Management decisions in extremely premature infants

Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation in Switzerland over a 3-year period

OBJECTIVES

The aim of this research is to assess causes and circumstances of deaths in extremely low gestational age neonates (ELGANs) born in Switzerland over a 3-year period.

DESIGN

Population-based, retrospective cohort study.

SETTING

All nine level III perinatal centres (neonatal intensive care units (NICUs) and affiliated obstetrical services) in Switzerland.

PATIENTS

ELGANs with a gestational age (GA) <28 weeks who died between 1 July 2012 and 30 June 2015.

RESULTS

A total of 594 deaths were recorded with 280 (47%) stillbirths and 314 (53%) deaths after live birth. Of the latter, 185 (59%) occurred in the delivery room and 129 (41%) following admission to an NICU. Most liveborn infants dying in the delivery room had a GA ≤24 weeks and died following primary non-intervention. In contrast, NICU deaths occurred following unrestricted life support regardless of GA. End-of-life decision-making and redirection of care were based on medical futility and anticipated poor quality of life in 69% and 28% of patients, respectively. Most infants were extubated before death (87%).

CONCLUSIONS

In Switzerland, most deaths among infants born at less than 24 weeks of gestation occurred in the delivery room. In contrast, most deaths of ELGANs with a GA ≥24 weeks were observed following unrestricted provisional intensive care, end-of-life decision-making and redirection of care in the NICU regardless of the degree of immaturity.

Limit of viability: The Swiss experience

Progress made in the field of perinatology over the past four decades has led to unprecedented low mortality rates for extremely low birth weight infants. However, because rates of important short-term complications and neurodevelopmental impairment among survivors have remained high, the best approach to borderline viable infants continues to be debated. Not surprisingly, guidelines from various national medical societies for the care of infants born at the limit of viability vary considerably. In 2002, the first Swiss recommendations for the care of borderline viable infants were published. They had been developed by a multidisciplinary team of experts from the fields of obstetrics, pediatrics, and neonatology. Despite the availability of national guidelines, center-to-center outcome variability has since persisted, suggesting that care for the most immature infants is not only evidence-based and guideline-driven but also strongly influenced by local neonatal intensive care unit (NICU) culture. In 2011, revised national recommendations for perinatal care at the limit of viability between 22 and 26 completed weeks of gestation were published. It remains to be seen whether this has led to more uniform outcomes across the Swiss centers in the years that followed.

Borderline Viability—Neonatal Outcomes of Infants in Singapore over a Period of 18 Years (1990 – 2007)

Introduction: This study assesses the trends and predictors of mortality and morbidity in infants of gestational age (GA) <27 weeks from 1990 to 2007. Materials and Methods: This is a retrospective cross-sectional cohort study of infant deliveries between 1990 and 2007 in the largest perinatal centre in Singapore. This is a study of infants born at <27 weeks in 2 Epochs (Epoch 1 (E1):1990 to 1998, Epoch 2 (E2):1999 to 2007) using logistic regression models to identify factors associated with mortality and composite morbidity. The main outcomes that were measured were the trends and predictors of mortality and morbidity. Results: Four hundred and eight out of 615 (66.3%) live born infants at 22 to 26 weeks survived to discharge. Survival improved with increasing GA from 22% (13/59) at 23 weeks to 87% (192/221) at 26 weeks (P <0.01). Survival rates were not different between E1 and E2, (61.5% vs 68.8%). In logistic regression analysis, higher survival was independently associated with increasing GA and birthweight, while airleaks, severe intraventricular haemorrhage (IVH) and necrotizing enterocolitis (NEC) contributed to increased mortality. Rates of major neonatal morbidities were bronchopulmonary dysplasia(BPD) (45%), sepsis (35%), severe retinopathy of prematurity (ROP) (31%), severe IVH/ periventricular leucomalacie (PVL) (19%) and NEC (10%). Although composite morbidity comprising any of the above was not significantly different between the 2 Epochs (75% vs 73%) a decreasing trend was seen with increasing GA (P <0.001). Composite morbidity/mortality was significantly lower at 26 weeks (58%) compared to earlier gestations (P<0.001, OR 0.37, 95% CI, 0.28 to 0.48) and independently associated with decreasing GA and birth weight, male sex, hypotension, presence of patent ductus arteriosus (PDA) and airleaks. Conclusion: Increasing survival and decreasing composite morbidity was seen with each increasing week in gestation with marked improvement seen at 26 weeks. Current data enables perinatal care decisions and parental counselling. Key words: Composite Morbidity, Neonatal Mortality

Changes in quality of life into adulthood after very preterm birth and/or very low birth weight in the Netherlands

Background

It is important to know the impact of Very Preterm (VP) birth or Very Low Birth Weight (VLBW). The purpose of this study is to evaluate changes in Health-Related Quality of Life (HRQoL) of adults born VP or with a VLBW, between age 19 and age 28.

Methods

The 1983 nationwide Dutch Project On Preterm and Small for gestational age infants (POPS) cohort of 1338 VP (gestational age <32 weeks) or VLBW (<1500 g) infants, was contacted to complete online questionnaires at age 28. In total, 33.8% of eligible participants completed the Health Utilities Index (HUI3), the London Handicap Scale (LHS) and the WHOQoL-BREF. Multiple imputation was applied to correct for missing data and non-response.

Results

The mean HUI3 and LHS scores did not change significantly from age 19 to age 28. However, after multiple imputation, a significant, though not clinically relevant, increase of 0.02 on the overall HUI3 score was found. The mean HRQoL score measured with the HUI3 increased from 0.83 at age 19 to 0.85 at age 28. The lowest score on the WHOQoL was the psychological domain (74.4).

Conclusions

Overall, no important changes in HRQoL between age 19 and age 28 were found in the POPS cohort. Psychological and emotional problems stand out, from which recommendation for interventions could be derived.

Ethical decision making in the resuscitation of extremely premature infants: the health care professional's perspective

Across Canada, the rate of preterm birth (i.e., at < 37 weeks' gestation) has been steadily increasing. Advances in perinatal medicine and neonatal intensive care have resulted in an increased capacity to intervene at the extremes of prematurity, leading to an increase in the overall survival of infants born at early gestations. There has been little corresponding decrease in long-term complications. As a result, additional stresses are placed on neonatal intensive care units across the country, impacting families, health care professionals, and society as a whole. Moral distress and moral residue are often cited in the neonatal-perinatal literature as stressors experienced by those who participate in the resuscitation decision-making process. They are directly related to the challenge of making a concrete decision about life and death at extremely early gestations in the context of long-term uncertainty. In this review, we performed a systematic search of medical and ethics literature pertaining to resuscitation at the extremes of prematurity. The perspective of health care professionals is explored, including how definitions of viability and parental perspectives contribute to the decision-making process. We argue for the necessity of further research exploring the inter-professional context of ethical decision making at the extremes of prematurity.

Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act

OBJECTIVE

The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation.

STUDY DESIGN

We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios.

RESULTS

Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled.

CONCLUSION

Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.

Effects of the use of semipermeable membranes on fluid loss in low-birth-weight premature newborns

Studies have shown that the application of semipermeable membranes to the skin of premature newborns (NBs) can aid in protecting the skin, reduce disturbances in fluid and electrolyte levels, and decrease neonatal mortality. The aim of this study was to verify the effect of using semipermeable membranes in low-birth-weight preterm newborns (PTNBs). A randomized controlled trial was carried out in the neonatal intensive care unit (NICU) with 42 NBs split evenly into an intervention group (IG), in which semipermeable membranes were used to cover large areas of the skin for the first 7 days of life, and a control group (CG), which received normal care. The variables investigated for the study were weight, hydration status, urinary density, glycemic control, sodium concentration, and daily hydration quota. The following variables displayed significant daily variation: weight, hydration quota, and sodium concentration. Statistically significant individual effects by day and by group were found only for sodium concentration. In the overall analysis of the intersubject effects, sodium concentration, alone, proved to be significant (p = .055). Significant effects by group in relation to the sodium concentration were found, with the IG showing a lower average sodium concentration than the CG. Thus, the use of semipermeable membranes reduced fluid loss in premature NBs in the current study, confirming the findings of previous studies. Guidelines for practice may now be warranted.

Eficácia do uso de membrana semipermeável em neonatos pré-termo na redução de perdas transepidérmicas

Neste estudo, investigou-se a eficácia do uso da membrana semipermeável na pele de recém-nascido pré-termo sobre a evolução da perda ponderal e valores da glicemia, cota hídrica, densidade urinária e sódio. Estudo experimental, tipo ensaio clínico randomizado, realizado no período de março a agosto de 2008, na Unidade de Terapia Intensiva Neonatal, de uma maternidade pública, na cidade de Fortaleza-Ceará, Brasil. A amostra foi constituída de 42 recém-nascidos pré-termo. Os dados foram apresentados em tabelas e quadros. Na aplicação da membrana semipermeável, os recém-nascidos pré-termos do Grupo de Intervenção tiveram uma diminuição de níveis de sódio e de exigências fluidas diárias, como também apresentaram menores episódios de hiperglicemia e a densidade urinária foi mantida dentro dos padrões de normalidade. A membrana semipermeável é, de fato, um recurso terapêutico eficaz para minimizar as perdas de água transepidérmicas.

Prediction of death for extremely premature infants in a population-based cohort

OBJECTIVE

Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.

METHODS

From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.

RESULTS

In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).

CONCLUSIONS

In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.

Survival and major disability rate in infant born at 22-25 weeks of gestation

Our aim was to evaluate the literature on survival and major disability rate in preterm infants born at 22- 25 weeks of gestational age (GA). Thirty-three studies were identified and reviewed. Survival was lower in population-based studies (2% at 22, 13% at 23, 35% at 24, and 56% at 25 weeks) than in center-based study (15% at 22, 41% at 23, 58% at 24, and 74% at 25 weeks). The severe disability rate was slightly higher in population-based studies than in center-based studies at 23 (29 vs. 32%) and at 24 (30 vs. 27%) week of GA, whereas it was similar in population and center-based studies at 25 (21 vs. 22%) weeks of GA. Survival rate seems to improve with time, whereas the change of severe disability rate cannot be adequately evaluated due to the paucity of available data. We conclude that the survival of infants born at 22 weeks is still an uncommon event, whereas the survival of infants born at 23, and mostly at 24 and 25 weeks of GA is significant in the majority of studies.

Unimpaired outcomes for extremely low birth weight infants at 18 to 22 months

OBJECTIVE

The goal was to identify, among extremely low birth weight (<or=1000 g) live births, the proportion of infants who were unimpaired at 18 to 22 months of corrected age.

METHODS

Unimpaired outcome was defined as Bayley Scales of Infant Development II scores of >or=85, normal neurologic examination findings, and normal vision, hearing, swallowing, and walking. Outcomes were determined for 5250 (86%) of 6090 extremely low birth weight inborn infants.

RESULTS

Of the 5250 infants whose outcomes were known at 18 months, 850 (16%) were unimpaired, 1153 (22%) had mild impairments, 1147 (22%) had moderate/severe neurodevelopmental impairments, and 2100 (40%) had died. Unimpaired survival rates varied according to birth weight, from <1% for infants <or=500 g to 24% for infants 901 to 1000 g. The regression model to predict unimpaired survival versus death or impairment for live births (N = 5250) indicated that 25.3% of the variance was derived from infant factors present at birth, including female gender, higher birth weight, singleton birth. The regression model to predict unimpaired survival for discharged infants indicated that most of the variance was derived from combined effects of major neonatal morbidities, neonatal interventions, and maternal demographic features (15.7%) and only 8.5% was derived from infant factors present at birth.

CONCLUSIONS

Although <1% of live-born infants of <or=500 g survive free of impairment at 18 months, this increases to almost 24% for infants of 901 to 1000 g. Female gender, singleton birth, higher birth weight, absence of neonatal morbidities, private health insurance, and white race increase the likelihood of unimpaired status.

Comparison of neonatal intensive care: Trento area versus Vermont Oxford Network

BACKGROUND

S. Chiara hospital is the only neonatal intensive care unit (NICU) in the Province of Trento (Italy). It serves a population of about 460000 people with about 5000 infants per year, admitting the totality of the inborn and outborn VLBWI of the province. The aim of this work is to compare mortality, morbidity and neonatal treatment of the very low birth weight infants (VLBWI) of Trento area with those recorded in the Vermont Oxford Network (VON) during 2004.

METHODS

In this retrospective analysis, the rates of complications and related treatments reported in VLBWI admitted in the S. Chiara NICU during the period 2000-2005 were compared with those recorded in the VON in 2004. The analysis included both the total populations and different weight groups.

RESULTS

The frequency of inborn infants was significantly higher in Trento than in VON: 91% vs 84% (MH 8.56; p-value 0.003). The administration of prenatal steroids (82% vs 74%; MH 7.47 and p-value 0.006) and caesarean section were significantly more frequent in the Trento area than in VON. In Trento significantly more VLBWI with BW

CONCLUSION

On the basis of this analysis, a less aggressive therapeutic strategy based on perinatal prevention in global management, such as that employed in Trento area, may be associated with an improvement in clinical outcomes in very low birth weight infants.

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Affiliation(s)

Giuseppe De Nisi Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Mariarosaria Berti Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Riccardo Malossi Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Fabio Pederzini Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Anna Pedrotti Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Alberta Valente Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy

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Outcomes for the extremely premature infant: what is new? And where are we going?

Two approaches were taken to determine what is new and where we are going in terms of outcomes for the extremely premature infant: publications from 2004 to 2007 were reviewed, and the 30-year outcome at the authors' institutions was assessed. Recent literature documents improving early childhood outcomes in the face of improved survival. Childhood cerebral palsy prevalence rates have been reported to be as low as 19 per 1000 live births for infants born at 20-27 weeks gestation. Vision and hearing loss have been reported in fewer than 1% of survivors. The rate of overall intellectual impairment has not improved, although impairment was reduced in a recent trial of caffeine therapy for apnea of prematurity, and this remains an important area for study. In sum, recent findings herald a more positive perspective on the outcome for extremely premature survivors. It can thus be expected that new intensive-care trials will attempt to reduce the proportion of survivors with adverse outcomes. Childhood assessments will have a greater focus on function and participation. Information on improved outcomes for preterm infants will inform guidelines of decision making used to help parents to determine what is best for their child. The audit component of follow-up studies will expand and more cohort and trial studies will become multicenter, national, and international.

Attitudes of Canadian neonatologists in delivery room resuscitation of newborns at threshold of viability

OBJECTIVE

There is great debate regarding the extent of intensive care interventions for extremely premature newborns. In this report, we describe Canadian neonatologists' attitudes towards delivery room resuscitation decisions in neonates at the threshold of viability.

METHODS

We interviewed neonatologists (N = 121) practising in Canadian tertiary care neonatal units between June 2004 and April 2005, and asked whether they would support a parental request not to initiate resuscitation for newborns of 23 to 26 weeks' gestation. Bivariate analyses were performed to identify sociodemographic or cultural factors that might affect resuscitation decisions.

RESULTS

Most Canadian neonatologists would support a parental request not to initiate resuscitation of an infant at 23 and 24 weeks' gestation (98% and 80%, respectively). However, we observed heterogeneity across the country in attitudes primarily at 25 weeks, but also at 24 weeks' gestation. At 24 weeks' gestation, decisions also appear to be significantly related to personal experience with a disabled close friend or relative. For newborns of 25 weeks' gestation, neonatologists are divided: a majority (76%) would strongly advocate resuscitation and/or resuscitate a "viable" fetus against parental wishes, and a minority (24%) would agree not to initiate treatment. At 26 weeks' gestation, more than 97% would not support a request not to initiate resuscitation.

CONCLUSION

Attitudes of Canadian neonatologists towards resuscitation of newborns at the threshold of viability primarily differ at 25 weeks and to a lesser extent at 24 weeks of gestation. Our findings highlight important nuances in relation to existing national guidelines.

Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop

Perinatal care at the borderlines of viability demands a delicate balance between parents' wishes and autonomy, biological feasibility, clinicians' responsibilities and expectations, and the prospects of an acceptable long-term outcome - coupled with a tolerable margin of uncertainty. A multi-professional workshop with consumer involvement was held in February 2005 to agree on management of this issue in New South Wales and the Australian Capital Territory. Participants discussed and formulated consensus statements after an extensive consultation process. Consensus was reached that the "grey zone" is between 23 weeks' and 25 weeks and 6 days' gestation. While there is an increasing obligation to treat with increasing length of gestation, it is acceptable medical practice not to initiate intensive care during this period if parents so wish, after appropriate counselling. Poor condition at birth and the presence of serious congenital anomalies have an important influence on any decision not to initiate intensive care within the grey zone. Women at high risk of imminent delivery within the grey zone should receive appropriate and skilled counselling with the most relevant up-to-date outcome information. Management plans can thus be made before birth. Information should be simple, factual and consistent. The consensus statements developed will provide a framework to assist parents and clinicians in communication, decision making and managing these challenging situations.

Survival and major neonatal complications in infants born between 22 0/7 and 24 6/7 weeks of gestation (1999-2003)

OBJECTIVE

This study was undertaken to compare survival and morbidity until discharge in infants born after 22-23 versus 24 weeks' gestational age (GA).

STUDY DESIGN

Cohort study of all infants 25 weeks or less, born in 3 tertiary perinatal centers (1999-2003).

RESULTS

Of a total of 336 infants, 133 (40%) died before or immediately after birth without the provision of life support, 203 (60%) received active neonatal treatment. Infants with life support (n = 82 at 22 to 23 weeks, n = 121 at 24 weeks) differed with respect to antenatal steroid prophylaxis (44% vs 62%) and cesarean section rate (51% vs 71%). Survival was 67% compared with 82% (P = .016). The incidence of intraventricular hemorrhage III or greater or periventricular leukomalacia (15/15%), severe retinopathy of prematurity (18/15%), and chronic lung disease (40/47%) was similar in both GA groups.

CONCLUSIONS

The provision of life support for extremely preterm infants increases their chance of survival without more neonatal morbidity.

Delivery room decision-making for extremely preterm infants in Sweden

OBJECTIVE

To assess neonatologists' attitudes and practices regarding treatment of extremely preterm infants in the delivery room, particularly in response to parental wishes.

STUDY DESIGN

Cross-sectional survey of all neonatologists in Sweden registered with the Swedish Pediatric Society.

RESULTS

The response rate was 71% (88 of 124 neonatologists). At 24[1/7] to 24[6/7] weeks of gestation, 68% of neonatologists considered treatment clearly beneficial; at 25[1/7] to 25[6/7] weeks of gestation, 93% considered it clearly beneficial. When respondents consider treatment clearly beneficial, 97% reported that they would resuscitate in the delivery room despite parental requests to withhold treatment. At or below 23[0/7] weeks of gestation, 94% of neonatologists considered treatment futile. Nineteen percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, 99% reported that they would resuscitate when parents request it, 99% reported that they would resuscitate when parents are unsure, and 25% reported that they would follow parental requests to withhold treatment.

CONCLUSION

Although neonatologists' attitudes and practices varied, respondents to our survey in general envisioned little parental role in delivery room decision-making for extremely preterm infants.

The marginally viable newborn: legal challenges, conceptual inadequacies, and reasonableness

Decisions to provide life-sustaining medical care for marginally viable newborns present a unique set of morally complex challenges for providers and parents in the United States. This article examines recent legal trends that restrict discretionary decision-making, and critiques commonly employed ethical justifications offered to support permitting such discretion.

Willingness or unwillingness to perform cesarean section for impending preterm delivery at 24 weeks' gestation: a cost-effectiveness analysis

OBJECTIVE

This study was undertaken to compare the costs and health outcomes of 2 management options when encountering a 24-week gestation in labor.

STUDY DESIGN

We constructed a decision model for willingness versus unwillingness to perform cesarean section for fetal indication (aggressive vs nonaggressive management). We modeled chance nodes for stillbirth, neonatal death, and long-term survival, with and without major morbidity. Main outcome measures were intact (healthy) infant and live infant. Cost-effectiveness analysis was conducted from a societal perspective to determine the cost-effectiveness of the 2 strategies.

RESULTS

The probabilities of both intact survival (16.8% vs 12.9%) and survival with major morbidity (39.2% vs 19.4%) were higher with willingness to perform cesarean section. Nonaggressive management was less costly for delivery at 24 weeks' gestation. Aggressive management strategy would cost dollar 4,680,387 more than nonaggressive management for each additional intact infant, and dollar 766,241 more per additional live infant.

CONCLUSION

Although the probability of survival is increased by physician willingness to perform cesarean section, the more cost-effective strategy is unwillingness because of a strong relationship to the increased probability of survival with major morbidity when physicians are willing to perform cesarean section for fetal indications.

Management of the neonate at the limits of viability

The active treatment of fetuses or neonates at the limits of viability is an ongoing debate for perinatal physicians. Although initiating intensive care at 26 weeks is generally accepted, the gray zone of gestational ages at which aggressive perinatal care should be offered is less clear and ranges from 22 to 25 weeks. The gray zone has remained rather unchanged over the last decade. Attitudes vary among different countries, centres and individuals. The benefit-burden ratio of neonatal intensive care is balanced differently according to competing moral values. Several factors underlie the difficulty in approaches to management decisions. Neonates lack the capacity to make decisions and most parents ignore the complexity of care during and after hospitalisation. Parents have to be informed about the survival rates and the risks of long term disabilities, but accuracy for each individual baby is very weak. Outcome data are published many years after the intensive care period, and results about the prevalence of severe disabilities over time are conflicting and vary widely (ranging from 10% to 60%). Information about more subtle disabilities which only become apparent around school age is scarce. Data on the impact of the longer term outcomes of new strategies like developmental care approaches (Neonatal Individual Developmental Care Assessment Programme: NIDCAP) are still insufficient but could prove to be an important recent step in improving outcome in extremely immature babies.