Beginning of Life By: 2D-MD Que, Scylla Kneisel C. Querubin, Genevieve Anne R. Quetulio, Ma. Kristina A. Quito, Ederlyn P. Rabo, Justin Iohanne S. Rama, Ardie S. Ramones, Roma P. Pediatric Issues
PEDIATRIC ISSUES Newborns, Infants and Children Around 2 million babies are born in the Philippines each year. The number of children aged 0 to four years old run up to around 10 million, and children aged five to 10 are another 10 million. Newborns refer to infants during the first month of life. Infants are those that are still below one year old. On the other hand, children refer to the age group between one year old to less than 10 years old. http://www2.doh.gov.ph/noh2007/NOHWeb32/NOHperSubj/Chap4/NewbornIC.pdf
CONGENITAL ANOMALIES • are a major cause of stillbirths and neonatal deaths, but • they are perhaps even more important as causes of acute • illness and long-term morbidity. • refer to structural defects, chromosomal abnormalities, • metabolic errors and hereditary disease present at birth. • It may occur as an isolated defect or as multiple • malformations. • Isolated congenital anomaly, is the structural defect, which can be traced down to one localized error in morphogenesis while multiple congenital malformations result from two or more different morphogenetic errors, which occur during development of individual. Nelson Textbook of Pediatrics, 18th ed 2007
CONGENITAL ANOMALIES Early recognition of anomalies is important for planning care; with some, such as tracheoesophageal fistula, diaphragmatic hernia, choanal atresia, and intestinal obstruction, immediate medical and surgical therapy is essential for survival. Parents are likely to feel anxious and guilty on learning of the existence of a congenital anomaly and require sensitive counseling. Nelson Textbook of Pediatrics, 18th ed 2007
TABLE 1 -- Common Life-Threatening Congenital Anomalies CHARGE, coloboma of the eye, heart anomaly, choanal atresia, retardation, and genital and ear anomalies; VATER, vertebral defects, imperforate anus, tracheoesophageal fistula, and radial and renal dysplasia. Nelson Textbook of Pediatrics, 18th ed 2007
CONGENITAL ANOMALIES http://wps.prenhall.com/wps/media/objects/740/758036/congenital_anomalies.pdf
ANOTHER VIDEO http://wps.prenhall.com/wps/media/objects/740/758036/congenital_anomalies.pdf
-Health Care Ethics 4th ed. • The need to develop satisfactory therapies for gene defects is medically important, as is evident in the ff: • There are approx. 3,000 different diseases which are known to involve single defective genes. • 33% of infant deaths are related to genetic causes • Parent carriers of defective genes may have as much as a 50% risk of generating offspring with a genetic defect
Chorionic Villi Sampling -Health Care Ethics 4th ed. It is a technique in prenatal testing in which a plastic catheter is inserted through the cervix to biopsy villi or hairlike projections in the placenta. The results of chromosome tests of these rapidly growing tissues are available in a few days.
Amniocentesis -Health Care Ethics 4th ed. It is a technique frequently employed in diagnosing the genetic and sexual characteristics of unborn infants. It is the extraction of amniotic fluid from a pregnant woman (in the 15th week) to aid in the diagnosis of fetal abnormalities.
In “The Gospel of Life”, Pope John Paul II wrote: • In view of the complexity of prenatal diagnostic techniques, an accurate and systematic moral judgment is necessary. • MORALLY LICIT: When they do not involve disproportionate risks for the child and the mother, and are meant to make possible early therapy or even to favor a serene and informed acceptance of the child not yet born.
But since the possibilities of prenatal therapy are still limited today, it not infrequently happens that these techniques are used with eugenic intention which accepts selective abortion in order to prevent the birth of children affected by various types of anomalies. Such an attitude is shameful and utterly reprehensible, since it presumes to measure the value of a human life only within the parameters of “normality” and physical well-being, thus opening the way to legitimizing infanticide and euthanasia as well.
-Bioethics for Students • Genetic Testing is licit: • if the motive is to identify diseases in order to correct a defect • or to prepare the parents • The methods used are with the informed consent of the parents and respect the life & integrity of the embryo and the mother without subjecting them to disproportionate risks.
Genetic Manipulation -Bioethics for Students Altering human genetic patrimony aimed to cure illness or improve future quality of life with illness caused by genetic or chromosomal anomalies May be ethical provided that they respect the embryo’s life & integrity and do not involve disproportionate risks
-Bioethics for Students • However, genetic manipulation that select sex or other predetermined qualities (gene enhancement) which change the genotype of the individual to improve a baby violates: • Stewardship • Non maleficence • Respect for human dignity • Justice
Stewardship -Bioethics for Students • Any manipulation should enhance not diminish humanness • Efforts to go beyond nature are wrong • Willfulness over giftedness (choose how the child should be rather than acknowledge them as gifts as they are) • Dominion over reverence (change accdg. to our desires are rather than accept as they are)
Stewardship -Bioethics for Students The right of parents to “beget” children instead to “design” them as well as to raise them with accepting and transforming love must be respected.
Non-Maleficence -Bioethics for Students The state of art is still with uncertainties and imperfections with yet unknown long term medical hazards. Known genetic characteristics may lead to discrimination.
Respect for human dignity -Bioethics for Students The fetus is objectified as something to be altered as desired. Financial gain or patents might be obtained from human genome in its natural state.
Justice -Bioethics for Students The procedure is only available for the rich.
Borderline of Viability time of birth of extremely premature babies who are born alive at or before the gestational age of 25 weeks, six days Causes spontaneous labour Delivered early to safeguard the health of the baby and/or the mother At these stages of gestation, the prospects of healthy survival are reduced, often necessitating critical care decisions after birth
Clinician’s Perspective on Resuscitation The doctors will try to ascertain whether parents would want resuscitation or, if there is little chance of survival, they would prefer the baby to be given palliative care alone, allowing him or her to die without the stress and pain of attempted resuscitation and intensive care. Maximizing the baby’s quality of life through relief from pain and stress is an important part of palliative care.
Clinician’s Perspective on Resuscitation Where parents would prefer that the clinical team made the decision about whether or not to initiate intensive care, the clinicians should determine what constitutes appropriate care for that particular baby. Where there has not been an opportunity to discuss a baby’s treatment with the mother (and where appropriate her partner) prior to the birth, the clinical team should consider offering full invasive intensive care until a baby’s condition and treatment can be discussed with the parents.
Clinician’s Perspective on Resuscitation If the mother does not want their baby to be subjected to prolonged intensive care, or feel that they could not cope with a disabled child, or believe that they could easily get pregnant again, the neonatologist may be more likely to opt for palliative care for a baby born in poor condition. If, on the other hand, a mother may not have another chance to have a pregnancy and she is willing to accept any outcome if the child survives, the doctor is likely to use all appropriate therapy to support the baby, even if the chances of survival without some level of disability are very low.
Ethical Issues The Value of Human Life Best Interest Deliberate action to end life Critical Care Decisions in Fetal and Neonatal Medicine
Ethical Issues The Value of Human Life SANCTITY OF LIFE taking human life is categorically wrong and it is never permissible not to strive to preserve the life of a baby all humans are of equal intrinsic value and should be treated with the same respect under some circumstances preserving the life of a baby can only lead to an ‘intolerable’ existence (extreme level of suffering or impairment which is either present may develop in the future)
Ethical Issues Best Interest the best interests of a baby must be a central consideration in determining whether and how to treat him or her interests can be understood in terms of the factors that affect a person’s quality of life constitutive elements of wellbeing - a person’s wellbeing prospers or declines as their interests grow or wane a person benefits from having their interests promoted and suffers from having their interests neglected
Ethical Issues Deliberate action to end life Taking intentional measures to end the life of a newborn baby is commonly regarded as a violation of the duty to protect the life of the patient This applies even when that baby’s condition is intolerable, with no prospect of survival or improvement