Comments on the management of newborn with spina bifida cystica--active treatment or no treatment.

From 1977-1984 46 children with myelomeningocele (MMC) have been admitted immediately following birth. According to Lorber's adverse criteria, 8 received no active treatment (17%) (rejected group). The other 38 were operated on within the first 24 hours (83%) (selected group). The first group had a mean of 3 criteria per patient. The decision not to treat was taken in consultation with the parents, social factors playing an important rôle, too. 5 children died within a few days to 2 months subsequent to an infection. 3 survived and were shunted at 2-4 months at the request of the parents. With the exception of 2, all mothers agreed with the former decision 1-8 years later. Among the 38 patients with active treatment 12 should not have been operated on (26% of all MMC cases), because they had adverse criteria too though less than the rejected group. Among these 12 patients, there are more shunt patients, and their walking capacity is inferior to that of the remaining 26, but there is no difference in respect of their intellectual capacity. Without additional measures Lorber's criteria refer rather to come than to spontaneous mortality. They predict subsequent walking capacity and bladder function correctly, but not the intelligence, and patients with good intellectual capacity may thus be excluded from treatment. To avoid this, at least 3 adverse criteria and/or the three last ones (hydrocephalus, birth injury, major congenital defects) as well as social factors, should be taken into account. Following selection the paediatric surgeon should remain available for the parents' support and reevaluation of the child.