limitation of resuscitation based on gestational age. It did not seem that consideration was being given to potential inaccuracies with gestational age dating which at best in the first trimester are +/- a few days and in the second trimester may be off up to 1-2 weeks. Furthermore no mention was made of accounting for other factors such as the findings on an ultrasound which if very discrepant might suggest an older fetus or perhaps equally important the wishes of the parents. What were their past experiences, religious beliefs or lengths to which they had tried for this pregnancy. The 16 year old single mother who conceived via rape might be expected to have a vastly different perspective than the mother at 43 who has tried 5 rounds of IVF and has finally conceived her first baby. Many of these points were highlighted in a response by a large group of care providers in a paper entitled “CPS position statement for prenatal counselling before a premature birth: Simple rules for complicated decisions.”
Now we have a new statement from the American Academy of Pediatrics which I have to complement as it addresses a number of concerns that the above group had with the Canadian version.
1. Fetal gestational age, as currently estimated, is an imprecise predictor of neonatal survival, but 22 weeks of gestation is generally accepted as the lower threshold of viability.
2. Although most infants delivered between 22 and 24 weeks’ gestation will die in the neonatal period or have significant long-term neurodevelopmental morbidity, outcomes in individual cases are difficult to predict.
3. Outcomes of infants delivered at 22 to 24 weeks of gestation vary significantly from center to center.
4. Because of the uncertain outcomes for infants born at 22 to 24 weeks’ gestation, it is reasonable that decision-making regarding the delivery room management be individualized and family centered, taking into account known fetal and maternal conditions and risk factors as well as parental beliefs regarding the best interest of the child.
The first four points address the issues of uncertainty in dates, variable outcomes and the importance of taking a family centred approach. On the surface this seems like the perfect statement but I have highlighted the third point as it really gets to what Nick Hall is referring to (or at least my interpretation). We know that there is a great variability in outcomes from 22-26 weeks across the US based on the recent study by Rysavy et al. In this study which involved 24 hospitals with tertiary care centres, the median survival across all hospitals at 22 weeks (who actively resuscitated infants) ranged from 0 – 14.6% and at 23 weeks 23.8 – 37.1%. Imagine you are a parent at a centre that has a zero percent survival rate at 22 weeks. Should the hospital inform you of that and if after hearing that you still want “everything done” should the Neonatal team resuscitate your infant? There is no doubt that the parental wishes as outlined in point 4 are important but I would counter that there is also little point in putting a family through a futile exercise.
Vince Lombardi the former head coach of the Green Bay Packers produced the following quote that has been used many times since his heyday in the 1960s. “Practice does not make perfect. Only perfect practice makes perfect”
This could not be more applicable to the situation in many centres thoughout the US. Resuscitating 22 and 23 week infants can be done and in a manner of speaking is a form of practice. Should centres though who have not “perfected” their approach by having rigorous audits of their practice, a “golden hour” approach and lastly the best equipment for resuscitation continue to offer families who wish to “do everything” just that? I would say no. While the AAP certainly endorses this type of approach centres need to be honest and disclose their success with such resuscitations. If you have zero survivors and know that there is a non standard approach at delivery of such patients and substandard equipment such as the absence of blenders to allow less than 100% O2 resuscitation do you not have a moral and ethical obligation to draw the line and say no?
The AAP offers the best approach to resuscitation from 22-25 weeks that I have seen but I don’t believe it is for every centre at the moment. Only those centres who believe that they have all the infrastructure and processes in place to achieve “perfect practice” should be routinely resuscitating infants at 22 and 23 weeks. To continue to offer these families everything and perform less than perfect practice will not lead to any improvements in their rate of success and do the families that come to their hospitals a disservice.
The first step in medicine is to pledge to do no harm. I would hope that hospitals would be honest with themselves and if they don’t have everything in place to achieve great results will spare families the experience of false hope when the only outcome will be the inevitable loss of a child.