**4. Allegations of professional liability in neonatal-perinatal medicine**

We next identified the most common events in the care of sick newborns leading to litigation against practitioners. Multiple allegations were common due to the prolonged care of the newborn. Table 4 lists the top ten allegations of professional liability against practitioners of neonatal perinatal medicine. The ten most frequent allegations brought against practitioners who care for newborns included: inadequate airway/intubation (21%), failure to recognize air leak (18%), delayed transfer to Level III facility (14%), inadequate treatment of seizures (11%), delayed attendance at delivery (10%), cardiac tamponade (malpositioned central line) (6%), failure to perform eye exam (6%), medication error (6%), midgut volvulus (5%), and hyperbilirubinemia (kernicterus) (3%). Meritorious allegations against practitioners in newborn care are frequently preventable events. Substandard neonatal resuscitation in the delivery room can also propagate non-meritorious allegations against obstetricians.


Table 4. Top ten allegations against practitioners of newborn medicine

We found that the most common allegations were a result of difficulties in the management of airways and air leaks in newborns. The procedural skills, including proficiency in intubation and thoracentesis, require a significant amount of clinical experience. Evolving technology over the last two decades with steroids, surfactants and ventilation have reduced the acuity of neonatal lung disease with concomitant reduction in intubations and chest tube placement. The recent restrictions on the time that pediatric residents are allowed to spend in intensive care units, set by the Accreditation Council for Graduate Medical Education, has contributed even more to their reduced experience with these procedures. More than half of all intubation attempts by pediatric residents are unsuccessful leading to multiple attempts by caregivers to properly place the endotracheal tube. Also, general pediatricians are often the primary caregiver when resuscitation of newborns in the delivery room is required. Their residency programs must ensure they become proficient in the resuscitation and care of the newborn.

after birth may appear normal even when there has been severe injury to the brain. It is important to consider not only which imaging studies to obtain but also when to schedule them to optimize the results in attempting to determine the timing of the alleged insult. Neuroimaging can be helpful in approximating a window of time when the injury might

We next identified the most common events in the care of sick newborns leading to litigation against practitioners. Multiple allegations were common due to the prolonged care of the newborn. Table 4 lists the top ten allegations of professional liability against practitioners of neonatal perinatal medicine. The ten most frequent allegations brought against practitioners who care for newborns included: inadequate airway/intubation (21%), failure to recognize air leak (18%), delayed transfer to Level III facility (14%), inadequate treatment of seizures (11%), delayed attendance at delivery (10%), cardiac tamponade (malpositioned central line) (6%), failure to perform eye exam (6%), medication error (6%), midgut volvulus (5%), and hyperbilirubinemia (kernicterus) (3%). Meritorious allegations against practitioners in newborn care are frequently preventable events. Substandard neonatal resuscitation in the delivery room can also propagate non-meritorious allegations

**4. Allegations of professional liability in neonatal-perinatal medicine** 

**Allegation N = 100**  Inadequate airway/intubation 21% Failure to recognize air leak (pneumothorax) 18% Delayed transfer to Level III facility 14% Inadequate treatment of seizures 11% Delayed attendance in the NICU/delivery room 10% Cardiac tamponade (central line) 6% Failure to do eye exam (blindness) 6% Medication error (overdose) 6% Midgut volvulus 5% Hyperbilirubinemia (kernicterus) 3%

We found that the most common allegations were a result of difficulties in the management of airways and air leaks in newborns. The procedural skills, including proficiency in intubation and thoracentesis, require a significant amount of clinical experience. Evolving technology over the last two decades with steroids, surfactants and ventilation have reduced the acuity of neonatal lung disease with concomitant reduction in intubations and chest tube placement. The recent restrictions on the time that pediatric residents are allowed to spend in intensive care units, set by the Accreditation Council for Graduate Medical Education, has contributed even more to their reduced experience with these procedures. More than half of all intubation attempts by pediatric residents are unsuccessful leading to multiple attempts by caregivers to properly place the endotracheal tube. Also, general pediatricians are often the primary caregiver when resuscitation of newborns in the delivery room is required. Their residency programs must ensure they become proficient in the resuscitation and care of the newborn.

Table 4. Top ten allegations against practitioners of newborn medicine

have occurred.

against obstetricians.

Procedural skills teaching based on observing the skill, performing the skill, then teaching the skill is not adequate for proper training. Improving opportunities for clinical experience with intubation and thoracentesis may reduce legal actions against practitioners. Simulation-based training can have a role to provide a realistic medical situation in which learners can gain exposure to clinical tasks and anatomical regions. Approximately 10% of newborns require some form of resuscitation at birth, and a skilled resuscitator is necessary for all deliveries even when they are considered low risk. In our clinical experience, the most common etiology of decompensation in a newborn is airway related, with chest compressions rarely indicated when an adequate airway is effectively established. When an adequate airway is achieved, but newborns do not respond to resuscitation, one needs to expediently consider a pneumothorax in the differential diagnosis. Failure to recognize an air leak was the second most common allegation found in this study. An unrecognized air leak is the most common etiology for sudden unexplained death in unsuccessful newborn resuscitation. A tension pneumothorax is an acute life threatening event that may not allow the time for x-ray confirmation. Prompt recognition and needle aspiration of the pleural space should result in rapid clinical improvement for these newborns. It has been our experience that poor newborn outcomes as a result of improper delivery room resuscitation often are erroneously attributed to the delivering obstetrician. A depressed newborn requiring vigorous resuscitation with poor Apgars more often than not creates the mindset that it must be the obstetrician's fault.

Due to the critical state of newborns in the NICU, numerous protocols have been instituted to reduce iatrogenic events. When set protocols were not followed rigorously, we found that cardiac tamponade and blindness resulted in allegations of malpractice. Central lines are frequently used in the treatment of newborns for both medication and nutrition infusion, but their use carries significant risks. The possible malposition and migration of a central catheter can result in perforation of the myocardium or pericardial effusion which can be fatal. It is recommended that the central line be optimally placed outside of the right atrium to reduce these risks. Newborns with central lines must be carefully monitored with serial radiographs to confirm the position of the central line throughout the course of their treatment. Another protocol set forth in the care of newborns is an eye exam for all preterm newborns less than 33 weeks gestational age at 4 to 6 weeks chronological age. A newborn is almost never too sick for an eye exam, although nurses may feel that their patient is too unstable to be dilated and examined.

The potential for rapid decline in an unstable newborn requires that their caregivers not delay in proper treatment measures. A prolonged response time for physicians during an emergency situation, as well as delayed transfer of newborns to a proper level NICU were common allegations found in this study. All hospitals have contracts that require trained personnel to be at a high-risk scenario within a certain time frame. A delayed response to a page, and the lack of an alternative plan to notify a skilled resuscitator can result in catastrophic consequences for a compromised newborn. In addition, critical care of a newborn often requires advanced services that are not available in all NICUs. Level I, II, II+, and community Level III centers have set policies and regulations overseen by their regional perinatal center. The lack of experience of nursing and respiratory personnel in a low volume NICU can contribute to deviations in the standard of care. Regionalization continues to have a role, and is in the best interest of mothers and their newborns.

Risk Management in Obstetrics and Neonatal-Perinatal Medicine 281

practitioners in our field need to examine these areas within their practice and address any deficiencies, implement new protocols, and improve communication and documentation in the medical record. Addressing the issues described can potentially have a favorable impact on the medical malpractice crisis, and more importantly avoid potentially preventable devastating outcomes. We cannot overemphasize the importance of honesty, humility,

ACOG Committee on Obstetric Practice. Umbilical cord blood gas and acid-base analysis.

American Academy of Pediatrics, John Kattwinkel ed, Neonatal Resuscitation Textbook, 5th

American College of Obstetricians and Gynecologists, American Academy of Pediatricians.

*encephalopathy and cerebral palsy.* ACOG: Washington, DC, 2003, pp 53-62. Arnon S, Litmonovitz I, Regev RH, Bauer S, Shainkin-Kestenbau R, Dolfin T. Serum amyloid

Baud O, d'Allest A-M, Lacaze-Masmonteil T, Zupan V, Nedelcoux H, Boithias C,

Bhutani VK, Donn SM, Johnson LH. Risk management of severe neonatal hyperbilirubinemia to prevent kernicterus. *Clin Perinatol* 2005; 32(1):125-39.

Bloom SL, Leveno KJ, Spong CY, Gilbert S, Hauth JC, Landon MB et al. Decision-to-incision times and maternal and infant outcomes. *Obstet Gynecol* 2006; 108: 6-11. Bullard J, Trajanowski M. Simulation and training. eNeonatal Review Newsletter 2011;

Buonocore G, Perrone S. Biomarkers of hypoxic brain injury in the neonate. *Clin Perinatol*

Byard RW, Bourne AJ, Moore L, Little KE. Sudden death in early infancy due to delayed

Carroll AE, Buddenbaum JL. Malpractice claims involving pediatricians: epidemiology and

Chauhan SP, Chauhan VB, Cowan BD, Hendrix NW, Magann EF, Morrison JC. Professional

Chauhan SP, Hendrix NW, Magann EF, Sanderson M, Bofill JA, Briery CM et al. Neonatal

Chauhan SP, Magann EF, Scott JR, Scardo JA, Hendrix NW, Martin JN Jr. Emergency

cardiac tamponade complicating central venous line insertion and cardiac

liability claims and Central Association of Obstetricians and Gynecologists

organ dysfunction among newborns at gestational age 34 weeks and umbilical

cesarean delivery for nonreassuring fetal heart rate tracings: compliance with

Blickstein I, Green T. Umbilical Cord Blood Gases. *Clin Perinatol* 2007; 34: 451-459.

catheterization. *Arch Pathol Lab Med* 1992; 116(6): 654-656.

members: Myth versus reality. *AJOG* 2005; 192:1820-8.

ACOG guidelines. *J Reprod Med* 2003; 48(12): 975-81.

arterial pH < 7.00. *J Matern Fetal Neonatal Med* 2005; 17: 261-268.

etiology. Pediatrics 2007; 120(1):10-17.

Chapter 5: Neonatal assessment. In: Van Eerden P, Bernstein PS (eds). *Neonatal* 

A: An early and accurate marker of neonatal early-onset sepsis. *J Perinatol* 2007; 27:

Delaveauecoupet J, Dehan M. The early diagnosis of periventricular leukomalacia in premature infants with positive rolandic sharp waves on serial

compassion and competency in all our interactions with our patients.

Baergen RN. The Placenta as a Witness. *Clin Perinatol* 2007; 34: 393-407.

electroencephalography. *J Pediatr* 1998; 132: 813-7.

*Obstet Gynecol* 2006; 108: 1319-22.

ed, 2006:16-17.

297-302.

8(9):1-11.

2004; 31: 107-116.

**5. References** 

Common allegations in this study also resulted from a failure to recognize life-threatening conditions including seizures and intestinal mid-gut volvulus. Newborn seizures can be difficult to clinically diagnose due to subtle abnormal ocular and focal movements. Subtle motor abnormalities with concomitant desaturation and/or apnea often represent seizure activity. The first line of medication in the treatment of seizures in newborns is phenobarbital at a loading dose of 20 mg/kg to achieve therapeutic levels of 20-40 g/mL. An adequate airway is essential if one desires to increase phenobarbital dosing. Persistent seizures may require the addition of phenytoin or ativan. Inadequately treated seizures can result in permanent neuronal cell damage due to enhanced metabolic activity. Malrotation of the intestine is usually observed in the neonatal period and presents with signs of acute intestinal obstruction and often bilious emesis. Mid-gut volvulus is a true surgical emergency, where delay can result in ischemic necrosis of the entire gut which is most often lethal. The upper GI series is the method of choice for diagnosing malrotation. Importantly, an acutely ill newborn with a history of bilious emesis needs immediate surgical consultation. Early diagnosis and treatment of these two conditions is essential in facilitating good outcomes.

Medication errors are preventable events that frequently occur in the NICU and are a common source of allegations. It has been previously reported that out of every five adverse drug events in pediatric patients, three of those events occurred in an NICU. Errors are particularly dangerous in the NICU due to the fragile state of newborns. The rapidly changing body weight, different rates of organ development affecting drug pharmacokinetics, and need for dilutions of medications contribute to the common occurrence of medication errors in the NICU. In this study, medication errors occurred as a result of incorrect dosing, documentation, or processing. Morphine, sodium supplementation, and aminoglycosides were the most frequent pharmacological agents administered inappropriately. With the advent of computerized order entry, a reduction in ordering errors is expected due to standardized templates for physicians and nurses. The computerized system also provides an additional way to intercept errors before they affect the newborn. Documentation, communication, and attention to detail can help to reduce preventable medication errors.

In the 21st century, kernicterus still occurs throughout the United States. The most common allegations in our experience were delayed contact and response of the blood bank as well as the inability to perform a timely exchange transfusion. An umbilical venous line is relatively easy to place, even in a newborn up to a week old. However, withdrawing blood is often problematic when using a 3.5 or 5.0 umbilical venous catheter due to the thin walled umbilical vein that collapses with minimal negative pressure. An exchange catheter in the exchange transfusion tray should be utilized whenever possible to expedite the procedure. Too often, subspecialty services are called to gain vascular access, which can greatly delay initiation of the exchange transfusion. A thorough physical exam documenting any signs or symptoms of kernicterus should be charted prior to, during, and after the exchange transfusion.

Although tort reform in some states has reduced non-meritorious legal suits, professional liability involving caregivers of mothers and newborns is significant. We have identified common areas in obstetrics and newborn medicine that resulted in malpractice claims. All practitioners in our field need to examine these areas within their practice and address any deficiencies, implement new protocols, and improve communication and documentation in the medical record. Addressing the issues described can potentially have a favorable impact on the medical malpractice crisis, and more importantly avoid potentially preventable devastating outcomes. We cannot overemphasize the importance of honesty, humility, compassion and competency in all our interactions with our patients.

### **5. References**

280 Complementary Pediatrics

Common allegations in this study also resulted from a failure to recognize life-threatening conditions including seizures and intestinal mid-gut volvulus. Newborn seizures can be difficult to clinically diagnose due to subtle abnormal ocular and focal movements. Subtle motor abnormalities with concomitant desaturation and/or apnea often represent seizure activity. The first line of medication in the treatment of seizures in newborns is phenobarbital at a loading dose of 20 mg/kg to achieve therapeutic levels of 20-40 g/mL. An adequate airway is essential if one desires to increase phenobarbital dosing. Persistent seizures may require the addition of phenytoin or ativan. Inadequately treated seizures can result in permanent neuronal cell damage due to enhanced metabolic activity. Malrotation of the intestine is usually observed in the neonatal period and presents with signs of acute intestinal obstruction and often bilious emesis. Mid-gut volvulus is a true surgical emergency, where delay can result in ischemic necrosis of the entire gut which is most often lethal. The upper GI series is the method of choice for diagnosing malrotation. Importantly, an acutely ill newborn with a history of bilious emesis needs immediate surgical consultation. Early diagnosis and treatment of these two conditions is essential in facilitating

Medication errors are preventable events that frequently occur in the NICU and are a common source of allegations. It has been previously reported that out of every five adverse drug events in pediatric patients, three of those events occurred in an NICU. Errors are particularly dangerous in the NICU due to the fragile state of newborns. The rapidly changing body weight, different rates of organ development affecting drug pharmacokinetics, and need for dilutions of medications contribute to the common occurrence of medication errors in the NICU. In this study, medication errors occurred as a result of incorrect dosing, documentation, or processing. Morphine, sodium supplementation, and aminoglycosides were the most frequent pharmacological agents administered inappropriately. With the advent of computerized order entry, a reduction in ordering errors is expected due to standardized templates for physicians and nurses. The computerized system also provides an additional way to intercept errors before they affect the newborn. Documentation, communication, and attention to detail can help to reduce

In the 21st century, kernicterus still occurs throughout the United States. The most common allegations in our experience were delayed contact and response of the blood bank as well as the inability to perform a timely exchange transfusion. An umbilical venous line is relatively easy to place, even in a newborn up to a week old. However, withdrawing blood is often problematic when using a 3.5 or 5.0 umbilical venous catheter due to the thin walled umbilical vein that collapses with minimal negative pressure. An exchange catheter in the exchange transfusion tray should be utilized whenever possible to expedite the procedure. Too often, subspecialty services are called to gain vascular access, which can greatly delay initiation of the exchange transfusion. A thorough physical exam documenting any signs or symptoms of kernicterus should be charted prior to, during, and after the exchange

Although tort reform in some states has reduced non-meritorious legal suits, professional liability involving caregivers of mothers and newborns is significant. We have identified common areas in obstetrics and newborn medicine that resulted in malpractice claims. All

good outcomes.

preventable medication errors.

transfusion.


Baergen RN. The Placenta as a Witness. *Clin Perinatol* 2007; 34: 393-407.


Risk Management in Obstetrics and Neonatal-Perinatal Medicine 283

Glass HC, Glidden D, Jeremy RJ, Barkovich AJ, Ferriero DM, Miller SP. Clinical neonatal

Goldaber KG, Gilstrap LC III, Leveno KJ, Dax JS, McIntire DD. Pathologic fetal academia.

Goodwin TM, Milner-Masterson L, Paul RH. Elimination of fetal scalp blood sampling on a

Graham EM, Ruis KA, Hartman AL, Northington FJ, Fox HE. A systematic review of the

Grether JK, Nelson KB. Maternal infection and cerebral palsy in infants of normal birth

Guidelines for expert witness testimony in medical malpractice litigation. Committee on

Hankins GDV, MacLennan AH, Speer ME, Strunk A, Nelson K. Obstetric litigation is asphyxiating our maternity services. *Obstet Gynecol* 2006; 107: 1382-5. Hayakawa F, Okumura A, Kato T, Kuno K, Watanabe K. Determination of timing of brain

Hermansen MC, Hermansen MG. Perinatal infections and cerebral palsy. *Clin Perinatol* 2006;

Hermansen MC, Hermansen MG. Pitfalls in neonatal resuscitation. *Clin Perinatol* 2005;

Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file

Hoffman MA, Johnson CL, Moore T, Pearl RH. Management of catastrophic neonatal

Johnston MV, Donn SM. Hypoxic-ischemic encephalopathy and traumatic intracranial

*Neonatal Practice.* Futura Publishing Company, Inc.: New York, 1996, p 453. Kain ZN, Caldwell-Andrews AA. What pediatricians should know about child-related malpractice payments in the United States. *Pediatrics* 2006; 118(2):464-468. Kirton A, deVeber G. Cerebral palsy secondary to perinatal ischemic stroke. *Clin Perinatol*

Korst LM, Phelan JP, Ahn MO, Martin GI. Nucleated red blood cells: an update on the

Korst LM, Phelan JP, Wang YM, Ahn MO. Neonatal platelet counts in fetal brain injury. *Am* 

Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe hyperbilirubinemia and phototherapy use. *Pediatrics* 2009; 124(4):1031-1039. Larroque B, Bertrais S, Czernichow P, Leger J. School difficulties in 20-year-olds who were

Lee HC, Chitkana R, Halamek C, Hintz S. A national survey of pediatric residents and

Lehmann CU, Kim GR. Prevention of medication errors. *Clin Perinatol* 2005; 32(1):107-23.

born small for gestational age at term in a regional cohort study. *Pediatrics* 2001;

marker for fetal asphyxia. *Am J Obstet Gynecol* 1996; 175: 843-6.

delivery room training experience. *J Pediatr* 2010; 157:158-6.

ischemic brain injury. *J Pediatr* 2009; 155(3):318-323.

large clinical service. *Obstet Gynecol* 1994; 83:971-974.

electroencephalography. *Pediatrics* 1999; 104: 1077-1081.

*Am J Obstet Gynecol* 2008; 199(6): 587-595.

weight. *JAMA* 1997; 278: 207-211.

33:315-333.

32(1):77-95

27(10):1336-1339.

2006; 33:367-386.

108: 111-115.

*J Perinatol* 1999; 16: 79-83.

1363.

*Obstet Gynecol* 1991; 78: 1103-7.

seizures are independently associated with outcome in infants at risk for hypoxic-

role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy.

Medical Liability. American Academy of Pediatrics. *Pediatrics* 2002; 109(5):974-979.

injury in preterm infants with periventricular leukomalacia with serial neonatal

medical malpractice claims following perinatal injuries. *JAMA* 1992; 267(10):1359-

midgut volvulus with a silo and second-look laparotomy. *J Pediatr Surg* 1992;

injuries. In: Donn SM, Fisher CW, eds. *Risk Management Techniques in Perinatal and* 


Chow LC, Wright KW, Sola A, CSMC Oxygen Administration Study Group. Can changes in

Chuo J, Hicks RW. Computer-related medication errors in neonatal intensive care units. *Clin* 

Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. Mortality in low birth

Clark SJ, Belfort MA, Byrun SL et al. Improved Outcomes, Fewer Cesarean Deliveries, and

Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through

Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy – fact and

Cornette L. Fetal and neonatal inflammatory response and adverse outcome. *Seminars in* 

Darling JC, Newell SJ, Mohamdee O, Uzun O, Cullinane CJ, Dear PR. Central venous

Donn SM, Faix RG, Roloff DW, Goldman EB. Medico-legal consultation: an expanded role of

Donn SM. Medicolegal issues get short shrift in pediatric residency training. *AAP News* 2006;

Donn SM. Take steps to minimize risk when consulting with another physician. *AAP News* 

Early Treatment For Retinopathy Of Prematurity Cooperative Group. Revised indications

Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric

Finer NN, Robertson CM, Richards RT, Pinnell LE, Peters KL. Hypoxic-ischemic

Freeman RK. Medical and legal implications for necessary requirements to diagnose

Gaies MG, Morris SA, Hafler JP, et al. Reforming procedural skills training for pediatric residents: a randomized, interventional trial. *Pediatrics* 2009; 124(2): 610-619. Gelfand SL, Fanaroff JM, Walsh MC. Controversies in the treatment of meconium aspiration

Geva R, Eshel R, Leiner Y, Valevski AF, Harel S. Neuropsychological outcome of children

91-100; www.pediatrics.org/cgi/dol/10.1542/peds.1005-2343.

alterations in practice patterns. *Obstet Gynecol* 2008; 112: 1279-83.

fiction. *Am J Obstet Gynecol* 2003; 188: 628-33.

the tertiary neonatologist. *J Perinatol* 1987; 7(3):238-241.

Ferriero DM. Neonatal brain injury. *N Engl J Med* 2004; 351: 1985-95.

*Fetal & Neonatal Medicine* 2000; (9)459-470.

low birth weight infants? *Pediatrics* 2003; 111(2):339-345.

*Perinatol* 2008; 35(1):119-39.

*Gynecol* 2008; 199: 105 e1-7.

*Perinatol* 2001; 21(7):461-464.

27(7):16.

1694.

112-7.

2005; 26(12):24.

112(6):1242-1247.

*Obstet Gynecol* 2008; 199:585-586.

syndrome. *Clin Perinatol* 2004; 31: 445-452.

2002; 109(5):745-751.

clinical practice decrease the incidence of severe retinopathy of prematurity in very

weight infants according to level of neonatal care at hospital of birth. *Pediatrics*

Reduced Litigation: Results of a new paradigm in patient safety. *Am J Obstet* 

catheter tip in the right atrium: a risk factor for neonatal cardiac tamponade. *J* 

for the treatment of retinopathy of prematurity: results of the early treatment for retinopathy of prematurity randomized trial. *Arch Ophthalmol* 2003; 121(12):1684-

residents in performing neonatal endotracheal intubation. *Pediatrics* 2003;

encephalopathy in term neonates: perinatal factors and outcome. *J Pediatr* 1981; 98:

damaging hypoxic-ischemic encephalopathy leading to later cerebral palsy. *Am J* 

with intrauterine growth restriction: a 9-year prospective study. *Pediatrics* 2006; 118:


Risk Management in Obstetrics and Neonatal-Perinatal Medicine 285

Neufeld MD, Frigon C, Graham AS, Nueller BA. Maternal infection and risk of cerebral palsy in term and preterm infants. *J Perinatol* 2005; 25:108-113; doi:10.1038/sj.jp.7211219. Newman TB, Liljestrand P, Jeremy RJ, et al. Outcomes among newborns with total serum

Okerafor A, Allsop J, Counsell SJ, Fitzpatrick J, Azzopardi D, Rutherford MA, Cowan FM.

Papoff P. Use of Hematologic Data to Evaluate Infections in Neonates. In: Christensen, (ed). *Hematologic Problems of the Neonate.* W.B. Saunders: Philadelphia, 2000, pp 389-404. Pasternak JF, Gorey MT. The syndrome of acute near-total intrauterine asphyxia in the term

Perlman J. Intrapartum Asphyxia and Cerebral Palsy: Is There a Link? *Clin Perinatal* 2006;

Phelan JP, Korst LM, Ahn MO, Martin GI. Neonatal nucleated red blood cell and lymphocyte counts in fetal brain injury. *Obstet Gynecol* 1998; 91: 485-489. Phelan JP, Martin GI, Korst LM. Birth asphyxia and cerebral palsy. *Clin Perinatol* 2005; 32: 61-

Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume

*Practical Neonatal Respiratory Care*. In: RL Schreiner, JA Kisling (eds). Raven Press: New York,

*Practical Neonatal Respiratory Care*. In: RL Schreiner, JA Kisling (eds). Raven Press: New York,

Ramachandrappa A, Jain L. Iatrogenic disorders in modern neonatology: a focus on safety

Ramasethu J. Complications of vascular catheters in the neonatal intensive care unit. *Clin* 

Raval NC, Gonzalez E, Bhat AM, Pearlman SA, Stefano JL. Umbilical venous catheters:

Rodger MA, Paidas M, McLintock C, Middeldorp S, Kahn S, Martinelli I et al. Inherited

Rutherford M, Counsell S, Allsop J, Boardman J, Kapellou O, Larkman D et al. Diffusion-

Rutherford MA. The asphyxiated term infant. In: Rutherford MA (ed). *MRI of the Neonatal* 

Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress: a clinical and

Sasidharan P, Billman D, Heimler R, Nelin L. Cardiac arrest in an extremely low birth

electroencephalographic study. *Arch Neurol* 1976; 33: 696-705.

with site of lesion and time from birth. *Pediatrics* 2004; 114: 1004-1014. Rutherford M. Neuroimaging. In: Donn SM, Sinha SK, Chiswick ML (eds). In: *Birth Asphyxia* 

evaluation of radiographs to determine position and associated complications of malpositioned umbilical venous catheters. *Am J Perinatol* 1995; 12(3):201-204. Riley RJ, Johnson JWC. Collecting and analyzing cord blood gases. *Clin Obstet Gynecol* 1993;

thrombophilia and pregnancy complications revisited. *Obstet Gynecol* 2008;112: 320-4.

weighted magnetic resonance imaging in term perinatal brain injury: a comparison

*and the Brain: Basic Science and Clinical Implications*. Futura Publishing Company,

weight infant: complication of percutaneous central venous catheter

and quality of care. *Clin Perinatol* 2008; 35(1):1-34.

of neonatal intensive care and mortality in very-low-birth-weight infants. *N Engl J* 

2008; 121: 906-915.

33:335-353.

1982, p 246.

1982, p 248.

36: 13-23.

76.

infant. *Pediatr Neurol* 1998; 18: 391-398.

*Med* 2007; 356(21):2165-2175.

*Perinatol* 2008; 35(1):199-222.

Inc.: New York, 2002, pp 320-321.

*Brain.* W.B. Saunders: London, 2002, p 101.

hyperalimentation. *J Perinatol* 1996; 16(2):123-126.

bilirubin levels of 25 mg per deciliter or more. *N Engl J Med* 2006; 354(18):1889-1900.

Patterns of brain injury in neonates exposed to perinatal sentinel events. *Pediatrics* 


Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. *J Pediatr* 

Levene MI, Sinha SK. Clinical management of the asphyxiated newborn. In: Donn SM, Sunil

Li AM, Chau V, Poskitt KJ, Sargent MA, Lupton BA, Hill A, et al. White matter injury in term newborns with neonatal encephalopathy. *Pediatr Res* 2009; 65: 85-89. MacLennan A, Nelson KB, Hankins G, Speer M. Who will deliver our grandchildren? Implications of Cerebral Palsy Litigation. *JAMA* 2005; 294(13): 1688-1690. Macones GA, Hankins GDV, Spong CY, Hauth J. The 2008 National Institute of Child

Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia

Mangurten HH, Angst DB, See C, Boyle D, Beckman S. Professional liability in a neonatal

Maung M, Saing H. Intestinal volvulus: an experience in a developing country. *J Pediatr* 

McAbee G. Pediatrics among specialties with highest payments for closed malpractice

Meadow W, Mendez D, Hipps R, Vakharia T, Husein G, Lantos J. The relationship between

Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. *N Engl J Med*

Mendelson RA. Careful communication, charting can head off malpractice suits. AAP News

Miller JD, Carlo WA. Pulmonary complications of mechanical ventilation in neonates. *Clin* 

Miller SP, Ramaswamy V, Michelson D, Barkovich J, Holshouser B, Wycliffe N et al.

Muraskas JK, Morrison JC. A proposed evidence-based neonatal work-up to confirm or refute allegations of intrapartum asphyxia. *Obstet/Gynecol* 2010;116:261-8. Nadroo AM, Glass RB, Lin J, Green RS, Holzman IR. Changes in upper extremity position

Naeye RL, Shaffer ML. Postnatal laboratory timers of antenatal hypoxemic-ischemic brain

Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability.

Neonatal Seizures. In: Volpe J. *Neurology of the Newborn*, 5th ed. Philadelphia, PA: Elsevier

Patterns of brain injury in term neonatal encephalopathy. *J Pediatr* 2005; 146: 453-60.

cause migration of peripherally inserted central catheters in neonates. *Pediatrics*

K. Sinha SK, Malcolm L. Chiswick ML, eds. *Birth Asphyxia and the Brain*: Basic Science and Clinical Implications. Armonk, NY: Futura Publishing; 2002:297-298. Levine MI, Chervenak FA, Whittle M. Congenital structural defects of the brain. In: Bennett

MF, Punt J (eds). *Fetal and Neonatal Neurology and Neurosurgery* 3rd Edition.

Health and Human Development Workshop Report on Electronic Fetal

in the newborn infant ≥ 35 weeks' gestation: an update with clarifications. *Pediatrics* 

intensive care unit: a review of 20 years' experience. *J Perinatol* 2000; 20(40):244-248.

physician behaviors and blood gas values in the first hours of life--implications for "standards" of medical care for infants with respiratory distress. *Am J Perinatol* 1996;

2005; 146(5):638-641.

2009; 124(4):1193-1198.

*Surg* 1995; 30(5):679-681.

2003; 348(23):2281-2284.

*Perinatol* 2008; 35(1):273-81.

2002; 110(1):131-136.

*Pediatrics* 1981; 2:181-8.

Science; 2002:203-244.

damage. *J Perinatol* 2005; 25: 664-668.

13(8):457-464.

2009; 30(2):16.

Harcourt: London, 2001, pp 211-212.

Monitoring. *Obstet Gynecol* 2008; 112: 661-6.

claims in 1985-2005. *AAP News* 2006; 27(8):18.


**Part 6** 

**Frequently Used Medications Guide**


**Part 6** 

**Frequently Used Medications Guide**

286 Complementary Pediatrics

Shah DK, Zempel J, Barton T, Lukas K, Inder TE. Electrographic seizures in preterm infants

Shah P, Perlman M. Time courses of intrapartum asphyxia: neonatal characteristics and

Shah PS, Shah V, Qiu Z, Ohlsson A, Lee SK, Canadian Neonatal Network. Improved

Shalak LF, Laptook AR, Jafri HS, Ramilo O, Perlman JM. Clinical Chorioamnionitis, elevated cytokines, and brain injury in term infants. *Pediatrics* 2002;110: 673-680. Stavroudis TA, Miller MR, Lehmann CU. Medication errors in neonates. *Clin Perinatol* 2008;

Steinman KJ, Gorno-Tempini ML, Glidden DV, Kramer JH, Miller SP, Barkovich AJ, Ferriero

Strauss RS. Adult functional outcome of those born small for gestational age: twenty-sixyear Follow-up of the 1970 British birth cohort. *JAMA* 2000; 283: 625-632. Subhani M, Combs A, Weber P, Gerontis C, DeCristofaro JD. Screening guidelines for

Tawil KA, Eldemerdash A, Hathlol KA, Laimoun BA. Peripherally inserted central venous

The American College of Obstetricians and Gynecologists and American Academy of

Thomson TL, Levine M, Muraskas JK, El-Zein C. Pericardial effusion in a preterm infant

Vargas JE, Allred EN, Leviton A, Holmes LB. Congenital microcephaly: phenotypic features in a consecutive sample of newborn infants. *J Pediatr* 2001; 139: 210-4. Volpe J. Hypoxic-ischemic encephalopathy: clinical aspects. In: *Neurology of the Newborn,* 5th

Walker MW, Shoemaker M, Riddle K, Crane MM, Clark R. Clinical process improvement:

Wall SN, Handler AS, Park CG. Hospital factors and nontransfer of small babies: a marker

Warner B, Musial MJ, Chenier T, Donovan E. The effect of birth hospital type on the outcome of very low birth weight infants. *Pediatrics* 2004; 113(1):35-41 Westgate J, Garibaldi JM, Greene KR. Umbilical cord blood gas analysis at delivery: a time

Wirrell EC, Pelausa EO, Allen AC, Stinson DA, Hanna BD. Massive pericardial effusion as a

Wu YW, Escobar GJ, Grether JK, Croen LA, Greene JD, Newman TB. Chorioamnionitis and cerebral palsy in term and near-term infants. *JAMA* 2003; 290: 2677-2684.

standing pediatric hospitals. *J Pediatr* 2005; 146(5):626-631.

with verbal IQ at 4 years. *Pediatrics* 2009; 123: 1025-1030.

American Academy of Pediatrics: Washington, DC, 2003.

Edition. W. B. Saunders: Philadelphia, 2008, pp 400-480.

for quality data. *Br J Obstet Gynaecol* 1994; 101:1054-63.

of deregionalized perinatal care? *J Perinatol* 2004; 24(6):351-359

67(1):102-106.

35(1):141-61.

290

*2002*; 22(8):641-645

10(6): 419-423

outcomes. *Am J Perinat* 2009; 26(1): 39-44.

infants. *Pediatrics* 2001; 107(4):656-659

catheter tips. *Am J Perinatol* 2006; 23(1):37-40

during the first week of life are associated with cerebral injury. *Pediatr Res* 2010;

outcomes of outborn preterm infants if admitted to perinatal centers versus free

DM. Neonatal watershed brain injury on magnetic resonance imaging correlates

retinopathy of prematurity: the need for revision in extremely low birth weight

catheters in newborn infants: malpositioning and spontaneous correction of

Pediatrics. *Neonatal encephalopathy and cerebral palsy*: defining the pathogenesis and pathophysiology. The American College of Obstetricians and Gynecologists,

resulting from umbilical venous catheter placement. *Pediatr Cardiol* 2010; 31(2):287-

reduction of pneumothorax and mortality in high-risk preterm infants. *J Perinatol* 

cause for sudden deterioration of a very low birthweight infant. *Am J Perinatol* 1993;

**16** 

*Turkey* 

Şenay Çetinkaya *Pediatric Nursing, Adana School of Health, Çukurova University,* 

**Administration and Dose of the** 

**Most Frequently Used Drugs in Paediatrics** 

Though the main aim of modern medicine is the prevention of healthy people, the most of the medical service for treatment today is applied as medical treatment of patients. One of the very important reasons of the service of medical treatment is choice of wrong drugs, and the other is not be able to use the planned treatment truly. The patients may not take the drugs that clinicians suggested themselves. This situation is known to be closely related to the presence of social health organization of patients. The patients may misuse a true treatment. Also the clinicians may cause the problem of drug misuse, especially the antibiotics. Whatever the reason is, the drug misuse causes the public health to deteriorate and economical loses and, this is inevitable. Moreover, some of the drug misuses, like of antibiotics, may imbalance the ecology and cause the problem to convey to next generations

World Health Organization has defined the use of rational medication as "providing medication to individuals easily, at the lowest prices, and for the most suitable dosages and periods according to clinical findings and personal characteristics of individuals" (Baytemur, 2005; Cetinkaya et al, 2010; Ozdemir, 2010). Antibiotics are among the most

Antibiotic use among the infants at newborn intensive care units is gradually increasing. In a study conducted over 29 newborns in USA, it was determined that 43% of the patients used antimicrobial during their stay. Undergoing microbial application poses a risk in terms of resistance. To avoid the use of antibiotics, in this sense, there have been training programs

Antibiotics sits atop in the list of most frequently used medication in all countries. Similarly in Turkey, antibiotics are placed on the top in terms of the average per capita medication with a ratio of 17-19% (Çetinkaya et al, 2010; Özdemir, 2010; Ozgunes, 2005). The frequency of antibiotics usage in Turkey for in-patients is over 30%. This ratio increases over 50% for intensive care units (Çetinkaya et al, 2010; Sardan, 2005). While the consumption costs of antibiotics in USA exceed 7 million dollars per year, such medications establish the 30% of the total medication budgets of all hospitals. Nearly half of the antibiotics usage is still not

important discoveries of the past century (Çetinkaya et al, 2010; Karabay, 2009).

developed by the American Society of Infection (Patel & Saiman, 2010).

**1. Introduction** 

(Gokalp & Mollaoglu, 2003).
