Redirecting Care for Sick Neonates: Ethical Dilemmas

It is not possible to talk about neonatal intensive care, without mentioning the complex and emotionally charged issue of redirecting care for critically ill neonates. This practice involves transitioning from aggressive life-sustaining treatments to palliative care, focusing on maximizing comfort and quality of life for the infant. While it’s a difficult decision, it’s one that’s rooted in the best interest of the baby. However, it is impossible to ignore the ethical dilemmas that healthcare providers, parents, and society as a whole must navigate.

The Balancing Act: Shared Decision-Making with Parents

The primary duty of healthcare providers is to promote the well-being of their patients. In cases where further medical intervention is unlikely to yield a positive outcome and may prolong suffering, redirection of care can be considered ethically justifiable.

It is crucial to involve parents in the decision-making process. Parents, overwhelmed by emotional distress, may struggle to accept that aggressive treatments may not improve their child’s prognosis. Healthcare providers, have to find a balance between respecting parental autonomy and advocating for the best interests of the child. Open communication, providing comprehensive information, and offering emotional support are essential in helping parents arrive at an informed decision.

In a multicultural country like Canada, cultural beliefs and values may also play a significant role, influencing parental decisions and medical recommendations. Healthcare providers must be sensitive to these factors and engage in culturally competent care.

The redirection of care for sick neonates is a heart-wrenching process with ethical dilemmas. While the decision to transition from aggressive treatments to palliative care is rooted in the best interest of the child, it requires delicate navigation of medical, parental, cultural and social aspects. Healthcare providers must strive for open communication, shared decision-making, and cultural sensitivity, but also remember our own emotional well-being when dealing with challenging situations.

The Neurodevelopmental Follow-up Clinic

New born baby from cesarean section in operating theater with mother. Illustration provided by Colourbox (UiT).

Having recently spent time in the Neonatal Intensive Care Unit (NICU), witnessing the dedicated efforts of healthcare professionals tending to critically ill infants while also providing support to parents, I was compelled to delve deeper into the realm of neonatal care. Thus, my journey led me to a day in the Neonatal Neurodevelopmental follow-up clinic, where I gained valuable insights into the challenges that parents and their newborns face during the first 1 year of life.

It’s hard to imagine the profound stress and anxiety that parents most likely endure when their infants are confined within the NICU. While some patient cases may share a common origin, the intricate interplay of individual variables can lead to varying outcomes.

Today, I took the opportunity to learn more about the impact of hypoxic congenital heart disease on brain maturation. Inflammatory cascades activation due to this condition can precipitate brain injuries and distort normal brain development. The degree of hypoxia dictates the extent of its influence, potentially giving rise to delayed motor, sensory, and cognitive impairments.

The clinical reassurance provided by normal head MRI images in such instances is indeed comforting. However, predicting long-term challenges remains a challenge, especially behavioral and psychological challenges. I also learnt that it is important to remember that infants possess an astonishingly adaptive and resilient brain structure capable of forging new neural pathways under optimal circumstances. This underscores the significance of monitoring these young patients, not only during the crucial initial year, but also throughout their developmental journey.

The multidisciplinary team at the clinic stands as a testament to the collaborative effort required in this intricate field. Addressing an array of developmental facets, from gross and fine motor skills to sensory perception and cognitive milestones, their expertise is both comprehensive and insightful. While standardized tests undoubtedly play a pivotal role in assessing developmental progress at key junctures, the parental history and concerns are truly important in these follow-up visits.

Insights from Pediatric Grand Rounds: Emergence of Invasive Group A Streptococcus (iGAS)

Shifting our focus once more, today’s exploration has shed further light on the topic of iGAS. Over the past two decades, iGAS cases in Canada have exhibited a twofold increase, prompting a deeper examination. Among the pediatric demographic, recent varicella infections and soft tissue trauma stand out as the principal risk factors, although certain studies have indicated potential connections to viruses such as influenza. The classification of these bacteria as “Group A” stems from the Lancefield categorization. GAS (Group A Streptococcus) are also constituents of our microbiome, taking up residence in the throat, particularly within the pharyngeal region. Notebly, pharyngitis is the most commonly associated ailment.

In the context of adults and children aged three and older, prudence dictates the application of the Citerion criteria prior to commencing GAS screening. This approach is judicious, given that a considerable portion of ENT (Ear, Nose, Throat) infections are caused by viral agents, making the judicious utilization of antibiotics a focal point.

The implications of iGAS are indeed significant. Of paramount concern is toxic shock syndrome, a condition capable of precipitating DIC (Disseminated Intravascular Coagulation), necrotizing fasciitis, and various dermatological manifestations. On an inflammation research point of view, GAS possess superantigens capable of stimulating a substantial proportion—ranging from 20% to 30%—of the T-cell population, a stark contrast to the marginal 0.01% to 0.1% activated by typical antigens. This heightened activation gives rise to an excessive cytokine response, prominently involving IL-6 and TNF. Additionally, M-type 1 and 3 surface proteins have been identified as prominent virulence factors.

Despite ongoing research endeavors, the sudden surge in iGAS cases since 2022 remains unknown and probably multifaceted.

To augment rates of survival, a comprehensive approach has been established:

  1. Supportive Measures: Prioritizing supportive care, including fluid management.
  2. GAS-Targeted Antibiotics: Penicillin is the foremost choice in addressing streptococcal infections.
  3. Adjunctive Therapies: Incorporating klindamycin to target GAS endotoxins, in certain cases along with the consideration of Intravenous Immunoglobulins (though this has mixed research data concerning its efficacy).
  4. Swift Surgical Debridement: Urgently instituting surgical debridement in cases of necrotizing fasciitis, emphasizing the importance of early surgical intervention within a hospital setting.

In instances where a definite diagnosis is established, penicillin emerges as the preferred therapeutic agent. However, in scenarios marked by diagnostic uncertainty, empirical antibiotic treatments are employed. Notably, in Norway, national guidelines thoughtfully integrate the antimicrobial resistance landscape specific to the region, while on a broader international scale, resources like the “Firstline” app offer invaluable assistance.

Regrettably, even with comprehensive care in place, some children inevitably face lingering complications—such as the need for amputation—or even death.

Enhancing Cultural Competence

Over the last month, cultural competence has been a prominent topic discussed at both SickKids and Mount Sinai. Embraced by Canada’s multicultural constitution, this concept holds immense importance in facilitating effective communication with patients, families, and colleagues alike. Lectures have shed light on the influence of departmental-dependent cultures within various hospital settings and emphasized the need to understand our own biases, attitudes, and assumptions to enhance our cultural competence.

By continuously striving to develop our cultural competence, we can create a more inclusive and empathetic healthcare environment. By valuing diversity and understanding the unique perspectives of those we serve and work with, we foster a stronger sense of community and collaboration. Hopefully I can carry these insights forward, applying them in my daily interactions, and contribute to a healthcare system that embraces and celebrates differences, ultimately leading to better patient outcomes and improved overall well-being.

Unraveling the Mysteries of Neonatal Seizures

I had a fascinating session today with Dr. Mehmet Cizmeci, delving into neonatal seizures. While infections are third to fifth leading cause of neonatal seizures, it’s crucial to keep them in mind as a possible differential. My main takeaways were gathering a thorough history, identifying risk factors, and observing clinical features and electrolytes.

Continuous EEG is the gold standard for detection, where we look for abrupt pattern changes, evolution, and eventual resolution. When it comes to treatment, benzodiazepines are often the first-line choice, but phenobarbital has proven to be the most effective and preferable option within the hospital setting. Both treatments target GABA A receptors, influencing chloride channels in nerve cells. Exciting insights! 🧠

As I continue my observership at sickkids, I’m looking forward to learning more from Dr. Mehmet Cizmeci. This experience will not only give me a clinical perspective for my ongoing PhD research but also broaden my understanding of neonatal infections across the Atlantic. Exciting times ahead! 🚀

Rehabilitation: “Embracing the Gift of Second Chances”

This week, I was fortunate to visit the pain clinic at Mount Sinai Hospital in Toronto. It was an incredible opportunity and allowed me to explore my future direction in specialization and research. Dr. Rebecca Titman, a physiatrist, leads a unique pregnancy pain program there. As my focus is on pregnant women and children in both research and clinic, I am thrilled to have made some valuable connections during my visit. 

I recently learned that WHO has outlined guidelines for children with chronic pain. Shockingly, between one-quarter and one-third of children may experience chronic pain. This not only affects their physical well-being but also their emotional, psychological, and social development, as well as their families’ overall well-being.

Children are unique, both physically and developmentally, compared to adults. Consequently, they require different pain care approaches. As I embark on my journey at SickKids and continue working on my PhD thesis, I can’t help but see the immense value of improving diagnostics and treatment measures for these young patients, whether dealing with infectious diseases or rehabilitation.

Antibiotics treatment: Balancing Benefits, Risks, and Resistance

Group B streptococcus
Picture from my experiments. Incubation of whole blood with added bacterial challenge.

So, still working on the interactive (neonatal) infectious disease case…Today, I want to dive into a topic that often leaves some us scratching our heads: Antibiotics treatment!

Starting or not starting antibiotics is like walking a tightrope between not wanting to jump the gun and wanting to nip that infection in the bud. We worry about unnecessary antibiotic use, but we also don’t want to risk the infection spreading or getting worse. It’s a tough call! We need to weigh the severity of the infection, consider the patient’s medical history, and rely on good old medical judgment to make the right decision.

When it comes to stoping the antibiotics. It’s a balancing act between ensuring a complete recovery and avoiding unnecessary exposure to antibiotics. It’s almost like playing detective…Has the infection been fully eliminated or are we just temporarily putting it to sleep. All the while, the fear of antibiotic resistance lurks in the background, reminding us not to overstay our welcome with these powerful drugs.

Lastly, we have to take into account the specific bacteria causing the infection and its susceptibility to different antibiotics. It’s a delicate process that requires expertise and a deep understanding of microbiology. Thank goodness for the amazing healthcare professionals who guide us through this maze and make informed choices.

It’s like a never-ending puzzle with high stakes. But fear not! We’re getting better at tackling these challenges.

Conquering Deadlines

Salsa festival

As usual I find myself juggling multiple responsibilities while also taking time to experience the vibrant cultural festivals here in Toronto.

One of my major focuses recently has been working on an exciting PhD article about experimental group B Streptococcus maternal vaccines. It’s fascinating to explore a vaccine that has the potential to protect both mothers and their newborns from harmful infections. But let me tell you, diving into the world of immunology and conducting research can be quite the adventure! 🧪🔬

I am also reviewing some comments on a paper regarding a maternal sepsis model. Receiving comments from peer-reviewers is in many ways an enlightening experience.

But it wasn’t all work! Toronto is known for its vibrant and multicultural atmosphere, and I couldn’t resist immersing myself in the city’s cultural festivals. This past weekend, I had the chance to attend the Salsa Festival. The food, energy, music, and dance moves were simply mesmerizing!

Tommy Thompson Park – view from bike trail

Experiencing these cultural festivals served as a reminder of the importance of balance in life. Amidst the rigorous demands of academia, it’s crucial to find time for joy, exploration, and connecting with diverse communities.

The Fascinating World of Neonatal Radiology Rounds

Toronto is a city that never fails to captivate! From strolling through the charming streets of Kensington Market to exploring the iconic CN Tower and experiencing the cultural richness of the Distillery District, there is truly something for everyone.

As a health worker, my recent visit to this captivating city included both delightful experiences and professional responsibilities, including the mandatory tuberculosis (TB) screening tests.

Today I had the opportunity to participate in virtual radiology rounds at the NICU. These rounds involved discussing various X-ray images and unraveling the mysteries behind the conditions affecting newborn babies. It was both a humbling and intellectually stimulating experience, as we delved into the world of differentials, debating whether the condition was infectious or congenital.

Interpreting X-rays in newborns proved to be an entirely different challenge compared to my own scans. The intricate nature of neonatal anatomy, coupled with the range of potential abnormalities, requires a keen eye and deep understanding. However, it is the collective effort of the multidisciplinary team, including radiologists, neonatologists, and other specialists, that truly make a difference in deciphering these conditions and providing the best care for these precious lives.

In clinical practice, having adequate time to carefully assess a patient and consult with experienced colleagues improves patient outcomes. Similarly, in research, a dedicated team working together with shared expertise is crucial for analyzing data, developing new insights, and advancing medical knowledge.

As a doctor and researcher, I am no stranger to the demanding nature of my work. Long hours, challenging cases, and the pursuit of scientific breakthroughs can easily consume one’s life. However, my colleague’s untimely passing has prompted me to reflect on the importance of finding equilibrium between my professional and personal spheres.

Severe neonatal infections and the Global Health Challenges

During the Pediatric Grand Rounds, I had the opportunity to attend a presentation closely related to my own PhD research on the diagnostic and prevention of severe neonatal infections. The speaker, Dr. Alasteir Fung, is currently pursuing a PhD in Clinical Epidemiology and Health Care Research at the Institute of Health Policy, Management, and Evaluation. His research aims to develop a prediction model for infant hospitalization by utilizing clinical features assessed by community health workers during home visits in Dhaka, Bangladesh.

In my own project, I am focusing on metabolic profiles. By exploring the potential of metabolic profiles, I aim to contribute to the development of more targeted and effective strategies for managing neonatal infections, ultimately improving the health outcomes of this vulnerable population.