Navigating the post-Dobbs landscape: ethical considerations from a perinatal perspective.

Restrictive abortion laws have impacts reaching far beyond the immediate sphere of reproductive health, with cascading effects on clinical and ethical aspects of neonatal care, as well as perinatal palliative care. These laws have the potential to alter how families and clinicians navigate prenatal and postnatal medical decisions after a complex fetal diagnosis is made. We present a hypothetical case to explore the nexus of abortion care and perinatal care of fetuses and infants with life-limiting conditions. We will highlight the potential impacts of limited abortion access on families anticipating the birth of these infants. We will also examine the legally and morally fraught gray zone of gestational viability where both abortion and resuscitation of live-born infants can potentially occur, per parental discretion. These scenarios are inexorably impacted by the rapidly changing legal landscape in the U.S., and highlight difficult ethical dilemmas which clinicians may increasingly need to navigate.

Pediatric Organ Donation and Transplantation: Across the Care Continuum.

This policy statement aims to enhance comfort and increase knowledge of pediatric organ donation and transplantation to the general pediatric community, specifically focusing on the pediatric health care professional and the medical home. The pediatric health care professional will care for neonates, infants, children, and adolescents who may become donors or transplant recipients and, thus, is a crucial member of the pediatric patient's care team. Understanding donation, transplantation, and follow-up care are important to primary care engagement. Furthermore, the pediatric health care professional may play a role in shaping public policies related to the process of organ donation and access to organ transplantation.

Ethics of age de-escalation in pediatric vaccine trials: Attending to the case of COVID-19.

In the development of new vaccines, many trials use age de-escalation: after establishing safety and efficacy in adult populations, progressively younger cohorts are enrolled and studied. Age de-escalation promotes many values. The responsibility to protect children from potential risks of experimental vaccines is significant, not only given increased risks of adverse effects but also because parents and medical professionals have a moral responsibility to protect children from harms associated with novel, uncertain interventions. Further, given that young children cannot provide informed consent, acceptable risks for research requiring proxy consent are lower than for adults making decisions for themselves. Although age de-escalation approaches are widely used in vaccine trials, including notably in the recent development of pediatric COVID-19 vaccines, ethicists have not addressed the benefits and risks of these approaches. Their benefits are largely assumed and unstated, while their potential risks are usually overlooked. There are no official ethics guidelines for the use of age de-escalation in clinical research. In this paper, we provide a systematic account of key moral factors to consider when employing age de-escalation. Analyzing pediatric COVID-19 vaccine development as our key case study, we clarify the benefits, risks, and trade-offs involved in age de-escalation approaches and call for the development of evidence-based best practice guidelines to identify when age de-escalation is likely to be an ethical strategy in vaccine development.

Parent Preferences for Neonatal Intensive Care Unit Physician Attire: A Cross-Sectional Study.

OBJECTIVE: Physician attire may influence the parent-provider relationship. Previous studies in adult and outpatient pediatrics showed that formal attire with a white coat was preferred. We aimed to describe parent preferences for physician attire in the neonatal intensive care unit (NICU). STUDY DESIGN: We surveyed 101 parents in a level IV NICU. The survey included photographs of a physician in seven different attires. Attire was scored in five domains and parents selected the most preferred attire in different contexts. All attires were compared with formal attire with white coat. Descriptive statistics, Fisher's exact tests, and one-way analysis of variance were used to compare parent responses. RESULTS: Scrubs without white coat (40.8 [7.0]) and formal attire without white coat (39.7 [8.0]) had the highest mean (standard deviation) composite preference scores. However, no significant differences between formal attire with white coat (37.1 [9.0]) versus any other attire were observed. When asked to choose a single most preferred attire, scrubs with a coat (32%) and formal with a coat (32%) were chosen most often, but preferences varied by clinical context and parent age. For example, parents preferred surgical scrubs for physicians performing procedures. Parents indicated that physician attire is important to them but does not influence their satisfaction with care. CONCLUSION: Although parents generally favored formal attire and scrubs, the variations based on the context of care and lack of significant preference of one attire suggests that a single dress code policy for physicians in a NICU is unlikely to improve the patient-provider relationship. KEY POINTS: · Adult patients prefer doctors to wear formal attire.. · Physician attire preferences influenced by age, setting, and context of care.. · Little is known about physician attire preferences of the parents of neonates.. · Unlike adult patients, NICU parents did not prefer formal attire with a white coat..

Beyond the Clinical Trials: Off-Protocol Therapeutic Hypothermia.

Mild therapeutic hypothermia has been extensively studied and validated as an effective and safe treatment for term and near-term infants with moderate and severe hypoxic encephalopathy meeting narrow inclusion criteria. Unanswered questions remain about whether cooling treatment can be optimized to improve outcomes even further, and whether it is reasonable to offer treatment to infants excluded from the foundational studies. Consideration of "off-protocol" cooling practices requires methodical review of available evidence and analysis using both a clinical and a research ethical framework.

Prognostic value of clinicians' predictions of neonatal outcomes in counseling at the margin of gestational viability.

Within antenatal counseling sessions at the margin of gestational viability, clinicians frequently to use population-based outcome data and statistical models to guide the decision-making process. These tools often utilize non-modifiable prenatal factors to estimate outcomes based on population averages. However, most parents prefer individualized predictions, which cannot be supported by these models. Additionally, prognostic accuracy is limited by institutional practices surrounding active management of infants at the margin of viability. Throughout the literature, parental perspectives emphasize the importance of communicating subjective information, such as providing hope and supporting personal values, over the importance of accurate prognostic information from the clinician. In this review we aim to describe the value of clinician prognoses in the decision-making process at the margin of gestational viability and emphasize the importance of addressing parental values during the counseling process, regardless of the expected outcome.

Shifting Provider Attitudes and Institutional Resources Surrounding Resuscitation at the Limit of Gestational Viability.

OBJECTIVE: This study aimed to provide contemporary data regarding provider perceptions of appropriate care for resuscitation and stabilization of periviable infants and institutional resources available to providers. STUDY DESIGN: A Qualtrics survey was emailed to 672 practicing neonatologists in the United States by use of public databases. Participants were asked about appropriate delivery room care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making, and resources utilized regarding resuscitation. Descriptive statistics were used to analyze the dataset. RESULTS: In total, 180 responses were received, and 173 responses analyzed. Regarding preferred course of care based on gestational age, the proportion of respondents endorsing full resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%, 23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors most impacting decision-making at 22 weeks gestational age included: outcomes based on population data (79%), parental wishes (65%), and quality of life measures (63%). Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the delivery room (77%), and vascular access (69%) were the most supported therapies for initial stabilization. Availability of institutional resources varied; the most limited were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care teams (54%). CONCLUSION: There appears to be discordance in provider attitudes surrounding preferred actions at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability and identified resource limitations are nonuniform. Between-hospital variations in outcomes for periviable infants may be partly attributable to lack of provider consensus and nonuniform resource availability across institutions. KEY POINTS: · Within the past decade, there has been a shift in the gray zone from 23-24 to 22-23 weeks gestation.. · Attitudes around resuscitation of infants are nonuniform despite perceived standardized approaches.. · Institutional variability in resources may contribute to variation in outcomes of periviable infants..

Conjoined twins: an obstetrician's guide to prenatal care and delivery management.

OBJECTIVE: Obstetricians infrequently encounter conjoined twins. Much of the clinical care literature focuses on postnatal management from a neonatology and pediatric surgery perspective; guidance on obstetrical management is limited. We outline steps for prenatal evaluation, obstetrical care, and delivery planning. STUDY DESIGN: Experiences with two cases of conjoined twins. RESULTS: We identified several points throughout the planning, delivery, and postnatal process that are important to highlight for optimizing clinical outcome, patient safety, and parental satisfaction. CONCLUSION: After diagnosis, patients should be referred to a center experienced in the management of conjoined twins. Specialists in fields including maternal fetal medicine, pediatric surgery, neonatology, and radiology play a vital role in the management of these patients. Early referral allows for timely family counseling and decision-making. Prenatal evaluation beyond the first trimester should include a detailed ultrasound, fetal echocardiogram, and fetal MRI. 3D printed life-sized models can improve delivery planning and patient understanding.

Visitor Guidelines in US Children's Hospitals During COVID-19.

OBJECTIVES: To examine visitor guidelines among children's hospitals in the United States in response to the coronavirus 2019 (COVID-19) pandemic. METHODS: A retrospective assessment of visitor guidelines in 239 children's hospitals in the United States. RESULTS: In this study, we present an analysis of 239 children's hospital visitor guidelines posted to hospitals' Web sites during 1 week in June 2020. Of the 239 hospitals, only 28 did not have posted guidelines for review. The guidelines were analyzed and grouped by how the guidelines were updated in response to COVID-19. Parental visitation was restricted to 1 parent in 116 of the posted guidelines (49%). There were no obvious similarities among guidelines associated with their geographical (eg, state or local) location. As of February 2021, 33 of 55 (60%) randomly selected hospitals had not changed their visitor policy since our initial review. CONCLUSIONS: The COVID-19 pandemic triggered changes in publicly reported visitor guidelines across the majority of children's hospitals. With our findings, we suggest wide variation in policies and practices in how guidelines were updated. More work is needed to understand how to optimize public safety and preserve family-centered care and parental authority in times of crisis.

Ethical Cultures in Perinatal Care: Do They Exist? Correlation of Provider Attitudes with Periviability Practices at Six Centers.

OBJECTIVE: This study aimed to compare attitudes of providers regarding perinatal management and outcomes for periviable newborns of caregivers at centers with higher resuscitation (HR) and lower resuscitation (LR) rates in the delivery room. STUDY DESIGN: All obstetric and neonatal clinical providers at six U.S. sites were invited to complete an anonymous online survey. Survey responses were compared with clinical data collected from a previous retrospective study comparing centers' rates of planned resuscitation. Responses were analyzed by multivariable logistic and linear regression to assess how HR versus LR center respondents differed in management preferences and outcome predictions. RESULTS: Paradoxically, HR versus LR respondents, when adjusting for other variables, were less likely to respond that interventions such as antenatal steroids (odds ratio: 0.61, 95% confidence interval [CI]: 0.42-0.88, p < 0.009) and resuscitation (OR: 0.59, 95% CI: 0.44-0.78, p < 0.001) should be given at 22 weeks. HR versus LR respondents also reported lower likelihood of survival and acceptable quality of life (OR: 0.7, 95% CI: 0.53-0.93, p = 0.012) at 23 weeks. CONCLUSION: Despite higher rates of planned resuscitation at 22 and 23 weeks, steroid usage and survival rates did not differ between HR and LR sites. In this subsequent survey, respondents from HR centers had a less favorable outlook on interventions for these newborns than those at LR centers, suggesting that instead of driving practices, attitudes may be more closely associated with experiences of clinical outcomes.

Hospital Visitation Policies During the SARS-CoV-2 Pandemic.

A significant change for patients and families during SARs-CoV-2 has been the restriction of visitors for hospitalized patients. We analyzed SARs-CoV-2 hospital visitation policies and found widespread variation in both development and content. This variation has the potential to engender inequity in access. We propose guidance for hospital visitation policies for this pandemic to protect, respect, and support patients, visitors, clinicians, and communities.

Intention to treat: obstetrical management at the threshold of viability.

BACKGROUND: Despite medical advances in the care of extremely preterm neonates and growing acceptance of resuscitation at 23 and even 22 weeks gestation, controversy remains concerning the use of antepartum obstetric intervention s that are intended to improve outcomes in the setting of anticipated extremely preterm birth. In the absence of demonstrated benefit at <23 weeks gestation and with uncertain benefit at 23 weeks gestation, previous obstetric committee opinions have advised against their use at these gestational ages. OBJECTIVE: The purpose of this study was to review the use of obstetric intervention s at the threshold of viability based on neonatal resuscitation plan and to review the odds of survival to neonatal intensive care unit discharge based on use of obstetric intervention s with adjustment for neonatal factors. STUDY DESIGN: This retrospective study of 6 study centers reviewed pregnant patients who were admitted between 22+0/7 and 24+6/7 weeks gestation facing delivery from 2011-2015. Patients with known anomalies or missing data were excluded. Records were reviewed for demographics, resuscitation plan, and obstetric intervention s. Mode of delivery, delivery room care, and final infant dispositions were recorded. Multiple gestations were included as 1 pregnancy in regard to the use of obstetric intervention s and were excluded from survival analysis. RESULTS: Four hundred seventy-eight mothers met the inclusion criteria. When resuscitation was planned, mothers were more likely to receive all conventional obstetric intervention s (antenatal steroids, magnesium sulfate for neuroprotection, tocolytics, and Group Beta Streptococcus prophylaxis), regardless of gestational age at admission, and were more likely to be delivered by cesarean section (P<.05). Analyzed as a group, when antenatal steroids, magnesium sulfate, tocolytics and Group Beta Streptococcus prophylaxis were administered, the odds of survival to neonatal intensive care unit discharge increased for newborn infants who were born at 22 (odds ratio, 11.33; 95% confidence interval, 1.405-91.4) and 23 weeks gestation (odds ratio, 15.5; 95% confidence interval, 3.747-64.11; P<.05). In singletons, the odds of survival to neonatal intensive care unit discharge was not improved by cesarean delivery vs vaginal delivery, even after adjustment for the use of additional interventions, weight, gender, and gestational age (odds ratio, 1.0; 95% confidence interval, 0.59-1.8; P=.912). CONCLUSION: In this study, when postnatal resuscitation was planned at 22 and 23 weeks gestation, women were more likely to receive antenatal steroids, magnesium sulfate, and antibiotics; provision of this bundle imparted survival benefit at 23 weeks gestation but could not be demonstrated at 22 weeks gestation because of the small sample size. These findings support of neonate-oriented obstetric interventions in the setting of delivery at 23 weeks gestation when resuscitation is planned and further exploration of optimal obstetric care when resuscitation of infants who were born at 22 weeks gestation is anticipated.

The impact of the COVID-19 pandemic on children with autism spectrum disorders.

In the unprecedented disruption and social isolation of the COVID-19 pandemic, families around the world are faced with questions of how their children can thrive in these conditions. On top of the ubiquitous challenges for all children, this public health crisis imparts unique difficulties for children with special health needs. We identify children with Autism Spectrum Disorder (ASD) as being particularly vulnerable to negative impacts of the COVID-19 pandemic. In this paper, we examine why children with ASD are uniquely vulnerable, recommend strategies to mitigate these stressors for children with ASD and their parents, explore the potential challenges of reintegration into society as conditions improve, and examine the obligations of healthcare and community stakeholders to support these families.