[ad_1]
For pediatric resident physicians, the nursery of newborns at a high-risk birthing center is a powerful mix of mundane and terrifying people. We spend most of our time teaching new parents the number of wet diapers to be expected in the day, making slight adjustments to badfeeding positions, listening to normal hearts again and again. Most babies do not need a pediatrician during delivery and these children simply arrive in our unit, swaddled and ready to live outside the womb.
Sometimes, however, birth is an emergency: the baby does not have a heartbeat; the baby is not breathing. I wear running shoes at work, even though I have lost a pair because of blood stains, so every time my pager rings, I'm ready to run to work and delivery.
In the middle of the morning, a nurse calls us downstairs to inform us that the mother who will have a caesarean section at noon refuses the vitamin K injection for her baby. Although the tendency to refuse neonatal vitamin K seems fresher than the refusal of the vaccine, it is perhaps less publicized. Like many pediatricians, I see a growing number of refusals.
Jen, my intern, sees me wince. "We have to go up and talk with her before birth," I say. "She refuses vitamin K. Do you want to lead this conversation or do you want to listen to me?"
"Maybe since the first time, I'll listen to you," Jen said.
"OK," I say. "So, let's go first, why am I so concerned that this baby is getting Vitamin K?"
"Her blood can not clot without it," says Jen.
"Exactly So, the risk of not having the shot is?
"Bleeding," Jen says.
"Cerebral hemorrhages and bleeding in the intestine are the ones we are interested in," I say. "And when can babies who do not get vitamin K start bleeding?"
"Soon?" Said Jen.
"Yeah," I say. Babies are at greatest risk of vitamin K deficiency bleeding (VKDB) during the first week of life. The standard treatment is therefore to administer the injection in the hour following birth. Many parents do not know that the risk of VKDB is high in untreated newborns: between one in 60 babies and one in 250 who do not receive the injection will have a clinically significant bleeding, such as a bleeding in the intestine that makes it anemic or bleeding from the brain that affects their neurological development.
A small minority of these bleeds will be devastating haemorrhagic strokes, which can leave previously healthy babies severely injured or even killed in the brain. Severe bleeding occurs later in life, between two weeks and six months. They are not provoked – there was no need for a car accident, trauma or abuse. There are usually no warning signs until the bleeding is severe enough to put pressure on the brain.
The Centers for Disease Control and Prevention, in an appeal to parents, have published a handful of stories of parents whose babies have suffered a life-threatening DVBD. "Judah's Story" is about a healthy boy whose parents refused to shoot. At five weeks, Judah began to vomit. At first, his parents thought he was suffering from intestinal flu, but in the evening he had become lethargic. His parents were preparing to take him to the emergency when he started having seizures. A few hours later, the baby underwent emergency brain surgery and went to the pediatric intensive care unit.
Such bleeding is not one of the conditions that physicians are required to report to public health authorities. We therefore do not have reliable data on the frequency of these accidents. Anecdotally, during my three years of residency, I have witnessed a handful of cases. In any case, it was a child in good health like Judah, whose life was forever altered by a cerebral hemorrhage that could have been prevented by a single injection of vitamin K.
"So what will this mom want to know?" I asked Jen.
"The side effects of the shot," she says. (There is no one but pain at the injection site.)
"There are chemicals in the shot." (Our hospital uses vitamin K. without preservatives.)
"If she can wait and get it from her pediatrician." (Not recommended because, again, babies are at high risk in the first days of life.)
At the top, Jen and I find the expectant mother alone in her room, waiting to be transferred to the operating room for her caesarean section. Her husband is at home and takes care of their other children. We introduce ourselves as pediatricians who will be present at the birth of his baby.
"So when Mia is born," I say, "the doctors will support her to see you. We will try to do a delayed tightening of the cord, then she will come to bed with us for a few minutes. Sometimes babies need a little extra help to adapt to the world at birth. Our job is to help her if she needs it. We will warm her up and make sure she is breathing well, and we will take her into your arms as soon as possible. "
The mother nods and smiles, so I continue. "We give three drugs to all babies the first day of their life: an erythromycin eye ointment and a hepatitis B and vitamin K vaccine," I say. Erythromycin prevents blindness caused by a gonorrhea infection of the baby's eyes. If we administer the hepatitis B vaccine so quickly, it is that vaccination within 12 hours of life can prevent mother-to-child infections.
"Oh, I do not want to do anything about it," she said.
"Tell me more about it," I say.
"I do not think she needs all these drugs immediately," she says. "My midwife told me to say no."
It really surprised me. Most midwives are nurses, professionals who provide excellent antenatal care, and safely and competently conduct low-risk pregnancies. I was surprised that a midwife in charge of the health of mother and baby gives such obviously unsafe advice.
We know that babies born in birth centers are less likely to receive vitamin K. After a cluster of four life-threatening VKDB cases in Tennessee in 2013, a study found that 28% of babies born in birth centers in the Nashville area had not received vitamin K. I had however badumed that parents who had refused the injection were acting against the baby. opinion of the midwives who took care of it.
"I know you have had good prenatal tests, so in your case, I think it's safe to stop on erythromycin and hepatitis B," I said. "But let's talk about vitamin K."
Jen and I spent some time in the room trying to ensure a safe delivery to the baby without arming the mother. We did what I think is our due diligence: we have pronounced the words "stroke" and "bleeding to the brain". We had promised to respect his choice, but had specified that our medical advice was to be vaccinated.
The mother called her husband and decided to make a decision after birth. The operation went well and Mia was born beautiful and vigorous. But the mother refused vitamin K. She said she did not want to "overwhelm her system with a mbadive overdose of vitamins".
It's not an overdose, I fretted internally. It's a dose.
Jen encouraged Mia's mother to talk again about her main partner with vitamin K, and we let her go. My doctor tried to call the midwife but could not reach her. I remained in the interrogation about Mia's vulnerability and what I saw differently from her mother.
Newborns are resilient in many ways: they have reshaped their skull to fit into the pelvis, activated the sleeping lungs with the first breath of air, opened and closed special pbadages in their heart to adapt to their new extra-uterine environment. Moments after birth, they break down blood cells and learn to see. I have seen babies born with no detectable heartbeat who receive good pediatric care and cry with vigor and are ready to eat within 15 minutes of their life. An adult could never do that. In short, newborns are robust and I do not think an injection can be very harmful. A dose of medically appropriate vitamin can not overwhelm them. Brain bleeding can.
Later in the week, Jen's co-intern, Emily, convinced another reluctant mother to accept the shot. This mother simply did not know what the stakes of the refusal were, and when Emily explained to her, she changed her mind.
This is what pediatricians can do best: we can be nice and we can make sure that parents who refuse vitamin K understand the possible consequences of this decision – as well as those who have never set foot in a home. pediatric intensive care unit. A colleague told me the story of an anesthetist who had heard a parent say, in the middle of a caesarean section, that she had chosen not to give Vitamin K. The parent was talking to the pediatrician, but the anesthetist snorted and said, "It's a bad choice. . Supposedly, the parent heard and changed it.
Photography: Mustafa Gull / Getty Images
The story makes me wonder if I should listen less and be more direct. But parents are allowed to make choices that put their children in unnecessary danger. They are allowed to weigh the risks and take advantage of their own scales. They can see an injection as an evil. Research has shown that parents who refuse vitamin K may continue to refuse vaccination. Like those who refuse vaccines, they tend to be educated, white and born in the United States – people like me, whose social privilege isolates them a bit from health problems.
Even though my body is isolated, my mind is not it. I'm afraid to give birth because I saw women dying while trying. I'm afraid of fever during the first eight weeks of life because I've seen how bacteria can liquefy children's brains. I'm afraid of whooping cough because I saw the level of oxygen drop and the heart rate of his baby, more and more close to cardiac arrest. I am afraid of nature because my work has infused the unsustainable vulnerability of life.
Children die of diarrhea and hunger; they are killed in the war. Pneumonia is still the leading cause of death in children worldwide, although we have vaccines that could prevent many of these deaths. In the United States, vaccines such as those against Streptococcus pneumoniae, Haemophilus influenzaePertussis and the flu virus prevent tens of thousands of child deaths every year. The influenza vaccine, for example, reduces the risk of dying of influenza in a healthy child by 65% - even if it catches the disease despite vaccination. About 80% of the 185 American children who died of influenza last year were not vaccinated. If the privilege allows some parents to believe that they are able to protect their children without vaccines or vitamin K, my experience at the Children's Hospital – where all the sickest children gather – makes me fear never to be able to do enough to protect the most vulnerable. we.
But parents who refuse preventive medications such as vaccines and vitamin K actually think of protecting their children. They tend to believe that children are constantly threatened: by toxins, medical interventions, corporate conspiracy. As the American writer Eula Biss writes in On Immunity: An Inoculation: "It's now, as activist Jenny McCarthy says," mercury, ether, aluminum, antifreeze "that we fear in our vaccines. The beer of our witches is chemical. There is no real ether or antifreeze in vaccines, but these substances raise concerns about our industrial world. They evoke the chemicals on which we now impute our poor health. "
These parents see a similar vulnerability to what I see in their children, but in their minds, the threats come from society. "We seem to believe, against all evidence, that nature is entirely benevolent," Biss writes. In my view, society is by no means trivial, but offers vaccines and vitamin K as protection against threats from nature.
Oe Friday afternoon, in my primary care clinic, I see a two-week-old boy who has not received vitamin K. During a conversation, I realize that the mother does not oppose the vitamin she -even; she opposes the blow.
This family is the ideal target for oral vitamin K supplementation, an option used as standard treatment in the Netherlands. In the United States, we do not have an oral form of vitamin K approved by the FDA to prevent VKDB, and there is no indication that we have the opportunity to do so (grind pills and mix them in water , or administer the injectable liquid through the mouth). are effective. When I tried to prescribe oral vitamin K to a baby, two different pharmacists had recommended me the dosage. No recommendation was based on evidence. To circumvent this confusion, an Oregon Children's Hospital has developed a standard protocol for oral vitamin K testing, but the site's doctors have finally abandoned the plan due to the lack of evidence of its Efficiency – a rational choice when we have a cheap, widely available and close medicine. – Efficient universal shooting.
Pediatricians Melissa Weddle and Carrie Phillipi have argued that US doctors should not recommend the unspecified use of oral vitamin K, even in countries where proven oral formulation is available, some treatments may not be available. have not succeeded. Oral vitamin K should be administered repeatedly, at specific intervals in a baby's life, and studies suggest that many children will not receive all the prescribed doses. Between this demand for repeated, timely doses and the tendency of babies to vomit oral medication (or just to vomit, at any time, for whatever reason), some babies treated with vitamin K orally always develop a VKDB. In addition, babies who have undetected liver or gallbladder problems may not be able to absorb the drug orally and will remain at risk despite oral therapy.
The safe, effective and proven method we already have should be the standard of care for all babies. But there are cases where a family would consent to treatment if it was not for injection. And even if oral vitamin K prophylaxis is a second-rate treatment, it is better than no prophylaxis. I would like us, in the United States, to evaluate oral vitamin K as a second-line option for the minority of babies whose parents categorically refuse injection.
"Tell me more," I say, because I feel that the mother is holding back something.
She looks at the baby's face as she responds, so softly that I almost do not catch it. "I do not think it's fair to pierce his sacred body with a needle," she says.
To that, my heart expects, because that's the kind of objection I feel. It is not based on imaginary risks proven by science, nor on false notions of "toxins", nor on the fear of chemicals naturally present in food and soil and added to drugs. This mother's child is holy, her body is perfect and we have to leave it.
I admit that they are holy, these tiny creatures, half myelinated, whose needs made me sleepy or prevented me from sleeping for a thousand nights. But to persist in my work, I must believe that holiness is inviolable even if the body itself is illuminated and bleeds. Babies are holy when they are fat and warm in the newborn's room. They are holy when they have nasogastric tubes coming out of their nostrils. Children sedated and paralyzed in the intensive care unit, with freshly bandaged surgical wounds, are sacred. Children with double-lumen central lines dripping chemotherapy drugs into their veins are sacred. Children read comics while a four-fold more powerful hemodialyzer pbades their blood into a filter, children underpbad heart-lung bypbad after drowning in a backyard pool, children who need four intravenous drugs so that their failing hearts swell long enough to keep them alive: holy, holy, holy.
No needle is strong enough to interrupt for a single second the holiness of a child's existence. The notion that this might seem to overestimate the ontological power of medicine: I certainly encroach on the bodies of children, but I do not believe that their essential identity – their spirit, their holiness or their soul – can be hurt with a needle. It takes stronger things.
It is common for religion to explain how drugs are used. A deeply Catholic mother who fasted for three days so that Jesus relieved her son of the symptoms of asthma recently told me that she was nevertheless convinced that albuterol inhalers were proof that God was acting in the hands of doctors . A practicing Muslim mother whose child refused to take pills was happy to follow my recommendation for gelling vitamins without gelatin. Some haram consider pork gelatin contained in many drugs, although an international council of imams convened by the World Health Organization has recommended that drugs and vaccines be considered exempted from the ban.) A woman raised as a Jehovah's Witness said her family had waived her for allowing her three-year-old son to receive an infusion of platelets while chemotherapy had lowered his rate so much that he risked dying from a nosebleed.
However, it is rare that religion presents categorical refusals that evade alternatives when the potential consequences of its refusal to use the drug are so terrible.
The boy who has not received the vitamin K vaccine is warm, swaddled and breathes gently. Her heart rate is steady and the breath of her normal newborn is blurred. He is holy; He is perfect. And it is shocking to realize the narrative place that holds my drugs in the cosmos of this mother. For her, my shot and I are pollutants. We are the bitter Samaritans, strewing the bones through the temple of Jerusalem.
But I'm not bitter inside me. I want him to get vitamin K for practical reasons: to be able to stay at home safely, in the arms of his mother, without any critical need for medicine and myself. I do not want him to bleed in his brain. I do not want neurosurgeons to crack the skull to relieve the pressure. I do not want him on a breathing tube in our intensive care unit. Vitamin is preventive, a charm to repel me.
The mother and I finally understand each other, but we do not agree and the baby leaves without an injection.
This is an edited version of a play that first appeared on the New York Daily Book Review
• Follow the long read on Twitter at @gdnlongread, or sign up for the weekly email here.
[ad_2]
Source link
