Population-Based Outcomes Data for Counseling at the Margin of Gestational Viability

The differential associative relationship between early risk factors, neonatal morbidities and early neurodevelopmental outcome in preterm infants <29 weeks' gestation

BACKGROUND

Very preterm infants of <29 weeks' gestation are at high risk for adverse neurodevelopment due to multiple risk factors in the early stages of life. There is little information regarding the associative effects of risk factors in early life, neonatal morbidities and subsequent neurodevelopmental outcomes.

AIMS

Investigate the association of early neurodevelopmental outcomes, neonatal complications and the risk factors in the early hours of life in a cohort of preterm infants <29 weeks' gestational age.

METHODS

We enrolled all surviving preterm neonates born at gestation <29 weeks between January 2015 and June 2021 in the University of Hong Kong-Shenzhen Hospital. Demographic and clinical characteristics were collected from a database of the neonatal intensive care unit. Neurodevelopmental outcomes of the survivors were evaluated using the Ages and Stages Questionnaire (ASQ-3) which were measured at the adjusted age of 12 to 18 months. The multivariate linear regression model was used to determine correlation presented as β coefficient (β) with 95 % confidence intervals (CI).

RESULTS

In this cohort of 56 survivors <29 weeks' gestation, urine output within the first 12 h of life and Apgar score at 5 min were positively associated with different domains of ASQ-3 score, however male sex and highest fraction of inspired oxygen (FiO2) in the first 12 h of life were negatively related with at least one of neurocognitive domains of ASQ-3 at adjusted age of 12 to 18 months. During hospitalization, in addition to the frequency of packed red cell transfusions, the development of severe necrotizing enterocolitis was inversely associated with both neuromotor and neurocognitive skills (gross motor domain: β = -16.93, CI: -32.04, -1.82; fine motor domain: β = -16.42, CI: -28.82, -4.02; problem solving domain: β = -13.14, CI: -24.45, -1.83; all P < 0.05), whereas severe intraventricular hemorrhage had adverse effects on gross motor only (β = -13.04, CI: -24.42, -1.65; P = 0.03). Bronchopulmonary dysplasia and retinopathy of prematurity were not related with ASQ-3.

CONCLUSIONS

In this small cohort study of very preterm neonates born at <29 weeks' gestation, risk factors in the early hours of life and neonatal morbidities during hospitalization had differential associative relationships with ASQ-3 at 12-18 months adjusted age. This information may be important for parental counseling and management including early diagnosis and intervention.

Shifting Provider Attitudes and Institutional Resources Surrounding Resuscitation at the Limit of Gestational Viability

OBJECTIVE

This study aimed to provide contemporary data regarding provider perceptions of appropriate care for resuscitation and stabilization of periviable infants and institutional resources available to providers.

STUDY DESIGN

A Qualtrics survey was emailed to 672 practicing neonatologists in the United States by use of public databases. Participants were asked about appropriate delivery room care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making, and resources utilized regarding resuscitation. Descriptive statistics were used to analyze the dataset.

RESULTS

In total, 180 responses were received, and 173 responses analyzed. Regarding preferred course of care based on gestational age, the proportion of respondents endorsing full resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%, 23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors most impacting decision-making at 22 weeks gestational age included: outcomes based on population data (79%), parental wishes (65%), and quality of life measures (63%). Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the delivery room (77%), and vascular access (69%) were the most supported therapies for initial stabilization. Availability of institutional resources varied; the most limited were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care teams (54%).

CONCLUSION

There appears to be discordance in provider attitudes surrounding preferred actions at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability and identified resource limitations are nonuniform. Between-hospital variations in outcomes for periviable infants may be partly attributable to lack of provider consensus and nonuniform resource availability across institutions.

KEY POINTS

· Within the past decade, there has been a shift in the gray zone from 23-24 to 22-23 weeks gestation.. · Attitudes around resuscitation of infants are nonuniform despite perceived standardized approaches.. · Institutional variability in resources may contribute to variation in outcomes of periviable infants..

Prognostic value of clinicians' predictions of neonatal outcomes in counseling at the margin of gestational viability

Within antenatal counseling sessions at the margin of gestational viability, clinicians frequently to use population-based outcome data and statistical models to guide the decision-making process. These tools often utilize non-modifiable prenatal factors to estimate outcomes based on population averages. However, most parents prefer individualized predictions, which cannot be supported by these models. Additionally, prognostic accuracy is limited by institutional practices surrounding active management of infants at the margin of viability. Throughout the literature, parental perspectives emphasize the importance of communicating subjective information, such as providing hope and supporting personal values, over the importance of accurate prognostic information from the clinician. In this review we aim to describe the value of clinician prognoses in the decision-making process at the margin of gestational viability and emphasize the importance of addressing parental values during the counseling process, regardless of the expected outcome.

Changes in Neurodevelopmental Outcomes From Age 2 to 10 Years for Children Born Extremely Preterm

OBJECTIVES

Evidence-based care of extremely preterm infants (<28 weeks' gestation) depends heavily on research in which a primary outcome is infant neurodevelopmental impairment (NDI), yet it is unclear how well NDI in infancy predicts long-term NDI. In this study, we aim to assess the relationship between 2- and 10-year neurodevelopment using a well-known 2-year definition and a 10-year definition developed by an expert panel.

METHODS

Using data from the Extremely Low Gestational Age Newborn Study cohort, we classified 2-year NDI using definitions developed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. We classified 10-year NDI using definitions developed by an expert panel, which added epilepsy and ASD at 10 years.

RESULTS

Of 1506 infants, 80% survived. Data sufficient to classify severity of NDI at both 2 and 10 years were available for 67% of survivors (n = 802). Among children classified as having moderate to severe NDI at 2 years, 63% had none to mild NDI at 10 years; among children classified as having profound NDI at 2 years, 36% had none to mild NDI at 10 years. Cohen's κ statistic indicated minimal to fair agreement between NDI at 2 and 10 years (0.34, P < .001).

CONCLUSIONS

NDI in infancy, as defined in this study, only weakly predicts NDI in middle childhood. For the parents at risk for delivery of an extremely preterm infant, a hopeful message can be taken from our findings that one-third of surviving children classified as having profound NDI and nearly two-thirds of those classified as having moderate to severe NDI at 2 years had none to mild NDI at 10 years.

Assessment of an Updated Neonatal Research Network Extremely Preterm Birth Outcome Model in the Vermont Oxford Network

IMPORTANCE

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals.

OBJECTIVE

To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks' 0 days' to 25 weeks' 6 days' gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019.

EXPOSURES

Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids.

MAIN OUTCOMES AND MEASURES

The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months' corrected age and measures of hospital resource use (days of hospitalization and ventilator use).

RESULTS

Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age-only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%).

CONCLUSIONS AND RELEVANCE

An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.

Worth a Try? Describing the Experiences of Families during the Course of Care in the Neonatal Intensive Care Unit When the Prognosis is Poor

OBJECTIVE

To determine how parents of infants in the neonatal intensive care unit with a poor or uncertain prognosis view their experience, and whether they view their choices as "worth it," regardless of outcome.

STUDY DESIGN

Parents of eligible neonates at 2 institutions underwent audiotaped, semistructured interviews while their infants were still in the hospital and then again 6 months to 1 year after discharge or death. Interviews were transcribed and data were analyzed using thematic analysis. Two authors independently reviewed and coded each interview and discrepancies were resolved by consensus.

RESULTS

Twenty-six families were interviewed in the initial group and 17 families were interviewed in the follow-up group. The most common themes identified included realism about death (24 families), appreciation for the infant's care team (23 families), and optimism and hope (22 families). Overall themes were very similar across both centers, and among parents of infants who died and those who survived. Themes of regret, futility, distrust of care team, and infant pain were brought up infrequently or not at all.

CONCLUSIONS

No family believed that the care being provided to their infant was futile; rather, parents were grateful for the care provided to their infant, regardless of outcome. Even in the case of a poor prognosis or the death of an infant, families in our study viewed their infant's stay in the neonatal intensive care unit favorably.

Ethical considerations in the care of complicated twin pregnancies

Twin gestations are increasing in prevalence worldwide, and are potentially subject to medical complications which present uniquely complex ethical and psychosocial challenges for the pregnant patient and obstetrician to navigate. In this article, we explore these issues as they relate to medical decision-making in cases of discordant growth and discordant anomalies in both monochorionic and dichorionic twin pregnancies, including those affected by twin-twin transfusion syndrome, with particular attention to scenarios in which the individual fetuses hold competing interests. For each of these scenarios, we consider how decisions may positively or negatively impact one or both fetuses, and how familiarity with population outcomes, as well as sensitivity to the complex psychosocial circumstances surrounding these pregnancies, can support and inform shared decision-making.

Opportunities and difficulties for counseling at the margins of viability

At the margins of viability, the interaction between physicians and families presents challenges but also opportunities for success. The counseling team often focuses on data: morbidity and mortality statistics and the course of a typical infant in the neonatal intensive care unit. Data that are generated on the population level can be difficult to align with the multiple facets of an individual infant's trajectory. It is also information that can be difficult to present because of framing biases and the complexities of intuiting statistical information on a personal level. Families also do not arrive as a blank slate but rather arrive with notions of prematurity generated from the culture they live in. Mothers and fathers often want to focus on hope, their changing role as parents, and in their desire to be a family. Multi-timepoint counseling provides the opportunity to address these goals and continue communication as the trajectories of infants, families and the counseling team change.