Monday, October 29, 2012

Answering your question on withdrawal of fluids in newborn

On Friday a parent posted this question on the BLOOM blog:

"Is it routine to withdraw fluids and nutrition from infants in the NICU? That is what we were offered for our son in hospital after we removed the ventilator and put a DNR on his chart and waited for him to die. He didn't die. He didn't need a g-tube, he was able to breastfeed and get enough nutrition for himself yet it was offered to us to just stop feeding him orally, give him morphine for the pain and let him go. Is this sort of thing common?"

I contacted Dr. Jonathan Hellmann, who is clinical director of the neonatology unit at the Hospital for Sick Children in Toronto for clarity on how to answer this question.

Dr. Hellmann authored a paper earlier this year about parent perspectives on withdrawing intravenous fluids in newborns with severe neurological injury or disease where the decision to stop life-sustaining medical treatment such as ventilation is made (Withdrawal of artificial nutrition and hydration in the Neonatal Intensive Care Unit: parental perspectives). None of the newborns in the study could safely be fed orally.

According to the study, in addition to requiring the full support of the parents and the senior medical staff and team, the practice of withdrawing artificial nutrition and hydration requires "the clear demonstration of the inability of an infant to safely tolerate oral feeds (oral feeding was regarded as routine care even in those in whom it took many hours to achieve a satisfactory intake.)"

Given this criteria, I asked Dr. Hellmann whether withholding milk from a baby who is able to breastfeed -- as reported above by the parent on BLOOM -- fell outside the practice of withdrawal of artificial fluids and nutrition.

Dr. Jonathan Hellmann: Your interpretation is correct. Only if the feeding is regarded as medical treatment i.e. requiring tubes, IVs, lines etc. is it ever our practice to possibly raise the issue with parents of a profoundly affected infant. If the child is able to tolerate feeding it is absolutely not acceptable to consider withdrawal of hydration and nutrition. I am extremely concerned that individuals might interpret our findings without every effort being made to feed even small sips, and only when it is unsafe to potentially raise the issue. It is certainly not common practice here and requires very careful consideration in every case.

I hope the parent who posed the question above sees this blog and lets us know if she has more questions.


Thanks Louise. This is a very important topic. How is an assessment made as to the child's predicted disabilities anyway? Do the personal values of the neonatologists challenge their ability to provide unbiased information to enable parents to make an informed decision? If the parents choose or ask to dehydrate their newborn, at what point do the rights of the child come into the question? As the child is legally a "person" after birth, should the agencies that protect children become involved?

Before birth, the parents can make any decision they want because the fetus has no legal rights. We know that the vast majority will choose to abort if there is indication that the fetus might have a cognitive disability. Does this fact affect or bias the counseling parents receive after birth?

Consider the study that was published in 2011 based on 720 patients who suffered brain trauma and were placed on life support at one of six level one trauma centres across Canada. The authors found that the outcome was centre-dependent suggesting that the culture of the centre (and its staff) was a factor in the decision to withdraw treatment. They concluded:

"We observed significant variation in mortality across centres. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury."*

Could the same circumstance, whereby treatment is withdrawn before there is a reasonably accurate ability to assess brain damage exist in the NICU?

I wonder what oversight exists to ensure that the best interests of the newborn "person" in these situations?

*Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ. 2011 October 4; 183(14): 1581–1588.