Various medications are available for symptom management during palliative care of the neonate. Neonatal nurses are knowledgeable about the use of these agents as a part of curative care and should become familiar with them as an essential aspect of palliative care. Pharmacologic symptom management is only one facet of peaceful, pain-free, family-centered palliative care. For an overview of a complete protocol for end-of-life care for neonates and their families, review Catlin and Carter's article, "Creation of a Neonatal End-of-Life Palliative Care Protocol," which appeared in an earlier issue of Neonatal Network (Vol. 21, No. 4).

Analgesics, Opioid↗

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Immunomodulation, part I: pentoxifylline.

PTXF appears to be a promising adjunct to antibiotic therapy in neonatal sepsis. No adverse effects were noted in either study reported in the literature. However, there is a need for large randomized clinical trials to confirm or refute the role of PTXF in the treatment of sepsis in neonates. Clinically important comorbidities such as chronic lung disease, periventicular leukomalacia, duration of assisted ventilation, and NEC should be evaluated as a part of these studies. Comparison of PTXF with immunomodulatory agents such as colony-stimulating factors and intravenous immunoglobulins is suggested. Part II of this five-part series on immunomodulation will explore the use of colony-stimulating factors in neonates. Other topics will include the amino acid glutamine, intravenous immunoglobulins, and probiotics.

Clinical Trials as Topic↗

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Immunomodulation, part II: granulocyte colony-stimulating factors.

Although rhG-CSF and rhGM-CSF appear to have no adverse side effects, their usefulness in treating and preventing sepsis in preterm infants remains uncertain. Adequately powered, random, controlled clinical trials of neutropenic infants are needed to further evaluate efficacy of these agents as adjuncts to antibiotic therapy. Carr and associates assert that available data do not support further study of rhG-CSF and rhGM-CSF in septic infants who are not neutropenic. A United Kingdom study of the efficacy of prophylactic GM-CSF in reducing systemic infection or mortality in infants at high risk for postnatal neutropenia is underway. No plans exist for a long-term follow-up study, however. Because infection has the potential to cause both short-term mortality and long-term neurologic disability, it is recommended that all future studies include long-term neurologic and neurodevelopmental follow-up. The next part of this series will explore the use of intravenous immunoglobulins to prevent and treat neonatal sepsis.

Drug Administration Schedule↗

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Immunomodulation, part III: intravenous immunoglobulin.

Intravenous immunoglobulin therapy does not appear to be efficacious in the prevention of neonatal sepsis. The value of a 3-4 percent reduction in sepsis or any serious infection without a reduction in mortality must be weighed against the cost of the therapy. The efficacy of IVIG therapy in the treatment of neonatal sepsis remains uncertain. The results of the ongoing International Neonatal Immunotherapy Study should provide definitive answers regarding the effectiveness of this therapy. Long-term follow-up and cost (length of stay) are important components of this study. Ohlsson and Lacy recommend studies evaluating the effectiveness of IVIG preparations with high concentrations of antibodies to common unit- or geography-specific pathogens. The cost-effectiveness of the production and use of such products should be included in study designs. Part IV of this series will explore the use of the amino acid glutamine as an immunomodulating agent in neonates.

Drug Administration Schedule↗

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Immunomodulation. Part IV: Glutamine.

Glutamine, a nonessential amino acid that appears to be conditionally essential during periods of physiologic stress, plays important physiologic roles in the immune system. However, neither enteral nor parenteral glutamine supplementation makes a difference in the rate of systemic infection or of NEC in very low birth weight infants. Thus, the search for agents to enhance the neonate's immune system and to serve as safe and effective adjuvants to antibiotics continues. Part V, the final article in this immunomodulation series, will explore the use of probiotics to support the neonatal immune system.

Antigen Presentation↗