Book Review

Fetal and Neonatal Brain Injury: Mechanisms, management, and the risks of practice

N Engl J Med 1998; 338:481February 12, 1998

Article

Fetal and Neonatal Brain Injury: Mechanisms, management, and the risks of practice
Second edition. Edited by David K. Stevenson and Philip Sunshine. 665 pp. New York, Oxford University Press, 1997. $175. ISBN: 0-29-262640-X

In the majority of children with cerebral palsy, mental retardation, and other chronic neurodevelopmental disorders, no specific cause can be identified. The inability of physicians to provide information about the cause of a child's disability is often a major source of parental frustration and distress. In their search for plausible explanations for an adverse outcome of neurologic development, both physicians and parents often focus on real or perceived difficulties during labor and delivery. In the absence of alternative factors to account for a child's neurologic problems, parental recollections of, for example, intrapartum irregularities of the fetal heart rate or of an infant who was blue at birth often lead to questions about whether medical mismanagement caused brain damage.

Until recently, neonatal asphyxia lacked precise diagnostic criteria; low Apgar scores, which served to indicate the need for urgent neonatal resuscitation, were often (but inappropriately) equated with evidence of an interruption of oxygen delivery to the fetal or neonatal brain. More rigorous diagnostic criteria for neonatal asphyxia have now been delineated, and since the mid-1980s there has been a critical reexamination of the role of perinatal events as causative factors in chronic neurodevelopmental disorders. These developments have led to a major revision of our understanding of the pathogenesis of fetal and neonatal brain injury. Despite compelling epidemiologic data that refute the hypothesis that perinatal asphyxia is a common cause of neurologic morbidity, “bad baby” cases remain a frequent subject of litigation. As the foreword indicates, these “medicolegal realities” provide the impetus for this book.

This second edition represents a substantial modification of the first edition, which was published in 1989; it is over twice as long and includes a broader range of themes. Obstetricians, neonatologists, and pediatric neurologists are often asked to provide opinions about the cause of a child's neurologic problems; this book incorporates chapters by experts in all three fields who provide distinctive perspectives on potential causes of fetal and neonatal brain injury and on optimal clinical management of specific problems, such as neonatal encephalopathy.

The excellent chapters on fetal and neonatal injury resulting from maternal substance abuse, the effect of maternal metabolic disorders on the fetus, the correlation of clinical findings with the timing of asphyxial events, and placental pathology epitomize the broad synthesis of information that readers should find useful. Similarly, the complementary chapters on the use of electroencephalography to assess acute brain damage in neonates and manage neonatal seizures incorporate practical clinical advice and broad-based discussions of important clinical controversies and potential medicolegal issues (e.g., optimal treatment of seizures detected by electrography without obvious clinical correlates).

Although a multidisciplinary approach is clearly optimal for addressing these complex issues, the organization of this multiauthored book is somewhat idiosyncratic and disjointed. The amount of information directly relevant to the subject of fetal and neonatal brain injury varies considerably from one chapter to another. The interspersion of practical, clinically oriented chapters with chapters in which experimental data are presented in detail detracts from the overall readability of the book. Many chapters would have benefited from more rigorous editing, particularly those that digress from the main theme of the book (e.g., discussions of tocolytic therapy, extended management of cardiopulmonary disease, and nutritional support in neonates).

Although perinatal asphyxia accounts for only a minority of cases of perinatal brain injury, the book overemphasizes this subject (perhaps because it is such a frequent focus of litigation) and leaves several important topics relatively neglected. For example, it would have been relevant to include a more systematic discussion of the potential impact of maternal events or illnesses (including maternal trauma and indolent bacterial infections) on the developing fetal brain, a more comprehensive discussion of the distinctive pathophysiology of brain injury in premature infants, and a more extensive review of the spectrum of congenital malformations of the central nervous system.

Overall, this book will provide readers with a broad, contemporary overview of pathophysiologic mechanisms that may contribute to fetal and neonatal brain injury and of current clinical practice. Physicians preparing to serve as expert witnesses in legal cases in which the cause of fetal or neonatal brain injury is in contention are likely to find it an informative reference.

Faye S. Silverstein, M.D.
University of Michigan, Ann Arbor, MI 48109-0646

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