Combination cyclopentolate and phenylephrine for mydriasis in premature infants with heavily pigmented irides.

PURPOSE: This study examined whether safe and effective mydriasis can be achieved in premature infants with heavily pigmented irides using combination cyclopentolate 0.2% and phenylephrine 1% eyedrops. METHODS: A prospective, randomized double-blind study was performed to compare combination cyclopentolate 0.2% and phenylephrine 1% eye-drops with triple instillation of tropicamide 0.5% and phenylephrine 2.5%. Twenty-eight consecutive babies with dark irides and birthweight <1600 g referred for screening for retinopathy of prematurity comprised the study population. Infants' eyes were randomly dilated twice with both regimens within a 2-week period. Blood pressure, heart rate, and pupil size were measured. RESULTS: Good mydriasis was achieved in both groups with no significant differences in pupil size or blood pressure (systolic, diastolic, or mean arterial pressures) over starting baseline values. Pulse rates decelerated below the baseline values in both groups, but these differences were not large. CONCLUSION: The single combination eyedrop of cyclopentolate 0.2% and phenylephrine 1% is as effective and safe a mydriatic for infants with dark irides as both tropicamide 0.5% and phenylephrine 2.5%.

Factors affecting responses of infants with respiratory distress syndrome to exogenous surfactant therapy.

Approximately 20% to 30% of infants with respiratory distress syndrome (RDS) do not respond to surfactant replacement therapy. Unfortunately there is no uniform definition of 'response' or 'non-response' to surfactant therapy. Response was based on improvement in a/A PO2 and/or mean airway pressure (MAP) by some and on improvement in FIO2 and/or MAP by others. Even the point of time at which evaluation of response was done is different in various reports. There is an urgent need to adopt an uniform definition. Most premature babies are surfactant deficient which is the aetiological factor of RDS. Generally good antenatal care and perinatal management are essential in avoidance of premature birth. Babies with lung hypoplasia and who are extremely premature (less than 24 weeks of gestation) do not respond well to exogenous surfactant replacement because of structural immaturity. Prompt management of asphyxiated birth and shock are necessary as there may be negative response to surfactant replacement. Foetal exposure to glucocorticoids improves responsiveness to postnatal administration of surfactant. Antenatal steroid therapy has become an important part of management of RDS with surfactant replacement. The premature lungs with high alveolar permeability tend to develop pulmonary oedema. With the presence of plasma-derived surfactant inhibitors, the response to exogenous surfactant may be affected. These inhibitors may also be released following ventilator barotrauma. The standard of neonatal intensive care such as ventilatory techniques has an important bearing on the outcome of the RDS babies.(ABSTRACT TRUNCATED AT 250 WORDS)

Resuscitation of the small baby--is there a limit?

Innovations in perinatal care in the last decade, in particular delivery room resuscitations and advanced technologies have probably contributed greatly to improved survival of the small newborns. As a result, progressively smaller and less mature infants are being resuscitated; but some survive with severe neurodevelopmental handicap. There should be guidelines about the lower limits of viability below which no resuscitation should be done. It is the view of many that resuscitation of critically ill small babies should be initiated at birth. Further management will be decided depending on the baby's progress and response. Clinicians have to look into the question of withdrawal of life support in small babies who survive with impairment and chronic illnesses.

Understanding traditional Chinese medicine--a doctor's viewpoint.

Singapore is a cosmopolitan country and its population comprises the Chinese, Malays, Indians, and others such as the Eurasians. In this heterogeneous, multi-racial, multi-lingual and multi-cultural society, medical treatment is also varied. People can seek modern (mainstream, western) medicine or traditional medicine when they are sick. Usually they first seek modern medicine. Some turn to traditional medicine as complementary treatment or alternative treatment. Traditional medicine is here to stay in this country. In November 2000, the Traditional Chinese Medicine (TCM) Practitioners Bill was passed in the Singapore Parliament. Health care providers, including doctors, would benefit from a good knowledge of both modern and traditional medicine. Practitioners in traditional medicine should also learn modern medicine.

Decision-making: initiation and withdrawing life support in the asphyxiated infants in developing countries.

The issues of life support in the asphyxiated infant are not only whether cardiopulmonary resuscitation or CPR will be successful, but also whether if successful, the infant will be severely damaged. This is particularly important in the developing countries because the damaged infants may burden the society. The country has to allocate huge financial and human resources to look after them. When it comes to decisions in initiation and withdrawal of life support, there are differences between the East and the West. Physicians are searching for reliable predictors of outcome of term asphyxiated infants to enable early decision-making, initiation and withdrawal life support, as well as counselling and planning appropriate level of treatment including trials of cerebroprotective therapies. Markers commonly used to identify birth asphyxia are not good predictors of brain injury or death. There is a myriad of reports on clinical or laboratory tests, some using single parameter, to help determine neurological outcome of asphyxiated term infants. Much frequently used equipment in developed countries can be expensive and inaccessible to developing countries. There is an urgent need to look for relevant, simple and inexpensive methods. A combination of measurements may look promising in the early selection of at-risk neonates for decision and counselling. Recently measurement of urinary lactate: creatinine ratio to identify early newborn infants at risk for HIE was proposed. Withdrawal of life support is an ethical issue. In withdrawing life support of the severely asphyxiated infants, one must be aware of the differences of approach. There are differences in religion and culture; in beliefs and philosophies, between the East and West The importance of neonatal resuscitation should be emphasised. Some regions still adhere to obsolete resuscitation methods. Neonatal Resuscitation Program (NRP) should be promulgated and organised resuscitation should be introduced. There is an urgent need to train the trainers in CPR in the developing countries.

Neonatal outcome of breech babies in Toa Payoh Hospital 1984-1989.

From 1984 to 1989, a total of 575 breech babies were born out of 21,243 livebirths (2.71%) in the Toa Payoh Hospital, Singapore. There were 259 male and 316 female infants, a sex ratio of 1 to 1.22. There were also no marked differences in the frequency of breech birth among the different racial groups. Many breech babies (385 or 67%) were delivered by Caesarean section and the mortality and morbidity were noted to be low in this series. We had 7 deaths, all weighing below 2000gm and only one, a premature infant, was delivered by Caesarean section. The majority of the infants had no evidence of asphyxia at birth (87.7%); and for those who had asphyxia (13.3%), two-thirds were delivered vaginally and one-third, by Caesarean section. The malformation rate in breech babies was twice that of non-breech babies (7.13% vs 3.08%, p = 10(-6)). Most birth defects were minor in nature. Only 10% of birth defects were major malformations. 5.9% (34) of all the breech babies were low birth weight (LBW), 1/3 (11) of them were delivered by Caesarean section with one death. However, there was no increasing trend of Caesarean section for LBW breech infants in the Hospital. Over the past 6 years, out of the 23 LBW breech babies delivered vaginally, 6 deaths were noted. There were 13 breech stillbirths, the majority of which were macerated (7/13 or 53.8%). The stillbirth rate (SBR) for breech was 22 per 1000 breech livebirths and stillbirths. The SBR for babies born normally was 5.15. The corrected breech SBR was 18.7 after exclusion of lethal malformations.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of 8 year neonatal deaths (1982-1989) of Toa Payoh Hospital.

A study of 233 neonatal deaths out of 30910 livebirths over an 8 year period in the Toa Payoh Hospital is done. The Hospital has since ceased providing obstetric and neonatal intensive services from April 1990 due to restructuring of hospital care. The Neonatal Mortality Rates (NNMR) from 1982-1989 ranged from 6.52 to 9.55 and there was no significant fall in trend (p = 0.13). One hundred and thirteen (48.5%) neonates who died were below 1500gm (VLBW). Various causes of neonatal deaths were examined and there was a decline in respiratory distress syndrome (RDS) death rates (p less than 0.0002). Deaths due to asphyxia (p greater than 0.05) and infections (p greater than 0.05) have not declined significantly over the same period. It is also observed that less VLBW babies died over this 8 year period and the VLBW mortality rates (p less than 0.02) have declined. However, the congenital malformation mortality has also not declined significantly (p = 0.92) though early study (1972-1981) showed an increasing trend of malformation deaths among total neonatal deaths (p less than 0.02). Improvement in VLBW and RDS management has not contributed to a significant decline in NNMR. It is observed that more VLBW babies were born during this 8 year period (p = 0.01) especially so in the less than 1000 gm group (p = 0.0005) and the survival of VLBW babies has improved (45.5% to 75.8% alive) as a result of advances in neonatal intensive care. The reasons for increase in incidence of VLBW births in the past few years are not known.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The effects of Level III care in 1981 in Poa Payoh Hospital, Singapore, on neonatal mortality, and the trends between 1982-89 are examined. Of the 30,910 births recorded over the 8 years, the neonatal mortality rates (NNMR) were 6.52-9.55 deaths/1000 live births. There was not a significant decline in neonatal (X-squared = 2.28, p = .13) or perinatal mortality (X-squared = 3.756, p .05). Significance is observed only when lethal malformations are excluded. Stillbirth rates, neonatal deaths from infection, and asphyxiated births also did not show a significant decline. Significant declines occurred only with respiratory distress syndrome (X-squared = 18.4, p = .0002) and low birth weight 1500 gm (x-squared = 6.12, p = .013). An ethnic analysis indicated that Malays and Indians have a significantly higher level of perinatal and neonatal mortality. More male than female neonatal deaths (51.9% vs. 48.1%). Mortality was highest in the first 7 days of life or 76.9% of all neonatal deaths. Congenital malformation dropped from the leading cause of neonatal death and was replaced by very low birth weight (VLBW) deaths as the leading cause in 1989. Survival of VLBW babies has improved, but there were also many extremely low birth weights babies (1000 gm). It is suggested that effective treatment of VLBW babies is important, but the reduction in admissions in this groups should not be overlooked. Neonatal death due to malformations does not follow the increasing trends of other countries and does not contribute significantly to the rise or fall in the NNMR. The goal may be to reduce premature births (VLBW), which constitute 50% of neonatal deaths, and congenital defects, which constitute 33% of neonatal, deaths. The importance of monitoring neonatal mortality and perinatal mortality enables the estimation of potentially salvageable neonates and the requirements for different levels of care. Future directions for research and education necessarily follow.

Priorities in neonatal care in developing countries.

Lower perinatal and neonatal mortality have been achieved in the developed countries following advancement of neonatal care, introduction of high technologies, and better knowledge of pathophysiology of the newborn infants. Other contributing factors are organised delivery room care with skillful resuscitative techniques as well as risk identification and efficient transport of the sick infants including in utero transfer of the fetus, etc. It cannot be assumed that similar results can be attained in developing countries where financial and human resources are the problems. With limited resources, it is necessary to prioritize neonatal care in the developing countries. It is essential to collect minimum meaningful perinatal data to define the problems of each individual country. This is crucial for monitoring, auditing, evaluation, and planning of perinatal health care of the country. The definition and terminology in perinatology should also be uniform and standardised for comparative studies. Paediatricians should be well trained in resuscitation and stabilisation of the newborn infants. Resuscitation should begin in the delivery room and a resuscitation team should be formed. This is the best way to curtail complication and morbidity of asphyxiated births. Nosocomial infections have been the leading cause of neonatal deaths. It is of paramount importance to prevent infections in the nursery. Staff working in the nursery should pay attention to usage of sterilised equipment, isolation of infected babies and aseptic procedures. Paediatricians should avoid indiscriminate use of antibiotics. Most important of all, hand-washing before examination of the baby is mandatory and should be strictly adhered to. Other simpler measures include warming devices for maintenance of body temperature of the newborn babies, blood glucose monitoring, and antenatal steroid for mothers in premature labour. In countries where neonatal jaundice is prevalent, effective management to prevent kernicterus is essential. Simple assisted ventilatory device such as nasal continuous positive airway pressure (nCPAP) is also useful.

PIP: Levels of perinatal and neonatal mortality have declined in the developed countries following advances in neonatal care, the introduction of high technology, and better knowledge of the pathophysiology of newborn infants. Organized and skilled delivery room care together with risk identification and the efficient transport of sick infants, including in utero fetal transfer, also contribute to the reduction in mortality. However, in developing countries constrained by limited financial and human resources, the nature and delivery of neonatal care must be prioritized. Meaningful perinatal data must first be collected to define the problems of each country related to the monitoring, auditing, evaluation, and planning of perinatal health care services. Definitions and terminology in perinatology should be standardized to facilitate comparative study. Pediatricians should be well trained in the resuscitation and stabilization of newborn infants, infections should be prevented in the nursery, warming devices must be made available to maintain the body temperature of newborns, blood glucose should be monitored, and antenatal corticosteroids provided to women in premature labor. In countries where neonatal jaundice is prevalent, proper and effective management to prevent kernicterus is essential. Finally, a simple assisted ventilatory device such as nasal continuous positive airway pressure is also useful.

Traditional Chinese medicine and treatment of neonatal jaundice.

OBJECTIVE: Treatment with herbs may increase the risk of neonatal jaundice (NNJ). It is logical to look into the current practice in some hospitals in China where herbs are being used in the treatment of NNJ. It is also the purpose of this study to find out the chemical constituents and actions of the herbs, and the rationale of the treatment. METHODS: Twenty reports, from 1973 to 1989, from different parts of China, come in a published book and the paediatric journals written in the Chinese language. The Zhong Yao Da Zi Dian, an encyclopedia of Chinese materia medica, and other books on the pharmacology and applications of Chinese materia medica were also referred to in the study. FINDINGS: Yin-chen (oriental wormwood or Artemisia) was the most commonly used herbs for NNJ (95%). Others were Da-huang (rhubarb or Rheum officinale), Huang-qin (skullcap root or Scutellaria), Gan-cao (licorice or glycyrrhiza) and Huang-lian (goldthread rhizome or Copts chinesis). Huang-lian, which contains the alkaloid berberine, was used in 4 centers (20%). Berberine can cause severe acute hemolysis in babies with G6PD deficiency. Currently, Yin-chen comes as a decoction Artemisia composita and an intravenous preparation. These preparations have potential central nervous system and cardiovascular toxicities. CONCLUSIONS: Chinese herbs have many pharmacological substances and therefore multiple actions. In recent years, Chinese herbs are used in conjunction with "Western" drugs, rendering the study of the effects of herbs on NNJ extremely difficult. The efficacy and safety of phototherapy for NNJ have been firmly established, thus diminishing the need for drug treatment. What is the present day role, therefore, of herbal medicine for NNJ? Is there a place for further research of these herbal medicines?

Outcome of the extremely low birth weight infants (less than 999 grams): what messages are we getting?

The outcome of the extremely low birth weight (less than 1,000g or ELBW) babies continues to improve. More ELBW babies are surviving, though some of them may have various degrees of impairment or disability. The chance of dying or surviving with a major disability or cerebral palsy declines significantly in recent years in the developed countries. The implication of these findings is that application of neonatal care does not increase the risk of disabled survival as has been often feared but promoted normal survival. Great effort has been put in to achieve good results and better outcome. Developing countries however, will face a problem of achieving similar results because of limited resources or priority of allocation of limited resources, inadequate facilities, lower socio-economic status, poor home environment and lack of follow-up services, training and rehabilitation set-ups or intervention programme. What is the relevance of these good results in relation to the developing or third world countries? The limit of viability may have to be redefined. Nevertheless, it should be the aim to lower the mortality of these high risk babies and to reduce complications and morbidity of the survivors. Maintenance and control of body temperature, control of infections, blood sugar monitoring, antenatal steroids for the mother in premature labour, resuscitation at birth or even simple nasal continuous positive airway pressure (CPAP) should come a long way in fulfilling these goals. Those ELBW children who survive without neurological damage may have learning difficulties. It is necessary to find out the reasons for that such as the impact of the home environment on mental development. Do the children have a good background conducive for learning? Are there establishments for intervention programme in the community for these high risk children? The ratio of neonatal beds per 1,000 deliveries may have to be reviewed now that more ELBW infants are staying in the hospital for a longer period, and surviving.

Perinatal infections--problems in developing countries.

The transmission of infections from the biologic mother to her offspring is popularly known as perinatal infection (PI). It is not synonymous to infections during the perinatal or neonatal period. Physicians should avoid focusing attention only on the TORCH agents in the evaluation of suspected PI. Perinatal period begins from 28 weeks of gestation. Would one consider in utero infections in the first or second trimester of pregnancy as PIs? Developing countries have difficulty in collecting reliable and accurate data of PIs. These data are useful to define the magnitude of the problems, to monitor the trends, to recognise the mode of spread, and to find a solution of PIs. Most PIs are asymptomatic and diagnosis is extremely difficult. Developing countries need rapid, easy-to-operate, simple, and cheap diagnostic tools urgently. Access to health care in the remote city is limited. Newer drugs are too expensive and very few patients can benefit from these. Each developing country should prioritize its PI problems and tackle those that have serious public health problems and socio-economic impact. Most developing countries should focus on HIV (human immunodeficiency virus) and HBV (hepatitis B virus) infections. Other countries where ophthalmia, malaria or tuberculosis are prevalent or endemic, should focus on these. Developing countries are more willing to allocate the budget for prevention of diseases than for treatment. There may be problem of promulgating the information on prevention of diseases because of illiteracy, multi-lingual community. Vaccines where available, should be affordable. Other effective prevention guidelines should be workable in poorer nations. The government should play an important role in enforcing immunisation program by intensive promotion program or by legislation.

Outcome of infants weighing 500-999 grams at birth in a Singapore hospital (1990-1993).

Over a 4-year period (1990-1993) 126 babies weighing 500-999 grams (0.39% of 32,362 livebirths) were born in the hospital that provides tertiary care. Seventy-eight babies (61.9%) were discharged alive. Survival rate (79.4% or 50/63) was higher in the larger babies (800-999 gm) than in the smaller babies (28/63 of the 500-799 gm or 44.4%, p = 0.0001). Survival rates among the 2 periods, 1990-91 (period 1) and 1992-93 (period 2) have also improved, from 44/74 or 59.5% to 34/52 or 65.4%, p = 0.62 (NS). Surfactant replacement therapy (SRT) has an impact on decreasing the mortality for babies < 1,000 gm. Only 35.3% (6/17) babies had SRT in 1993. Other perinatal factors are also contributing to a better outcome of these high risk babies. Neurodevelopmental outcome at 2 years of age of the 39 babies (50%) born in period 1 has been determined. Thirty-five percent (5/14) of the smaller babies and 28% (7/25) of the larger babies had MDI (Bayley Mental Developmental Index) of < 69. For cerebral palsy, it was 14% and 8% respectively; and for neurosensory disorder, 7% and 4% respectively. Some babies had a combination of 2 or 3 major impairments. It is estimated that 33% of babies who weighed less than 1,000 gm at birth had a disability. It was found that severe intraventricular haemorrhage (IVH) of grade III and IV correlated significantly with MDI of < 69 (p < 0.05). Severe IVH in period 2 (17.2%) did not differ significantly from that of period 1 (29.4%, p = 0.55).(ABSTRACT TRUNCATED AT 250 WORDS)

Stillbirths--ten years experience at Toa Payoh Hospital.

An analysis of 287 consecutive stillbirths associated with 47,171 deliveries in Toa Payoh Hospital between 1978 and 1987 was undertaken. The incidence of stillbirths was 6.1 +/- 1.26 per 1,000 total births. 149 out of 287 cases (51.9%) had known causes of death. Intrauterine anoxia and congenital malformations are the commonest diagnosis. In contrast, in 48.1% (138/287) of the stillbirths, we were unable to determine the underlying causes because of maceration and a low autopsy rate. Among the 287 stillborn infants, 54% were born prematurely, and 64.2% were born with birth weights of less than 2,500 g. 8.4% of the mothers had a past history of one to three abortions, and 5.6% of the mothers had a past history of one or more stilbirths. This study showed that the stillbirth rate in this hospital has not changed significantly in the last ten years.

Septic arthritis in the newborn--a 17 years' clinical experience.

Septic arthritis is an uncommon, yet serious disorder in the newborn. Most patients survive with permanent handicaps. We encountered 11 cases of neonatal septic arthritis in the Hospital over the past 17 years (1971-87), an incidence of 0.12 per 1000 livebirths or 0.67 per 1000 admissions to the neonatal nursery. The clinical experience is presented. The diagnosis of septic arthritis in the newborn is more difficult than in the older children. Joint swelling (10/11), tenderness (9/11) and limitations of joint movement (8/11) were the common presenting clinical signs. Constitutional symptoms (fever, leucocytosis, gastrointestinal disturbances) were unremarkable. More than half of the babies (6/11) were prematurely born. The knees and the hips were frequently infected, many had multiple joint involvement (6/11). Septic arthritis commonly manifested between 20-40 days of life. The causative agents viz. Staphylococcus aureus (4/11), Candida (2/11), Citrobacter (1/11) and Methicillin Resistant Staphylococcus aureus MRSA (4/11) showed that septic arthritis was a nosocomial infection. Many babies (9/11) had insertion of intravascular catheter for 1-3 weeks and 9/11 babies had concomitant positive blood culture, 2/11 coexisting osteomyelitis and 1, meningitis. Though there was no death, majority of the babies had joint destruction and severe handicap. Early diagnosis including frequent examinations of joints, prompt treatment and control of nosocomial infection are important in management.

Reduction of nosocomial infection in a neonatal intensive care unit (NICU).

UNLABELLED: New measures aimed at reducing nosocomial infection in our neonatal intensive care unit (NICU) were introduced over a 3-month period from 1 July to 30 September 1994. OBJECTIVE: The aim of this study was to evaluate the impact of these measures on the incidence of nosocomial infection in our NICU. METHODS: The new measures introduced were: 1. grouping of all blood investigations to allow for fewer blood samplings per baby per day; 2. reduction of routine blood investigations after the acute illness has stabilised, and 3. a system of aseptic delivery of drugs through a central venous catheter, thereby reducing the need for peripheral intravenous lines. Nosocomial infections were defined according to the criteria spelt out in the Centres for Disease Control (CDC) guidelines. Data for the study was obtained from the ongoing surveillance carried out by the hospital's infection control team. Period 1 (1 year duration) was prior to the implementation of the new measures. Period 2 (1 year duration) was after implementation of the new measures. RESULTS: The overall nosocomial infection patient rates (expressed as number of infections per 100 intensive care unit patients) were 17.6 for Period 1 and 7.5 for Period 2. The overall nosocomial infection patient-day rates (expressed as number of infections per 1000 patient-days) were 13.5 and 6.1 respectively (p < 0.01). When the infants' birth weights were stratified as < 1500 g, 1500-2500 g, and > 2500 g, the greatest decline in both the overall nosocomial infection patient rate and nosocomial infection patient-day rate was seen in infants weighing < 1500 g. There was also a significant decline in the rates of blood-stream infections in infants weighing < 1500 g (from 7.5 to 2.8 per 1000 patient-days) (p < 0.05). Ventilator associated pneumonias also showed a decline from 3.3 to 1.0 pneumonia per 1000 ventilator days. The organisms responsible for the majority of blood stream infections in Period 1 were methicillin-resistant Staphylococci Aureus (MRSA), coagulase-negative staphylococci, gram-negative bacilli and candida. In Period 2, coagulase-negative staphylococci was the predominant organism. CONCLUSION: We conclude that there was a reduction in nosocomial infection rates. The new measures introduced may have contributed to this reduction.

Systemic candidiasis in premature infants detection by urine microscopy and culture.

Routine microscopic examinations and/or urine culture for Candida were done in all premature infants associated with perinatal factors viz prolonged hospitalisation, broad spectrum antibiotic therapy, use of intravascular catheter, endotracheal intubation. We report another seven infants with systemic candidiasis over a two year period (1983-1984). All, except one, had positive microscopic examination and/or urine culture. We advocate routine microscopic examination urine in premature infants at risk and a positive result is an indication for antifungal therapy. The significance of positive cultures of endotracheal tube and umbilical catheter is discussed.

Systemic candidiasis in premature infants experience with drug treatment.

Eleven premature infants with systemic candidiasis from 1981 to 1984 have been reported previously. The experience with antifungal drugs is presented. Amphotericin B at lower maintenance dose, together with 5 flucytosine (5FC), are the preferred drugs for treatment of systemic candidiasis at present.

Neonatology in Singapore: the way we were, the way forward.

Singapore has a maternity hospital since 1924, but for many decades the newborns could only receive basic care. Neonatal and perinatal mortality rates were high. Marked improvement in neonatal care began from the 1980s when many neonatal departments were set up to provide intensive care. Improved socioeconomic status, better healthcare facilities, effective infection control, immunisation programmes and availability of potent antibiotics contributed to the decline of perinatal and neonatal mortality. Following the implementation of the glucose-6-phosphate dehydrogenase (G6PD) deficiency screening programme, severe neonatal jaundice and kernicterus were largely reduced. Exchange blood transfusions initiated in the 1960s and phototherapy in the 1970s had saved many babies. Kernicterus is almost not seen now. With more neonatal-trained staff, organised resuscitation teams, advances in respiratory management and better monitoring equipment, more babies have survived. Closer cooperation between obstetricians and neonatologists was a great leap forward towards perinatal medicine. Physicians should endeavour to reduce the incidence and prevalence of birth defects and metabolic errors. Perinatal asphyxia should be promptly detected and managed effectively, including neuroprotective strategies. There should be markers to predict the outcome of asphyxiated babies for decision-making. Neonatologists should be mindful of safe introduction of new technologies and rapid diagnostic techniques for infections, including group B streptococcal screening and chemoprophylaxis when required. Other current issues include prevention of major morbidities, preservation of brain function, improved neurodevelopmental outcome of premature babies, use of blood substitutes, optimal nutrition, fetal surgery, evidence-based medicine, better information systems, avoidance of medication errors, adequate sedation and pain relief of the baby, and the use of nitric oxide. One should bear in mind the need to enhance the neonatal intensive care environment, improve non-invasive monitoring and minimise invasive procedures. Physicians should prioritise neonatal care for their country and utilise less costly neonatal care. Ethical issues in neonatology that arise following advancement in neonatal care deserve attention. Advances in life sciences, such as the completion of the human genome project, cloning of tissues and organs, human stem cell research and technology, gene therapy, deoxyribonucleic acid vaccines and nanomedicine, should benefit neonatology.

Congenital malformations in Toa Payoh hospital--a 18 year experience (1972-1989).

A ten year experience (1972-1981) of congenital malformations in Toa Payoh Hospital was presented previously. The experience of birth defects of the second decade (1982-1989) is reviewed and compared. The mortality rates of babies with malformations ranged from 1.52 to 3.55 per 1000 livebirths. There was no significant increase in congenital malformation death rates over the past eight years. There was an increasing trend of malformation deaths among the total neonatal deaths from 1972-1981 (p less than 0.05), but this was not so for the period 1982-1989. The incidence of minor congenital malformations has not changed except that more cases of undescended testes were recorded (p less than 0.05). Central Nervous System (CNS) malformations, congenital heart defects and chromosomal abnormalities still remain the leading cause of malformation deaths. Neural Tube Defects (NTD) were the commonest type of CNS defect and the death rates of NTD for these two periods remain the same (about 0.65 per 1000 births). The prevalence of anencephaly at birth in Chinese and Malay from 1982-1989 is 0.45 and 0.84 per 1000 livebirths respectively. Down syndrome was the commonest type of chromosomal abnormality (63%) and coarctation of aorta (40%) was the commonest type of congenital heart disease causing death. Many congenital malformations are genetically determined. More knowledge of the aetiological factors, antenatal diagnosis of birth defects, preventive measures and genetic counselling are, therefore, important in lowering birth defect rates.

Ethical issues in neonatal paediatrics--the Singapore perspective.

In Singapore, formulating ethical guidelines for people who live in a multiracial, multilingual, multicultural and multi-religious community can be difficult. The "individualised prognostic" strategy in the management of critically ill infants has been followed. Our neonatal paediatricians encounter the following ethical problems: extremely premature babies whose viability is doubtful, babies born with severe congenital malformations, babies born with signs of life in legal or therapeutic termination of pregnancy, the asphyxiated babies or babies with severe or extensive brain damage, and babies who are chronically sick and have no chance of recovery or leaving the hospital. Good ethical decisions require medical facts. The infant's diagnosis and prognosis must be accurate. There should also be detailed information that continuation of any form of medical treatment for the infant is futile, will do more harm than good and is inhumane. Ethical decisions should be made in the best interests of the infant. Dating of the infant's gestational age should be accurate and reliable, and there should also be unanimous definitions such as fetal viability, abortions and lethal malformations. Ethical guidelines and the law must also keep pace with changes in medical practice.