Ethics of maintaining extremely preterm infants

Outcomes of infants born at 22 and 23 weeks' gestation

OBJECTIVE

To provide instructive information on death and neurodevelopmental outcomes of infants born at 22 and 23 weeks' gestational age.

METHODS

The study cohort consisted of 1057 infants born at 22 to 25 weeks in the Neonatal Research Network, Japan. Neurodevelopmental impairment (NDI) at 36 to 42 months' chronological age was defined as any of the following: cerebral palsy, hearing impairment, visual impairment, and a developmental quotient <70. A systematic review was performed by using databases of publications of cohort studies with neonatal and neurodevelopmental outcomes at 22 and 23 weeks.

RESULTS

Numbers and incidences (%) of infants with death or NDI were 60 (80%) at 22 weeks and 156 (64%) at 23 weeks. In logistic regression analysis, gestational ages of 22 weeks (odds ratio [OR]: 5.40; 95% confidence interval [CI]: 2.48-11.76) and 23 weeks (OR: 2.14; 95% CI: 1.38-3.32) were associated with increased risk of death or NDI compared with 24 weeks, but a gestational age of 25 weeks (OR: 0.65; 95% CI: 0.45-0.95) was associated with decreased risk of death or NDI. In the systematic review, the medians (range) of the incidence of death or NDI in 8 cohorts were 99% (90%-100%) at 22 weeks and 98% (67%-100%) at 23 weeks.

CONCLUSIONS

Infants born at 22 and 23 weeks' gestation were at higher risk of death or NDI than infants at born at 24 weeks. However, outcomes were improved compared with those in previous studies. There is a need for additional discussions on interventions for infants born at 22 or 23 weeks' gestation.

Characteristics of deaths in paediatric intensive care: a 10-year study

OBJECTIVE

To describe the patient mortality over a 10-year period in a paediatric intensive care unit (PICU) including patient demographics, length of stay, cause and mode of death and to compare these findings with pre-existing literature from the western world.

DESIGN

A retrospective chart review.

SETTING

A UK tertiary PICU.

PATIENTS

All children who died in the PICU over a 10-year period between 1 November 1997 and 31 October 2007 (n = 204).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data recorded for each patient included patient demographics, length of stay and cause of death according to the International Classification of Disease-10 classification, and mode of death. Mode of death was assigned for each patient by placement in one of four categories: (i) brain death (BD), (ii) managed withdrawal of life-sustaining medical therapy (MWLSMT), (iii) failed cardiopulmonary resuscitation (CPR) and (iv) limitation of treatment (LT). Over the study period, findings showed a median length of stay of 2 days (IQR 0-5 days), with a mortality rate of 5%. The most common mode of death was MWLSMT (n = 112, 54.9%) and this was consistent across the 10-year period. Linear regression analysis demonstrated no significant change in trend over the 10 years in each of the modes of death; BD (p = 0.84), MWLSMT (p = 0.88), CPR (p = 0.35) and LT (p = 0.67).

CONCLUSION

End-of-life care is an important facet of paediatric intensive nursing/medicine. Ten years on from the Royal College of Paediatrics and Child Health publication 'Withholding or withdrawing life sustaining treatment in children: A framework for practice', this study found managed withdrawal of MWLSMT to be the most commonly practised mode of death in a tertiary PICU, and this was consistent over the study period.

Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births

Over the last 2 decades, the survival rate of infants born at < or = 25 weeks of gestation has increased; however, significant morbidity and disability persist. The commitment for their care gives rise to a variety of complex medical, social, and ethical aspects. Decision-making is a crucial issue that involves the infant, the family, health care providers, and society. In a review of the existing guidelines, we investigated the different approaches in the care of extremely preterm births in various countries. We found that many scientific societies and professional organizations have issued guidelines that address the recommendations for the care of these fetuses/neonates although to varying degrees. In this article we compare different approaches and assess the scientific grounds of the specific recommendations. With current standards, intensive care is generally considered justifiable at > or = 25 weeks, compassionate care at < or = 22 weeks, and an individual approach at 23 to 24 weeks, consistent with the parents' wishes and the infant's clinical conditions at birth.