J. Paediatr. Child Health (1992) 28, 362-363
State of infant around birth: Do we know what we are talking about? R. N. HOWIE Department of Paediatrics, University of Auckland, Auckland, New Zealand
This is written to provoke some long overdue debate on terminology. These notes were prompted by discussion at a recent seminar on perinatal monitoring, which once again exposed our current confusion. Medicine can hardly claim to be scientific if its practitioners make no effort to be precise in the use of words. The confusion may be of importance not only scientifically but also medico-legally, to the disadvantage of those practising obstetrics and newborn medicine. For example, it has been suggested that the word ‘asphyxia’ written in case records, at least in some parts of the world, may be an invitation for parents to sue.
‘ASPHYXIA’
This word is among the most misused in medicine. Dorland defines asphyxia as ‘a condition due to lack of oxygen in respired air, resulting in impending or actual cessation of apparent life’.’ That definition is not helpful in a perinatal context, and the further definition of ‘fetal asphyxia’ as ‘asphyxia in utero due to anoxia caused by premature placental separation (abruptio placentae), injudicious use of anaesthetics etc‘ is no better. Dorland’s definition of ‘asphyxia neonatorum’ as ‘respiratory failure in the newborn’ may be more acceptable. It would be interesting for someone with a bent for history and access to the appropriate literature (mostly unavailable to me) to research the history of the word, as it applies to the newborn. By derivation from the Greek, its original meaning was ‘absence of pulse’. The word has clearly moved far from that meaning since, but in the early 19th century it may have been used in its original sense, perhaps synonymous with the word ‘stillborn’ as used by Dr James Blundell in 1834: ‘You will sometimes find that children are stillborn, as it is called, that is, although they are not dead, they do not cry, or manifest other indications of life.. .’.‘William Little, in his classic first description of cerebral palsy published in 1861, used the term asphyxia neonatorum . . in its widest sense, embracing in it all the conditions of suspended animation in the newborn infant which have for their result to prevent the immediate establishment of proper respiration and circuation . . .’.3 He recognized, however, that others would disI.
Correspondence: Dr R. N. Howie. Department of Paediatrics, National Women’s Hospital, Auckland 3, New Zealand. R. N. Howie, FRACP, Associate Professor. Accepted for publication 26 March 1992.
tinguish several states, for example asphyxia, asthenia (weakness) and apoplexy (stroke, presumably intracranial haemorrhage), but pointed out that it was not then possible to distinguish before death ‘upon which of these three conditions the suspended animation depends’. Nearly a century later Windle (1958), in another classic work, commented on the term asphyxia that it was ‘high time that we He was concerned decide what it means and when to use that the words asphyxia, anoxia and apnoea were being used synonymously. More than 30 years after Windle the confusion remains, but to my knowledge no one has done better than he did in his statement that ’asphyxia implies anoxia plus accumulation of waste materials, etc’. What he meant by ‘etc’ is not clear, and many prefer the term ’hypoxia’ to ‘anoxia’, but the use of the term asphyxia in a perinatal context by the most careful writers since Windle’s time appears to have conformed to his, and it seems appropriate to base a present-day definition on it. That otherwise great authority on the history of words, the Oxford D i ~ t i o n a r ygives , ~ little help on the history of the word in its application to the foetus and newborn. It quotes Phillips (1706) on the original meaning: ’a Cessation of the Pulse throughout the whole Body; which is the highest degree of Swooning and next to Death’. It gives a second definition: ‘The condition of suspended animation produced by a deficiency of oxygen in the blood; suffocation’, but quotes an 1881 comment: ‘It indicates a curious infelicity of etymology that the pulse in asphyxiated animals continues to beat long after all signs of respiratory action have ceased’. Much as linguistic purists may deplore it, however, we have to accept this ‘infelicity of etymology’ as now so well-established as to be irretrievable.
APGAR SCORES
Another point of serious confusion is that low Apgar scores are often equated with asphyxia. It is clear from the work of Sykes‘ and others that they are different states and should be clearly differentiated. The confusion is not helped by current disease classifications, for example ICD-g-CM,’ and I suggest the ICD usagebeabandoned. A word is needed to encompass the phrase ‘low Apgar score’. I suggest ‘depression’. Depression may be described as mild, moderate or severe, as does the ICD for asphyxia. Some have objected that the word ‘depression’ implies a psychological state, but that is too narrow a view of the word. A low Apgar score indicates physical depression, depression of vital functions (i.e. all those assessed by the score), and I see no difficulty in using the word in this sense.
363
State of infant around birth
‘ENCEPHALOPATHY’
Can anyone do better, and can we - after at least 130 years of uncertainty - reach any agreement?
Dorland’s definition is of little help: ‘any degenerative disease of the brain’.’ Used of the newborn, some restrict the term to ‘hypoxic-ischaemic encephalopathy’. In fact the word, by its derivation, is a general one (from Greek encephalos = brain; pathos = suffering, feeling), and is quite properly used for other disorders of the brain that cannot be more precisely described.
ACKNOWLEDGEMENTS Thanks are due to a number of colleagues, notably Drs Jane Harding and Andrew Howie, for helpful comments.
REFERENCES
DEFINITIONS
I propose the following, for discussion: (1) ‘Anoxia’: absence of oxygen.
(2) ‘Hypoxia’: insufficient oxygen. (3) ‘Hypoxaemia’: blood oxygen measurement below normal range. (4) ‘Asphyxia’: Hypoxia with accumulation of waste products. (Assessed by measures of oxygen, carbon dioxide, pH and possibly other wastes, for example lactate.) (5) ’Fefaldisfress’: impairment of the well-being of the foetus. (6) ‘Apnoea’: absence of breathing. (7) ‘Depression’: impaired vital functions. (Assessed at birth by Apgar scores.) (8) ‘Encephalopathy’: disorder of brain (from whatever cause).
Asphyxia. Dorland’s lllustrated Medical Dictionary, 27th edn. W. 8. Saunders. Philadelphia. 1988; 156. Blundell J. Principles and Practice of Obstefricy. London. 1834. (Quoted by Dunn. 8) Little W. J. On the influence of abnormal parturition, difficult labours, premature birth, and asphyxia neonatorurn. on the mental and physical condition of the child, especially in relation to deformities. Trans. Obstet. SOC.Lond. 1861; 3: 314. Windle W. F. ed. Neurological and psychological deficits of asphyxia neonatorurn. Thomas, Springfield, IL. 1958; 84-5. Asphyxia. The Oxford English Dictionary, Vol. 1,2nd edn. Clarendon Press, Oxford. 1989; 695. Sykes G. S., Johnson P.. Ashworth F. eta/. Do Apgar scores indicate asphyxia? Lancet 1982; I: 494-6. lnternational Classificationof Diseases, 9th Revision, Clinical Modification, Vol. 1. ICD-9-CM. Ann Arbor. 1980; 693. Dunn P. M. Dr James Blundell and neonatal resuscitation. Arch. Dis. Child. 1989; 64: 494-5.
State of infant around birth: Do we know what we are talking about? R. N. HOWIE Department of Paediatrics, University of Auckland, Auckland, New Zealand
This is written to provoke some long overdue debate on terminology. These notes were prompted by discussion at a recent seminar on perinatal monitoring, which once again exposed our current confusion. Medicine can hardly claim to be scientific if its practitioners make no effort to be precise in the use of words. The confusion may be of importance not only scientifically but also medico-legally, to the disadvantage of those practising obstetrics and newborn medicine. For example, it has been suggested that the word ‘asphyxia’ written in case records, at least in some parts of the world, may be an invitation for parents to sue.
‘ASPHYXIA’
This word is among the most misused in medicine. Dorland defines asphyxia as ‘a condition due to lack of oxygen in respired air, resulting in impending or actual cessation of apparent life’.’ That definition is not helpful in a perinatal context, and the further definition of ‘fetal asphyxia’ as ‘asphyxia in utero due to anoxia caused by premature placental separation (abruptio placentae), injudicious use of anaesthetics etc‘ is no better. Dorland’s definition of ‘asphyxia neonatorum’ as ‘respiratory failure in the newborn’ may be more acceptable. It would be interesting for someone with a bent for history and access to the appropriate literature (mostly unavailable to me) to research the history of the word, as it applies to the newborn. By derivation from the Greek, its original meaning was ‘absence of pulse’. The word has clearly moved far from that meaning since, but in the early 19th century it may have been used in its original sense, perhaps synonymous with the word ‘stillborn’ as used by Dr James Blundell in 1834: ‘You will sometimes find that children are stillborn, as it is called, that is, although they are not dead, they do not cry, or manifest other indications of life.. .’.‘William Little, in his classic first description of cerebral palsy published in 1861, used the term asphyxia neonatorum . . in its widest sense, embracing in it all the conditions of suspended animation in the newborn infant which have for their result to prevent the immediate establishment of proper respiration and circuation . . .’.3 He recognized, however, that others would disI.
Correspondence: Dr R. N. Howie. Department of Paediatrics, National Women’s Hospital, Auckland 3, New Zealand. R. N. Howie, FRACP, Associate Professor. Accepted for publication 26 March 1992.
tinguish several states, for example asphyxia, asthenia (weakness) and apoplexy (stroke, presumably intracranial haemorrhage), but pointed out that it was not then possible to distinguish before death ‘upon which of these three conditions the suspended animation depends’. Nearly a century later Windle (1958), in another classic work, commented on the term asphyxia that it was ‘high time that we He was concerned decide what it means and when to use that the words asphyxia, anoxia and apnoea were being used synonymously. More than 30 years after Windle the confusion remains, but to my knowledge no one has done better than he did in his statement that ’asphyxia implies anoxia plus accumulation of waste materials, etc’. What he meant by ‘etc’ is not clear, and many prefer the term ’hypoxia’ to ‘anoxia’, but the use of the term asphyxia in a perinatal context by the most careful writers since Windle’s time appears to have conformed to his, and it seems appropriate to base a present-day definition on it. That otherwise great authority on the history of words, the Oxford D i ~ t i o n a r ygives , ~ little help on the history of the word in its application to the foetus and newborn. It quotes Phillips (1706) on the original meaning: ’a Cessation of the Pulse throughout the whole Body; which is the highest degree of Swooning and next to Death’. It gives a second definition: ‘The condition of suspended animation produced by a deficiency of oxygen in the blood; suffocation’, but quotes an 1881 comment: ‘It indicates a curious infelicity of etymology that the pulse in asphyxiated animals continues to beat long after all signs of respiratory action have ceased’. Much as linguistic purists may deplore it, however, we have to accept this ‘infelicity of etymology’ as now so well-established as to be irretrievable.
APGAR SCORES
Another point of serious confusion is that low Apgar scores are often equated with asphyxia. It is clear from the work of Sykes‘ and others that they are different states and should be clearly differentiated. The confusion is not helped by current disease classifications, for example ICD-g-CM,’ and I suggest the ICD usagebeabandoned. A word is needed to encompass the phrase ‘low Apgar score’. I suggest ‘depression’. Depression may be described as mild, moderate or severe, as does the ICD for asphyxia. Some have objected that the word ‘depression’ implies a psychological state, but that is too narrow a view of the word. A low Apgar score indicates physical depression, depression of vital functions (i.e. all those assessed by the score), and I see no difficulty in using the word in this sense.
363
State of infant around birth
‘ENCEPHALOPATHY’
Can anyone do better, and can we - after at least 130 years of uncertainty - reach any agreement?
Dorland’s definition is of little help: ‘any degenerative disease of the brain’.’ Used of the newborn, some restrict the term to ‘hypoxic-ischaemic encephalopathy’. In fact the word, by its derivation, is a general one (from Greek encephalos = brain; pathos = suffering, feeling), and is quite properly used for other disorders of the brain that cannot be more precisely described.
ACKNOWLEDGEMENTS Thanks are due to a number of colleagues, notably Drs Jane Harding and Andrew Howie, for helpful comments.
REFERENCES
DEFINITIONS
I propose the following, for discussion: (1) ‘Anoxia’: absence of oxygen.
(2) ‘Hypoxia’: insufficient oxygen. (3) ‘Hypoxaemia’: blood oxygen measurement below normal range. (4) ‘Asphyxia’: Hypoxia with accumulation of waste products. (Assessed by measures of oxygen, carbon dioxide, pH and possibly other wastes, for example lactate.) (5) ’Fefaldisfress’: impairment of the well-being of the foetus. (6) ‘Apnoea’: absence of breathing. (7) ‘Depression’: impaired vital functions. (Assessed at birth by Apgar scores.) (8) ‘Encephalopathy’: disorder of brain (from whatever cause).
Asphyxia. Dorland’s lllustrated Medical Dictionary, 27th edn. W. 8. Saunders. Philadelphia. 1988; 156. Blundell J. Principles and Practice of Obstefricy. London. 1834. (Quoted by Dunn. 8) Little W. J. On the influence of abnormal parturition, difficult labours, premature birth, and asphyxia neonatorurn. on the mental and physical condition of the child, especially in relation to deformities. Trans. Obstet. SOC.Lond. 1861; 3: 314. Windle W. F. ed. Neurological and psychological deficits of asphyxia neonatorurn. Thomas, Springfield, IL. 1958; 84-5. Asphyxia. The Oxford English Dictionary, Vol. 1,2nd edn. Clarendon Press, Oxford. 1989; 695. Sykes G. S., Johnson P.. Ashworth F. eta/. Do Apgar scores indicate asphyxia? Lancet 1982; I: 494-6. lnternational Classificationof Diseases, 9th Revision, Clinical Modification, Vol. 1. ICD-9-CM. Ann Arbor. 1980; 693. Dunn P. M. Dr James Blundell and neonatal resuscitation. Arch. Dis. Child. 1989; 64: 494-5.
