Interview - Dr. Simon Attard Montalto - The Times - 2/1/2007

link to The Times

Early life
Cynthia Busuttil

Simon Attard Montalto: "If you have a case of a very sick child - that you know from experience is highly unlikely to make it - whose kidneys stop functioning, it would be unfair to put him on life support. In some cases you need to let nature take its course". Photo: Matthew Mirabelli.

About 350 babies, the majority of them newborns, are admitted to St Luke's Hospital's Special Care Baby Unit every year. Cynthia Busuttil speaks to the head of paediatrics, Simon Attard Montalto, about treating the tiny creatures.

A British bioethics council last month published guidelines recommending that babies born before 22 weeks gestation should not be given intensive care while those born between 22 and 23 weeks should not, in normal practice, be given intensive care.

The Nuffield Council on Bioethics suggested that in the second case intensive care should only be given if parents make a specific request and doctors agree that treatment is possible and in the baby's best interests.

In Malta, doctors do not follow a strict policy and Dr Attard Montalto said a decision is always taken in favour of the baby. Although the cut-off date for resuscitation is 24 weeks gestation, Dr Attard Montalto explained there have been cases of younger babies who beat the odds and survived.

"Our policy is very flexible, but as a matter of course we do not resuscitate babies born before 24 weeks gestation unless the baby is in good condition. If the baby looks as if he is trying to fight for his life, then we do resuscitate. But this does not mean that within a couple of days he might not develop complications. In that case we would look at the situation again, and there might be cases when we decide not to continue with life support," he said.

He pointed out that although certain countries have brought down the cut-off date to 23 and even 22 weeks, the Maltese hospital has resisted following suit because the outcome is so poor.

"But if a baby is making significant efforts to live, we will support him fully. If not, we will help him until nature takes its course. But although we do resuscitate those who are fighting for their lives, the vast majority of those born before 24 weeks gestation will die.

"On the other hand, we do everything in our power to resuscitate babies born at more than 26 weeks," he said.

On a positive note, Dr Attard Montalto said most babies born at 28 weeks will survive.

Speaking to The Times at his office in Disneyland, Dr Attard Montalto stressed that doctors do not do anything to speed a child's demise. But in very dismal cases the health professionals do not try to prolong the poor quality of life.

"If you have a case of a very sick child - that you know from experience is highly unlikely to make it - whose kidneys stop functioning, it would be unfair to put him on life support. In some cases you need to let nature take its course," he said.

This, he emphasised, is completely different from switching off machines to let somebody die.

Dr Attard Montalto spoke about the importance of making sure the children are not suffering by giving them pain killers and morphine.

"If you have a child who is already on morphine but who still looks like he is still suffering, you increase the dose. There is no limit when somebody is suffering," he said.

Babies, unlike adults, are not able to say when they are suffering, but Dr Attard Montalto said that experienced doctors and nurses would know when the child was in pain. Moreover, the baby would be connected to a monitor, which allows the specialists to see changes in the heart rate. Their behaviour, he continued, would also indicate whether they were suffering.

Dr Attard Montalto explained that the risks of morbidity depend greatly on the age that the baby is born at. Very few of those who are born at term pass away. He explained that the majority of term babies admitted to the SCBU need intensive care because of curable conditions.

"We either cure them ourselves or share care with other hospitals abroad. The majority of times problems lie in congenital heart defects and we send the babies to Great Ormond Street Hospital, in London," he said.

Mortality, on the other hand, is highest in the very small babies born at 28 weeks gestation or before. These usually weigh between 600 and 700 grammes and fit in the palm of a hand. Dr Attard Montalto said most times they have to spend a long time in the SCBU before being discharged. Statistics from the National Obstetrics Information System show that six babies weighing between 500 and 999 grammes were born in the first six months of the year. The average birth weight in this period was 3,210 grammes.

Dr Attard Montalto said in Malta there have been babies born weighing less than 500 grammes who survived.

Premature babies, he continued, are most likely to have problems with their lungs, since this is the organ that develops last. "Many of them are born with immature lungs and most will need help," he explained.

Medical advances over the past years have contributed to the survival of younger babies. Dr Attard Montalto said the single biggest improvement in the medical sphere for the management of premature babies was the development of a substance - surfactant - that allows the lungs to glide over each other and expand.

"This has been around for about 20 years and has made a phenomenal amount of difference. We inject it directly into the lungs and usually within two to three days the baby can be put off the ventilator. This has been the biggest advance in medicine where premature babies are concerned," he said.

The majority of babies who need special care are born in St Luke's Hospital. Dr Attard Montalto said there is an agreement with private hospitals that if there is a complicated pregnancy or an anticipated problem the baby will not be delivered outside the state hospital, which is equipped to take care of them. Out of the 300 to 400 babies born in private hospitals every year there is still a small number who are born with problems that were not anticipated. He mentioned as an example full-term babies who are born with immature lungs, adding that in such cases they are transferred to St Luke's Hospital for treatment. There are cases, he continued, where babies are transferred back to the private hospital.

The fact that in Malta there is no legal option for the termination of pregnancies that are clearly problematic might have an effect on the number of babies needing intensive care. Dr Attard Montalto said that in a number of other countries the lives of some children with significant difficulties are terminated before they are even born. "In Malta we look after them all and this does result in an increase of children with difficulties, especially those suffering from spina bifida and Down Syndrome."

With regard to staff, Dr Attard Montalto said these are trained in dealing with very small babies and seeing a child who weighs 800 grammes is not unusual for them. However, he went on, his does not mean they do not feel for the baby and the parents. "Many times they get very close to the parents. They walk with them throughout the way and treat the child as an individual." A stroll through the SCBU's corridor shows photos of former patients and heartfelt letters of thanks lining the walls, a reflection of the parents' gratitude to the staff.

He stressed the importance of parents being kept in the picture and understanding what is happening to their child. "Information needs to be accessible to them, irrespective of whether it is good or bad because they need to be involved in the decision-making, including whether to pursue life support."

Dr Attard Montalto emphasised that mothers should not feel guilty if their child has problems. "This is not their fault and many times there is no obvious reason why the baby is having problems," he said.

Referring to multiple births, Dr Attard Montalto said the risks were always higher, especially when there were more than two babies. "Having three or more babies in one pregnancy is always a big risk. We see many multiples who have problems and suffer."

This brings to the fore questions about in vitro fertilisation, which increases the chances of multiple births. "Personally, I do not think that IVF should not take place, but the number of fertilised ova implanted should be restricted to two. At the most in these cases the mother can have twins, which is acceptable and does happen naturally," he said.

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