New treatment challenges in neonatal medicine
Welcoming participants to the conference JONATHAN
BEST (chief executive, Yorkhill Trust) spoke of the levels of deprivation
for children in the Glasgow area. He explained how, in partnership with
other services, the health service, by offering initiatives such as free
fruit for primary schools, free swimming in all health centres for children
and oral hygiene services to nurseries, was hoping that early intervention
in child health would lead to a reduction in adult health problems. In
a press release issued after the conference, the Department of Health
announced the expansion of the National School Fruit Scheme to over one
million children. This will use £42m of the fund to entitle every child
aged four to six to a free piece of fruit at school every day by 2004.
Dr JONATHAN COUTTS (consultant neonatologist, Yorkhill
Trust) spoke of the advances in respiratory management of premature babies.
These advances have led to a decrease in the number of babies who develop
bronchopulmonary dysplasia (BPD), defined as being oxygen dependent at
28 days of age. The introduction of artificial lung surfactant has led
to a decrease in lung disease and the main debate over its use now lies
in whether to use artificial or naturally derived drug, and whether its
use should be prophylactic or as rescue therapy. New ventilator techniques,
including high frequency ventilation which optimises lung inflation, have
also been of benefit, as has the usage of steroids antenatally to mature
premature lungs. As a result a "new" type of BPD is now seen where there
is less lung damage and the babies are, in the main, just oxygen dependent.
Treatment revolves around oxygen therapy, short-term
high-dose steroids in severe cases, bronchodilators and diuretics. There
is a move to discharging more babies with home oxygen. This provides a
better environment for both babies and parents than long-term stays in
a hospital ward. It also leads to increased demands on both hospital and
community pharmacists and is an area which involves a high degree of liaison
between secondary and primary care.
Premature babies have a high pulmonary vascular
resistance and a potential result of this is the development of persistent
pulmonary hypertension of the newborn. This is a cardiopulmonary disorder
characterised by systemic arterial hypoxemia secondary to elevated pulmonary
vascular resistance with resultant shunting of pulmonary blood flow to
the systemic circulation. Systemic vasodilators have side effects and
are not recommended. The treatment of choice is inhaled nitric oxide,
which is a natural vasodilator and only enters the ventilated alveoli.
It is inactivated by haemoglobin once it enters the bloodstream. It is
easy to give via a ventilator and a portable system is available for transfer
of patients between hospitals. Extra corporeal membrane oxygenation is
used as rescue therapy in cases of severe respiratory failure.
RSV (respiratory syncytial virus) is a common cause
of bronchiolytis in babies and young children. Healthy infants do well
(mortality <1 per cent) but high risk infants can have a mortality
up to 30 per cent, or can suffer long term respiratory problems. Recently
palivizumab (a humanised murine RSV IgG monoclonal antibody) has been
launched for passive vaccination against this illness. Studies have shown
it to decrease hospital and intensive care unit admissions, but treatment
is expensive at around £3,000 per patient. In Greater Glasgow strict adherence
to the summary of product characteristics guidance could have resulted
in an annual cost of over £2m. Following a review by paediatricians and
pharmacists, treatment criteria were agreed to target the most vulnerable
patients and this was funded by the health board. In addition to vaccination,
in the community parents have to be educated about the risk of RSV, including
the prevention of cross infection.
Speaking on the topic of "Neonatal surgery — size
does matter" CARL DAVIS (consultant neonatal surgeon, Yorkhill Trust)
covered the range of neonatal conditions treated surgically at Yorkhill,
including congenital anomalies (often multiple) and prematurity associated
conditions such as necrotising enterocolitis. As with respiratory problems
there is a changing pattern in the diseases to be treated. The prevalence
of neural tube defects continues to fall, even with the lack of publicity
on the use of folic acid in women's press. Many other defects are picked
up antenatally.
With respect to pain control the use of epidural
analgesia has greatly benefited neonatal surgery, with a resultant decrease
in the need for postoperative ventilation. There still remains, however,
the need to find a suitable agent to bridge the gap between paracetamol
and morphine.
Neonatal surgery requires a multi-disciplinary team.
An example of this is in the treatment of short bowel disease. Here the
aim is to get patients home, possibly on home total parenteral nutrition
(TPN). The pharmacy at Yorkhill provides, on average, 400 TPN bags to
the neonatal surgery unit per month. Enteral feeding is used where possible
and, as with healthy babies, "breast is best".
Congenital diaphragmatic hernia is a long term in
utero problem which can result in complications, even after surgery.
An option is the use of in utero surgery, but this is controversial.
Treatment strategies include extra corporeal membrane oxygenation, but
this does not treat the smaller lung, only rests the respiratory circulation.
A possible option is the use of liquid ventilation with perfluorocarbons.
There have been no trials to date, only anecdotal data and small series
reports.
Back to Top
|
