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

Extremely Preterm Babies-Legal Aspects and Palliative Care at the Border of Viability

There are various legal considerations and rare decisions of courts in western countries concerning palliative care and the border of viability in cases of extremely preterm babies. Nevertheless, on the one hand, regulations and decisions of courts describe the conditions physicians have to accept. On the other hand, courts are also able to accept that every case can be special, and needs a unique answer. Therefore, the framework can be described as well as the medical disciplines, which should be involved in a particular case.

Survival prediction modelling in extreme prematurity: are days important?

OBJECTIVE

To demonstrate that days are important in extreme prematurity when creating survival prediction models based on gestation.

STUDY DESIGN

Prospectively collected data were analysed for all admitted infants born 23 + 0 to 27 + 6 weeks gestation in the Australian and New Zealand Neonatal Network from 2009 to 2016. The effect of days on observed survival rates was assessed using a non-parametric test for trend. Prediction models created based on gestational age in completed weeks only or weeks plus days were compared.

RESULT

Seven thousand eight hundred and thirty-six extreme preterm infants were studied. Observed survival increased with days for 23, 24, 25, and 27 weeks gestational age (P = 0.01; P < 0.001; P = 0.003; P = 0.003) but not for 26 weeks (P = 0.19). A survival prediction model based on weeks and days performed better than completed weeks only (AUC 0.722 vs 0.712; P < 0.001).

CONCLUSION

In extreme prematurity, survival estimate accuracy improves when survival prediction models include days in addition to weeks.

The Etiology of Neonatal Intensive Care Unit Death in Extremely Low Birth Weight Infants: A Multicenter Survey in China

OBJECTIVE

The aim of this study is to identify causes of neonatal intensive care unit (NICU) death in extremely low birth weight (ELBW) infants less than 1,000 g admitted in Chinese tertiary NICUs.

STUDY DESIGN

We retrospectively collected data on 607 ELBW infants from 39 level III NICUs from July 2016 to June 2019. The primary causes of death were compared among different gestation age, postnatal age groups, and areas with variable economic status.

RESULTS

Among all 607 ELBW NICU deaths, 47.1% were multiple gestation with high rate of in vitro fertilization (IVF) (43.3%); 53.4 and 34.1% received any or full course of antenatal corticosteroid (ACS). The most common causes of ELBW NICU death were respiratory distress syndrome-related neonatal respiratory failure (RDS-NRF, 43.5%), severe infection (19.1%), necrotizing enterocolitis or bowel perforation (9.4%), severe central nervous system injury (8.4%), and bronchopulmonary dysplasia-related respiratory failure (BPD-NRF, 7.7%). Causes of ELBW NICU death varied across postnatal age groups. RDS-NRF was the leading cause of early neonatal death, while severe infection in late neonatal death and BPD in postneonatal EBLW NICU death. RDS-NRF, severe brain injury, and asphyxia were most likely to die at early neonatal age (median age [interquartile range], 2 [0-5], 6 [3-9], and 3 [1-6] days, respectively) while severe infection and necrotizing enterocolitis (NEC) at late neonatal age, BPD-NRF at postneonatal age.

CONCLUSION

In Chinese tertiary NICUs, the major causes of death in extremely low birth weight infants were RDS, infection, NEC, brain injury and BPD, and they varied with postnatal age. Developing specific prevention strategies for identified causes of death in ELBW NICU may potentially improve ELBW survival.

Temporal changes in rates of active management and infant survival following live birth at 22-24 weeks' gestation in Victoria

BACKGROUND

Management of livebirths at 22-24 weeks' gestation in high-income countries varies widely and has changed over time.

AIMS

Our aim was to determine how rates of active management and infant survival of livebirths at 22-24 weeks varied with perinatal variables known at birth, and over time in Victoria, Australia.

MATERIALS AND METHODS

We conducted a population-based cohort study of all 22-24 weeks' gestation live births, free of lethal congenital anomalies in 2009-2017. Rates of active management and survival to one year of age were reported. 'Active management' was defined as receiving resuscitation at birth or nursery admission for intensive care.

RESULTS

Over the nine-year period, there were 796 eligible live births. Overall, 438 (55%) were actively managed: 5% at 22 weeks, 45% at 23 weeks and 90% at 24 weeks' gestation, but rates of active management did not vary substantially over time. Of livebirths actively managed, 263 (60%) survived to one year: 0% at 22 weeks, 50% at 23 weeks and 66% at 24 weeks. Apart from gestational age, being born in a tertiary perinatal centre and increased size at birth were associated with survival in those actively managed, but sex and plurality were not. Survival rates of actively managed infants rose over time (adjusted odds ratio 1.09 per year; 95% CI 1.01-1.18; P = 0.03).

CONCLUSIONS

Although active management rates did not change substantially over time in Victoria, an overall increase in infant survival was observed. With increasing gestational age, rates of active management and infant survival rapidly rose.

Exploring implicit bias in the perceived consequences of prematurity amongst health care providers in North Queensland - a constructivist grounded theory study

Background

A study was done to explore the attitudes of relevant health care professionals (HCP) towards the provision of intensive care for periviable and extremely premature babies.

Methods/design

Applying a constructivist grounded theory methodology, HCP were interviewed about their attitudes towards the provision of resuscitation and intensive care for extremely premature babies. These babies are at increased risk of death and neurodisability when compared to babies of older gestations. Participants included HCP of varying disciplines at a large tertiary centre, a regional centre and a remote centre. Staff with a wide range of experience were interviewed.

Results

Six categories of i) who decides, ii) culture and context of families, iii) the life ahead, iv) to treat a bit or not at all, v) following guidelines and vi) information sharing, emerged. Role specific implicit bias was found as a theoretical construct, which depended on the period for which care was provided relative to the delivery of the baby. This implicit bias is an underlying cause for the negativity seen towards extreme prematurity and is presented in this paper. HCP caring for women prior to delivery have a bias towards healthy term babies that involves overestimation of the risks of extreme prematurity, while neonatal staff were biased towards suffering in the neonatal period and paediatricians recognise positivity of outcomes regardless of neurological status of the child. The implicit bias found may explain negativity towards intensive care of periviable neonates.

Conclusion

Understanding the presence and origins of role specific implicit bias may enable HCP to work together to improve care for parents preparing for the delivery of extremely premature babies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03539-5.

When should intensive care be provided for the extremely preterm infants born at the margin of viability? A survey of Australasian parents and clinicians

AIM

This study aimed to explore clinician and parent opinions of risk limits on resuscitation and intensive care (IC) for extremely premature infants born at the margin of viability.

METHODS

Two anonymous on-line surveys were conducted from August 2016 to January 2017. Survey participants were: (i) clinicians affiliated with neonatal intensive care units in Australia; and (ii) parents or individuals who expressed interest in premature babies through the Facebook page of Miracle Babies Foundation.

RESULTS

A total of 961 responses were received. Among 204 clinicians, 52% were neonatologists, 22% obstetricians, 20% neonatal intensive care unit nurses and 4% were midwives. Among 757 parents, 98% had a premature baby. Only 75% of clinicians responded to the risk limits questions. Median mortality risk above which they would not recommend resuscitation/IC was 70% (interquartile range (IQR) 50-80%); major disability risk in survivors 60% (IQR 50-75%); and composite risk of mortality and major disability 70% (IQR 50-80%). All parents answered the risk limit questions. The median mortality risk for not planning resuscitation was 90% (IQR 60-90%); major disability risk in survivors 50% (IQR 30-90%); and composite risk 90% (IQR 50-90%). Most clinicians (82%) stated that decisions should be guided by parent opinions if there are uncertainties. Parents had varying perception of previous counselling, and 57% stated that both their viewpoint and doctor's predicted risk influenced their decision-making.

CONCLUSIONS

Clinicians and parents had different views on mortality and major disability risks when deciding on resuscitation/neonatal IC treatment. When there was uncertainty, both agreed on working together.

An alternative approach to developing guidelines for the management of an anticipated extremely preterm infant

Objectives To identify the probability of survival and severe neurodevelopmental impairment (sNDI) at which perinatal physicians would or would not offer or recommend resuscitation at birth for extremely preterm infants. Methods A Delphi process consisting of five rounds was implemented to seek consensus (>80% agreement) amongst British Columbia perinatal physicians. The first-round consisted of neonatal and maternal-fetal-medicine Focus Groups. Rounds two to five surveyed perinatal physicians, building upon previous rounds. Draft guidelines were developed and agreement sought. Results Based on 401 responses across all rounds, consensus was obtained that resuscitation should not be offered if survival probability <5%, not recommended if survival probability 5 to <10%, resuscitation recommended if survival without sNDI probability >70 to 90% and resuscitation standard care if survival without sNDI >90%. Conclusions This physician consensus-based, objective framework for the management of an anticipated extremely preterm infant is a transparent alternative to existing guidelines, minimizing gestational-ageism and allowing for individualized management utilizing up-to-date data. Further input from other key stakeholders will be required prior to guideline implementation.

Changing consumption of resources for respiratory support and short-term outcomes in four consecutive geographical cohorts of infants born extremely preterm over 25 years since the early 1990s

OBJECTIVES

It is unclear how newer methods of respiratory support for infants born extremely preterm (EP; 22-27 weeks gestation) have affected in-hospital sequelae. We aimed to determine changes in respiratory support, survival and morbidity in EP infants since the early 1990s.

DESIGN

Prospective longitudinal cohort study.

SETTING

The State of Victoria, Australia.

PARTICIPANTS

All EP births offered intensive care in four discrete eras (1991-1992 (24 months): n=332, 1997 (12 months): n=190, 2005 (12 months): n=229, and April 2016-March 2017 (12 months): n=250).

OUTCOME MEASURES

Consumption of respiratory support, survival and morbidity to discharge home. Cost-effectiveness ratios describing the average additional days of respiratory support associated per additional survivor were calculated.

RESULTS

Median duration of any respiratory support increased from 22 days (1991-1992) to 66 days (2016-2017). The increase occurred in non-invasive respiratory support (2 days (1991-1992) to 51 days (2016-2017)), with high-flow nasal cannulae, unavailable in earlier cohorts, comprising almost one-half of the duration in 2016-2017. Survival to discharge home increased (68% (1991-1992) to 87% (2016-2017)). Cystic periventricular leukomalacia decreased (6.3% (1991-1992) to 1.2% (2016-2017)), whereas retinopathy of prematurity requiring treatment increased (4.0% (1991-1992) to 10.0% (2016-2017)). The average additional costs associated with one additional infant surviving in 2016-2017 were 200 (95% CI 150 to 297) days, 326 (183 to 1127) days and 130 (70 to 267) days compared with 1991-1992, 1997 and 2005, respectively.

CONCLUSIONS

Consumption of resources for respiratory support has escalated with improved survival over time. Cystic periventricular leukomalacia reduced in incidence but retinopathy of prematurity requiring treatment increased. How these changes translate into long-term respiratory or neurological function remains to be determined.

Decision-making at the limit of viability

Babies born at the limit of viability have a high risk of morbidity and mortality. Despite great advances in science, the approach to these newborns remains challenging. Thus, this study reviewed the literature regarding the treatment of newborns at the limit of viability. There are several interventions that can be applied before and after birth to increase the baby's survival with the least sequelae possible, but different countries make different recommendations on the gestational age that each treatment should be given. There is more consensus on the extremities of viability, being that, at the lower extremity, comfort care is preferred and active care in newborns with higher gestational age. The higher the gestational age at birth, the higher the survival and survival without morbidity rates. At all gestational ages, it is important to take into account the suffering of these babies and to provide them the best quality of life possible. Sometimes palliative care is the best therapeutic approach. The parents of these babies should be included in the decision-making process, if they wish, always respecting their needs and wishes. Nevertheless, the process of having such an immature child can be very painful for parents, so it is also important to take into account their suffering and provide them with all the necessary support. This support should be maintained even after the death of the newborn.

Negativity about the outcomes of extreme prematurity a persistent problem - a survey of health care professionals across the North Queensland region

Background

Extremely preterm babies are at risk of significant mortality and morbidity due to their physiological immaturity. At periviable gestations decisions may be made to either provide resuscitation and intensive care or palliation based on assessment of the outlook for the baby and the parental preferences. Health care professionals (HCP) who counsel parents will influence decision making depending on their individual perceptions of the outcome for the baby. This paper aims to explore the knowledge and attitudes towards extremely preterm babies of HCP who care for women in pregnancy in a tertiary, regional and remote setting in North Queensland.

Methods

A cross sectional electronic survey of HCP was performed. Perceptions of survival, severe disability and intact survival data were collected for each gestational age from 22 to 27 completed weeks gestation. Free text comment enabled qualitative content analysis.

Results

Almost all 113 HCP participants were more pessimistic than the actual outcome data suggests. HCP caring for women antenatally were the most pessimistic for survival (p = 0.03 at 23 weeks, p = 0.02 at 25,26 and 27 weeks), severe disability (p = 0.01 at 24 weeks) and healthy outcomes (p = 0.01 at 24 weeks), whilst those working in regional and remote centres were more negative than those in tertiary unit for survival (p = 0.03 at 23,24,25 weeks). Perception became less negative as gestational age increased.

Conclusion

Pessimism of HCP may be negatively influencing decision making and will negatively affect the way in which parents perceive the chances of a healthy outcome for their offspring.

Perceptions of Australian and New Zealand clinicians caring for neonates born at the borderline of viability have changed since the 2005 consensus guideline

AIM

To determine whether clinician and consumer considerations have changed regarding the resuscitation and support of neonates born at the borderlines of viability since the 2005 New South Wales (NSW) and Australian Capital Territory (ACT) consensus guidelines were developed.

METHODS

A prospective survey based on the hypotheses and scenarios developed in the original NSW and ACT consensus workshop on perinatal care at the borderlines of viability was sent to neonatologists, fetal medicine specialists, clinical midwife and clinical neonatal consultants and consumer representatives in Australia and New Zealand. Four scenarios and 16 questions were used to explore the respondent's views towards different aspects of the management of neonates born at the borderlines of viability. Australian and New Zealand Neonatal Network data from 2013 or NSW/ACT Neonatal Intensive Care Units (NICUS) data from 1998 to 2004 were used to provide outcome data for each scenario.

RESULTS

A total of 87% or more of respondents advocated for resuscitation of neonates at 24 and 25 weeks' gestation in 2015. Only 29% (49/169) would agree to parental request not to resuscitate at 25 weeks and only 10% (17/170) at 26^0-6 weeks. The number of perinatal clinical care providers considering resuscitation at 23⁵ weeks' gestation increased from 23% in 2005 to more than 50% in 2015.

CONCLUSION

These findings support the development of updated guidelines for the management of neonates in Australia and New Zealand born at the borderlines of viability to reflect the changes in clinical perceptions and management.

Five-year survival of infants with major congenital anomalies: a registry based study

AIM

To determine survival of infants with major congenital anomalies (CA) and assess the effect of co-existing anomalies and gestational age.

METHODS

All liveborn infants with major CA born in New South Wales (NSW), Australia, 2004-2009 were identified from the NSW Register of Congenital Conditions. Deaths were identified via record linkage to death registrations and five-year survival was estimated using Kaplan-Meier methods.

RESULTS

There were 8521 liveborn infants with CA of whom 617 (7.2%) died within the first five years of life. Half of deaths occurred in the first week of life. The overall five-year survival rate was 92.8% (95%CI: 92.2-93.3) and 83.2% (95%CI: 79.0-87.4) for syndromes, 83.4% (95%CI: 80.9-85.9) for multiple, 85.1% (95%CI: 82.6-87.5) for chromosomal, 95.3% (95%CI: 94.8-95.8) for isolated and 96.2% (95%CI: 94.3-98.1) for non-Q chapter anomalies. Five-year survival for chromosomal, syndromes and sub-groups was higher for isolated compared with multiple anomalies ranging from 77.5% to 98.9% and 68.6% to 89.5%, respectively. Survival was lower for preterm (79.4%; 95%CI: 77.5-81.4) than for term infants (95.8%; 95%CI: 95.3-96.3).

CONCLUSION

Nine in ten infants with major CA survive up to five years, although there is variability in survival across CA groups. Survival of infants with major congenital anomalies has improved in recent years.

Active care of infants born between 22 and 26 weeks of gestation does not follow consensus expert recommendations

AIM

To determine the relationship between clinical practice and publication of an Australian consensus statement for management of extremely preterm infants in 2006.

METHODS

A population-based study using linked data from New South Wales, Australia for births between 22 + 0 and 26 + 6 weeks of gestation between 2000 and 2011.

RESULTS

There were 4746 births of whom 2870 were liveborn and 1876 were stillborn. Of the live births, 2041 (71%) were resuscitated, 1914 (67%) were admitted into a neonatal intensive care unit (NICU) and 1310 (46%) survived to hospital discharge. Thirty-nine (2%) stillbirths were resuscitated but none survived. No 22-week infant survived to hospital discharge. Fewer 23-week gestation infants were resuscitated between 2004 (52%) and 2005 (20%) but resuscitation rates increased by 2008 (44%). There was no difference at other gestations. Adjusted odds ratio (OR) for resuscitation was increased by birthweight (OR: 1.01), tertiary hospital birth (OR: 3.4) and Caesarean delivery (OR: 11.3) and decreased by rural residence (OR: 0.4) and male gender (OR: 0.7).

CONCLUSION

Expert recommendations may be shaped by clinical practice rather than the converse, especially for 23-week gestation infants. Recommendations should be revised regularly to include clinical practice changes.

Development of Nationwide Recommendations to Support Prenatal Counseling in Extreme Prematurity

OBJECTIVES

To develop a nationwide, evidence-based framework to support prenatal counseling in extreme prematurity, focusing on organization, decision-making, content, and style aspects.

METHODS

A nationwide multicenter RAND-modified Delphi method study was performed between November 2016 and December 2017 in the Netherlands. Firstly, recommendations were extracted from literature and previous studies. Secondly, an expert panel (n = 21) with experienced parents, obstetricians, and neonatologists rated the recommendations on importance for inclusion in the framework. Thirdly, ratings were discussed in a consensus meeting. The final set of recommendations was approved and transformed into a framework.

RESULTS

A total of 101 recommendations on organization, decision-making, content, and style were included in the framework, including tools to support personalization. The most important recommendations regarding organization were to have both parents involved in the counseling with both the neonatologist and obstetrician. The shared decision-making model was recommended for deciding between active support and comfort care. Main recommendations regarding content of conversation were explanation of treatment options, information on survival, risk of permanent consequences, impossibility to predict an individual course, possibility for multiple future decision moments, and a discussion on parental values and standards. It was considered important to avoid jargon, check understanding, and provide a summary. The expert panel, patient organization, and national professional associations (gynecology and pediatrics) approved the framework.

CONCLUSIONS

A nationwide, evidence-based framework for prenatal counseling in extreme prematurity was developed. It contains recommendations and tools for personalization in the domains of organization, decision-making, content, and style of prenatal counseling.

Outcomes of infants born at borderline viability (23-25 weeks gestation) who received cardiopulmonary resuscitation at birth

AIM

The practice of providing advanced resuscitative measures to infants born at borderline viability (23-25⁺⁶ weeks gestation) varies among clinicians due to perception of futility. The aim of our study was to compare mortality and major morbidities in infants born at borderline viability who did not receive cardiopulmonary resuscitation (CPR) in the delivery room (No DR-CPR) as compared to those who did (DR-CPR).

METHODS

A retrospective analysis of prospectively collected data of infants born between 23 and 25⁺⁶ weeks gestation who were resuscitated at birth at the study centre or admitted to neonatal intensive care unit from peripheral hospitals, over 8 years (2007-2014). The primary outcome was survival, free of disability at 2 years corrected age and secondary outcomes were survival at discharge and neonatal morbidities.

RESULTS

Of 123 infants in the study cohort, 21 received DR-CPR. In unadjusted analysis, there was increased mortality rate in the DR-CPR group which was statistically insignificant (26.5 vs. 42.9%, P = 0.15). After adjustment for potential confounders, there was no significant difference in the mortality rate with odds ratio of 1.10 (confidence interval: 0.34-3.53, P = 0.86). Among infants who received DR-CPR for >2 min, the mortality rate was significantly higher (25.2 vs. 56.3%, P = 0.01). Survival free of disability was similar in two groups (50.9 vs. 47.6%, P = 0.78).

CONCLUSIONS

Among infants born at borderline viability, the vast majority of infants did not receive CPR and, if CPR was prolonged for >2 min, mortality was increased. Among survivors of the small DR-CPR group, early neurodevelopmental outcomes were comparable to the No DR-CPR group.

Cost is an important factor influencing active management of extremely preterm infants

AIM

The attitudes of neonatologists towards the active management of extremely premature infants in a developing country like China are uncertain.

METHODS

A web-based survey was sent to neonatologists from 16 provinces representing 59.6% (824.2 million) of the total population of China on October 2015 and December 2017.

RESULTS

A total of 117 and 219 responses were received in 2015 and 2017, respectively. Compared to 2015, respondents in 2017 were more likely to resuscitate infants <25 weeks of gestation (86% vs. 72%; p < 0.05), but few would resuscitate infants ≤23 weeks of gestation in either epoch (10% vs. 6%). In both epochs, parents were responsible for >50% of the costs of intensive care, but in 2017, significantly fewer clinicians would cease intensive care (75% vs. 88%; p < 0.05) and more would request for economic aid (40% vs. 20%; p < 0.05) if parents could not afford to pay. Resource availability (e.g. ventilators) was not an important factor in either initiation or continuation of intensive care (~60% in both epochs).

CONCLUSION

Cost is an important factor in the initiation and continuation of neonatal intensive care in a developing country like China. Such factors need to be taken into consideration when interpreting outcome data from these regions.

Shared decision making during antenatal counselling for anticipated extremely preterm birth

Objectives

To explore health care providers' (HCPs) perceptions of using shared decision making (SDM) and to identify facilitators of and barriers to its use with families facing the anticipated birth of an extremely preterm infant at 22⁺⁰ to 25⁺⁶ weeks gestational age.

Study Design

Qualitative descriptive study design: we conducted interviews with 25 HCPs involved in five cases at a tertiary care centre and completed qualitative content analysis of their responses.

Results

Nine facilitators and 16 barriers were identified. Facilitators included: a correct understanding of this process and how to apply it, a belief that parents should be the decision makers in these situations, and a positive outlook toward using SDM during antenatal counselling. Barriers included: HCPs' misunderstandings of how and when to apply SDM during antenatal counselling, challenges using the process for cases at the lower end of the gestational age range, fear of the negative emotions and stress parents face when making decisions, and HCPs' uncertainty about their ability to properly apply SDM.

Conclusions

This study identified facilitators and barriers to use of SDM during antenatal counselling for anticipated birth of extremely preterm infants that can be used to inform development of tailored strategies to facilitate future implementation of shared decision making in this area.

Implicit Physician Biases in Periviability Counseling

OBJECTIVE

To assess whether neonatologists show implicit racial and/or socioeconomic biases and whether these are predictive of recommendations at extreme periviability.

STUDY DESIGN

A nationwide survey using a clinical vignette of a woman in labor at 23^2/7 weeks of gestation asked physicians how likely they were to recommend intensive vs comfort care. Participants were randomized to 1 of 4 versions of the vignette in which racial and socioeconomic stimuli were varied, followed by 2 implicit association tests (IATs).

RESULTS

IATs revealed implicit preferences favoring white (mean IAT score = 0.48, P < .001) and greater socioeconomic status (mean IAT score = 0.73, P < .001). Multivariable linear regression analysis showed that physicians with implicit bias toward greater socioeconomic status were more likely than those without bias to recommend comfort care when presented with a patient of high socioeconomic status (P = .037). No significant effect was seen for implicit racial bias.

CONCLUSIONS

Building on previous demonstrations of unconscious racial and socioeconomic biases among physicians and their predictive validity, our results suggest that unconscious socioeconomic bias influences recommendations when counseling at the limits of viability. Physicians who display a negative socioeconomic bias are less likely to recommend resuscitation when counseling women of high socioeconomic status. The influence of implicit socioeconomic bias on recommendations at periviability may influence neonatal healthcare disparities and should be explored in future studies.

Ethical implications of the use of decision aids for antenatal counseling at the limits of gestational viability

Shared decision-making is a recent priority in neonatology. However, its implementation is at an early stage. Decision aids are tools designed to assist in shared decision-making. They help patients competently participate in making healthcare decisions. There are limited studies in neonatology on the formal use of decision aids as used in adult medicine. Decision aids are relatively new, even in adult medicine where they were pioneered; therefore, there is a lack of systematic oversight to their development and use. Despite evidence reporting a powerful effect on patients' decisions, decision aids are not subject to quality control, leading to potentially enormous ethical implications. These include: (i) possible introduction of developers' biases; (ii) use of outdated or incorrect information; (iii) misuse to steer a patient towards less expensive treatments; (iv) clinician liability if negative patient outcomes occur, since decision aids are currently not standard of care.

Outcomes of 23- and 24-weeks gestation infants in Wellington, New Zealand: A single centre experience

Optimal perinatal care of infants born less than 24 weeks gestation remains contentious due to uncertainty about the long-term neurodevelopment of resuscitated infants. Our aim was to determine the short-term mortality and major morbidity outcomes from a cohort of inborn infants born at 23 and 24 weeks gestation and to assess if these parameters differed significantly between infants born at 23 vs. 24 weeks gestation. We report survival rates at 2-year follow-up of 22/38 (58%) at 23 weeks gestation and 36/60 (60%) at 24 weeks gestation. Neuroanatomical injury at the time of discharge (IVH ≥ Grade 3 and/or PVL) occurred in in 3/23 (13%) and 1/40 (3%) of surviving 23 and 24 weeks gestation infants respectively. Rates of disability at 2 years corrected postnatal age were not different between infants born at 23 and 24 weeks gestation. We show evidence that with maximal perinatal care in a tertiary setting it is possible to achieve comparable rates of survival free of significant neuroanatomical injury or severe disability at age 2 in infants born at 23-week and 24-weeks gestation.

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.

Antenatal corticosteroids for neonates born before 25 Weeks-A systematic review and meta-analysis

BACKGROUND

Efficacy of antenatal corticosteroids before 25 weeks of gestation is unclear.

OBJECTIVE

To assess and compare neonatal outcomes following ANC exposure at 22, 23 and 24 weeks of gestation by conducting systematic review and meta- analysis.

METHODS

A systematic review of randomised controlled trials (RCT) and non-RCTs reporting on neonatal outcomes after exposure to ANC up to 246 weeks of gestation using the Cochrane systematic review methodology. Databases Pubmed, CINAHL, Embase, Cochrane Central library, and online abstracts of conference proceedings including the Pediatric Academic Society (PAS) were searched in Feb 2017. Primary outcome was in-hospital mortality defined as death before discharge during the first admission. Secondary outcomes included severe intraventricular hemorrhage (IVH> grade III and IV)/or periventricular leukomalacia (PVL), necrotising enterocolitis (NEC >stage II) and chronic lung disease (CLD). Meta-analysis was performed using a random-effects model. The level of evidence (LOE) was summarised using the GRADE guidelines.

MAIN RESULTS

There were no RCTs; 8 high quality non-RCTs were included in the review. Meta-analysis showed reduction in mortality [N = 10109; OR = 0.47(0.39-0.56), p<0.00001; LOE: Moderate] and severe IVH and PVL [N = 5084; OR = 0.71(0.61-0.82), p<0.00001; LOE: Low] after exposure to ANC in neonates born <25 weeks. There was no significant difference in CLD [N = 4649; OR = 1.19(0.85-1.65) p = 0.31; LOE: Low] and NEC [N = 5403; OR = 0.95 (0.76-1.19) p = 0.65; LOE: Low]. Mortality was comparable in neonates born at 22, 23 or 24 weeks.

CONCLUSION

Moderate to low quality evidence indicates that exposure to ANC is associated with reduction in mortality and IVH/or PVL in neonates born before 25 weeks.

Decision-making at the borderline of viability: Who should decide and on what basis?

Parents and medical staff usually agree on the management of preterm labour at borderline viability, when there is a relatively high risk of long-term neurodevelopmental problems in survivors. If delivery is imminent and parents and staff cannot agree on the best management, however, who should decide what will happen when the baby is delivered? Should the baby be resuscitated? Should intensive care be initiated? Three ethicists, one of whom is also a neonatologist, discuss this complex issue.

Prediction of outcomes of extremely low gestational age newborns in Australia and New Zealand

OBJECTIVE

To determine the accuracy of the National Institute of Child Health and Human Development (NICHD) calculator in predicting death and neurodevelopmental impairment in Australian and New Zealand infants.

DESIGN

Population-based cohort study.

SETTING

Australia and New Zealand.

PATIENTS

Preterm infants 22-25 completed weeks gestation.

INTERVENTIONS

Comparison of NICHD calculator predicted rates of death and death or neurodevelopmental impairment, with actual rates recorded in the Australian and New Zealand Neonatal Network cohort.

MAIN OUTCOME MEASURES

Infant death and death or neurodevelopmental impairment rates.

RESULTS

A total of 714 infants were included in the study. Of these infants, 100 (14.0%) were <24 weeks, 389 (54.5%) male, 529 (74.1%) were singletons, 42 (5.9%) had intrauterine growth restriction, 563 (78.9%) received antenatal steroids and 625 (87.5 %) were born in a tertiary hospital. There were 288 deaths (40.3%), 75 infants (10.5%) with neurodevelopment impairment and 363 (50.8%) with death or neurodevelopmental impairment. The area under the curve (AUC) for prediction of death and the composite death or neurodevelopmental impairment by the NICHD calculator in our population was 0.65(95% CI 0.61 to 0.69) and 0.65 (95% CI 0.61 to 0.69), respectively. When stratified and compared with gestational age outcomes, the AUC did not change substantially for the outcomes investigated. The calculator was less accurate with outcome predictions at the extreme categories of predicted outcomes-underestimation of outcomes for those predicted to have the lowest risk (<20%) and overestimation for those in the highest risk category (>80%).

CONCLUSION

In our recent cohort of extremely preterm infants, the NICHD model does not accurately predict outcomes and is marginally better than gestational age based outcomes.

Artificial placenta: Analysis of recent progress

The artificial placenta (AP) has for many decades captured the imagination of scientists and authors with popular fiction including The Matrix and Aldous Huxley's "Brave New World", depicting a human surviving ex-utero in an artificial uterine environment (AUE). For scientists this has fascinated as a way forward for extremely preterm infants (EPIs) born less than 28 weeks of gestation. Early successes with mechanical ventilation (MV) for infants born above 28 weeks of gestation meant that AP research lost momentum. More recently, the gestational age limit for survival now borders on 23 weeks and corresponds to the biological milestone of lung development marked by the early canalicular stage of lung morphogenesis. The so called greyzone of 23-25 weeks represents a steep increase in mortality with decreasing gestational age and current options in neonatal care are on the fringes of efficacy for this population. A shift in thinking recognizes the vitality of EPIs as a fetus rather than a 37-40 week neonate and this has reinvigorated the concept of the AP. This review will discuss the scale of extreme preterm birth with special reference to previable infants born in the greyzone. Recent AP studies using sheep models are compared, technical obstacles discussed and future research themes identified.

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.

Shared decision making for infants born at the threshold of viability: a prognosis-based guideline

OBJECTIVE

Making prenatal decisions regarding resuscitation of extremely premature infants, based on gestational age alone is inadequate. We developed a prognosis-based guideline.

STUDY DESIGN

We followed a five step approach and used the AGREE II framework: (1) systematic review and critical appraisal of published guidelines; (2) identification of key medical factors for decision making; (3) systematic reviews; (4) creation of a multi-disciplinary working group and (5) external consultation and appraisal.

RESULT

No published guideline met high-quality appraisal criteria. Survival, neurodevelopmental disability, quality of life of child and parents, and maternal mortality and risk of long-term morbidity were identified as key for quality decision-making. Eighteen stakeholders (including parents) advocated for the incorporation of parents' values and preferences in the process.

CONCLUSION

A novel framework, based on prognosis, was generated to guide when early intensive and palliative care may both be offered to expectant parents. Pre-implementation assessment is underway to identify barriers and facilitators to putting in practice.

Why birthplace still matters for infants born before 32 weeks: Infant mortality associated with birth at 22-31 weeks' gestation in non-tertiary hospitals in Victoria over two decades

BACKGROUND

Very preterm infants born in non-tertiary hospitals ('outborn') are known to have higher mortality rates compared with infants 'inborn' in tertiary centres.

AIM

The aim of this study was to report changes over time in the incidence of outborn livebirths, 22-31 weeks and infant mortality rates for outborn compared with inborn births.

METHODS

We conducted a population-based cohort study of consecutive livebirths, 22-31 weeks' gestation in Victoria from 1990 to 2009. The relationship between birthplace, gestational age, birthweight, sex and infant mortality were analysed by logistic regression.

RESULTS

There were 13,760 livebirths, 22-31 weeks: 14% were outborn. The proportion of outborn livebirths fell from 19% in 1991 to a nadir of 9% in 1997, but climbed to 17% by 2009. At all times, outborns had higher mortality rates compared with inborns. The overall infant mortality rate was 250.6 per 1000 outborn compared with 113.3 per 1000 inborn livebirths (adjusted odds ratio (aOR) 2.76 (95% CI 2.32, 3.27, P < 0.001). There were no differences between outborn and inborn mortality risks for 22-week livebirths (OR 7.04, 95% CI 0.87, 56.8, P = 0.067), but there were at 23-27 weeks (aOR 3.16, 95% CI 2.52, 3.96, P < 0.001) and at 28-31 weeks (aOR 1.66, 95% CI 1.19, 2.31, P = 0.003). Over time, mortality rates fell for inborn 23-27 week infants. Mortality rates fell for outborn 23-27 week infants in 1990-2005, but rose in 2006-2009.

CONCLUSIONS

Outborn livebirths at 22-31 weeks' gestation occur too frequently and are associated with a significantly increased risk of mortality. Strategies to reduce outborn livebirths are required.

Factors influencing the care provided for periviable babies in Australia: a narrative review

Survival at extreme prematurity is becoming increasingly common. Neurodisability is an increasing risk with decreasing gestation. This review outlines the risks of extreme prematurity and the attitudes of health care providers and families in Australia of periviable babies. High quality data is difficult to find due to differing definitions and methods of assessment of disability. Meta-analyses of outcomes of prematurity published from 2008 to 2013, including babies born from 1990 onwards, suggest a severe disability rate of around 20 % at 22 to 26 weeks completed gestation, with moderate disability decreasing with increasing gestation. Studies show that Australian health care providers underestimate the survival and positive outcomes of these babies. The majority of Australian health care providers state that parental preference would determine the decision to offer care to babies at 23 weeks gestation, however, all had a threshold above which parental preference would be ignored in favour of resuscitation .This ranged from 22 to 27 completed weeks gestation. The few studies examining Australian parental involvement in resuscitation decisions, showed that the majority of parents felt that health professionals alone had made the decision to resuscitate their extremely preterm babies and the parents themselves did not wish to be the primary decision makers in withholding care. The babies progressed better than parents had expected following antenatal counselling. The attitudes of health care providers, experiences and opinions of parents seem to be at odds with the current move to increase parental decision making at the most extremes of gestation. Current Australian guidelines suggest parental decision making below 25 weeks gestation, and primarily clinician decision making over this gestation. The increased risks of prematurity and adverse outcomes for the North Queensland population is also explored. This population has a high proportion of Aboriginal and Torres Strait Islanders who have increased risks which are primarily linked to poor socioeconomic factors and are highest for the most remote residents. Attitudes towards delivery of care to these highest risk babies from health professionals and in the populations themselves have not been studied.

The influence of mode of birth on neonatal survival and maternal outcomes at extreme prematurity: A retrospective cohort study

BACKGROUND

There is a paucity of published clinical data to guide obstetric decision-making regarding mode of birth at extreme prematurity.

AIMS

To evaluate whether neonatal survival or maternal outcomes were affected by the decision to perform a caesarean section (CS) between 23 + 0 and 26 + 6 weeks' gestation.

MATERIALS AND METHODS

A single-centre retrospective cohort study of all liveborn infants born with a plan for active resuscitation at 23-26 weeks' gestation was performed. Descriptive and multivariate logistic regression analyses compared outcomes after vaginal birth and CS. Subgroup analyses of nonfootling breech presentations, multiple pregnancies and singleton pregnancies in spontaneous preterm labour were performed.

RESULTS

Outcomes for 625 neonates delivered by 540 mothers were analysed. A total of 300 (48%) neonates were born vaginally and 325 (52%) by CS. Mode of birth was not associated independently with survival for any multivariate analysis; gestational age at birth was an independent predictor across all analyses. Adverse maternal outcomes were documented in 112 (21%) pregnancies; the rate of severe maternal complications was low. Maternal morbidity was not affected by mode of birth.

CONCLUSIONS

Mode of birth did not affect neonatal survival or the rate of maternal morbidity for deliveries at 23-26 completed weeks' gestation.

Attitudes of Australian neonatologists to resuscitation of extremely preterm infants

AIM

We aimed to investigate how Australian neonatologists made decisions when incompetent patients of different ages needed resuscitation.

METHODS

A survey including vignettes of eight incompetent patients requiring resuscitation was sent to 140 neonatologists. Patients ranged from a very preterm infant to 80 years old. While some had existing impairments, all faced risk of death or neurological sequelae. Respondents indicated whether they would resuscitate, whether they believed resuscitation was in the patients' best interests, whether they would want intervention for a family member and whether they would comply with families' wishes to withhold resuscitation. They were also asked how they would rank the eight patients in a triage situation.

RESULTS

Seventy-eight per cent of specialists completed the survey. The majority of respondents gave priority to the resuscitation of children over adults. Less than 40% would agree to withhold resuscitation at families' request for all children except for the preterm infant, where 96% would comply with families' wishes to withhold intensive care despite 77% believing resuscitation to be in the infant's best interest.

CONCLUSION

This study found inconsistencies between physicians' perceptions of the patient's best interest regarding resuscitation and their willingness to comply with families' wishes to withhold resuscitation and give comfort care. Accepting a family's refusal of resuscitation was more marked for the premature infant, even among respondents who thought that resuscitation was in the patient's best interest. These findings are consistent with other international studies.

Deficiencies and Missed Opportunities to Formulate Clinical Guidelines in Australia for Withholding or Withdrawing Life-Sustaining Treatment in Severely Disabled and Impaired Infants

This paper examines the few, but important legal and coronial cases concerning withdrawing or withholding life-sustaining treatment from severely disabled or critically impaired infants in Australia. Although sparse in number, the judgements should influence common clinical practices based on assessment of "best interests" but these have not yet been adopted. In particular, although courts have discounted assessment of "quality of life" as a legitimate component of determination of "best interests," this remains a prominent component of clinical guidelines. In addition, this paper highlights the lack of uniform clinical guidelines available to medical professionals and parents in Australia when making end-of-life decisions for severely ill infants. Thus, it is argued here that there is a need for an overarching prescriptive uniform framework or set of guidelines in end-of-life decision-making for impaired infants. This would encourage greater transparency, consistency, and some degree of objectivity in an area that often appears subjective.

Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review

BACKGROUND AND OBJECTIVES

Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22-25 weeks' gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants.

METHODS

We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme's Human Development Index as "very highly developed." The primary outcome was rating of recommendations from "comfort care" to "active care." Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival.

RESULTS

Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks' gestation, and 20 (65%) supported active care at 25 weeks' gestation. Between 23 and 24 weeks' gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7).

CONCLUSIONS

Although there is a wide variation in recommendations (especially between 23 and 24 weeks' GA), there is general agreement for comfort care at 22 weeks' GA and active care at 25 weeks' GA.

Preterm infant outcomes in New South Wales and the Australian Capital Territory

AIM

This study aimed to provide updated information on gestation-specific hospital outcomes of extreme to very preterm infants admitted to neonatal intensive care units.

METHODS

A population-based retrospective cohort study of infants born between 23(+0) and 31(+6) weeks gestation and admitted to a network of neonatal intensive care units between 2007 and 2011 in a well-defined geographic area of New South Wales and the Australian Capital Territory. Main outcome measures were survival and major morbidities prior to hospital discharge.

RESULTS

Of 4454 infants included, hospital survival rates based on gestational age alone were 27%, 59%, 76%, 85%, 91% and over 95% at 23, 24, 25, 26, 27 and 28-31 weeks, respectively. Survival rates for each week up to 29 weeks gestation differed by at least 5% when perinatal risk factors including birthweight percentile, exposure to antenatal steroids, birth outside a tertiary hospital and gender were included in the survival estimation. All the major outcome figures were then simplified and displayed in a simple, easy-to-understand preterm outcome table for counselling purposes.

CONCLUSION

We report the latest hospital outcomes of extreme to very preterm infants in New South Wales and the Australian Capital Territory. Survival rates based on gestational age alone may not provide the true estimate as the survival for these infants can vary based on the presence or absence of other relevant perinatal factors.

Borderline viability: controversies in caring for the extremely premature infant

Controversy surrounding the decision to resuscitate at the limits or borderline of viability has been at the center of neonatal ethical debate for decades. This debate has led to numerous reports from individual institutions, councils, and advisory committees that all have remarkable consistency in the development of gestational age-based guidelines. This article reviews legal or regulatory concerns that may contradict ethical discussion and guidelines, discriminatory and scientific basis concerns with consensus guidelines, and personal controversy about how to determine best interest. Guidelines are a reasonable place to start in helping determine parental authority and autonomy. The article also addresses controversies raised in counseling and costs.

Review of respiratory management of extremely premature neonates during transport

INTRODUCTION

The objective was to evaluate the respiratory management of neonates of 23 to 26 weeks' gestation transported after birth outside a tertiary center. Another objective was to collect data regarding survival, intraventricular hemorrhage (IVH), and chronic lung disease.

METHODS

This was a retrospective study of transports from a statewide dedicated neonatal and pediatric transport service over a 3-year period. Data were collected from the local databases. Neonates with and without transcutaneous carbon dioxide (TcCO2) monitoring were compared. Outcomes were compared with the inborn group from the same period.

RESULTS

A total of 43 mechanically ventilated neonates were included. Significant hypocarbia and/or hypercarbia were seen in 49%. Hyperoxia was noted in 46.5%. Despite the moderate correlation between PCO2 and TcCO2 readings, no clinical benefit was seen with TcCO2 monitoring. Survival was 65.1%. Rates of IVH were 60% for any IVH and 27.5% for severe IVH. IVH was more common in the study cohort.

CONCLUSIONS

Neonates born at 23 to 26 weeks' gestation outside tertiary centers have high rates of mortality and morbidity. The avoidance of hypocarbia, hypercarbia, and hyperoxia is challenging in the transport environment. Transcutaneous monitoring is an imperfect tool for following PCO2 levels.

Moral distress in the resuscitation of extremely premature infants

OBJECTIVE

To increase our understanding of moral distress experienced by neonatal registered nurses when directly or indirectly involved in the decision-making process of resuscitating infants who are born extremely premature.

DESIGN

A secondary qualitative analysis was conducted on a portion of the data collected from an earlier study which explored the ethical decision-making process among health professionals and parents concerning resuscitation of extremely premature infants.

SETTING

A regional, tertiary academic referral hospital in Ontario offering a perinatal program.

PARTICIPANTS

A total of 15 registered nurses were directly or indirectly involved in the resuscitation of extremely premature infants.

METHODS

Interview transcripts of nurses from the original study were purposefully selected from the original 42 transcripts of health professionals. Inductive content analysis was conducted to identify themes describing factors and situations contributing to moral distress experienced by nurses regarding resuscitation of extremely premature infants.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the research ethics review board for both the initial study and this secondary data analysis.

RESULTS

Five themes, uncertainty, questioning of informed consent, differing perspectives, perceptions of harm and suffering, and being with the family, contribute to the moral distress felt by nurses when exposed to neonatal resuscitation of extremely premature infants. An interesting finding was the nurses' perceived lack of power and influence in the neonatal resuscitation decision-making process.

CONCLUSION

Moral distress continues to be a significant issue for nursing practice, particularly among neonatal nurses. Strategies are needed to help mediate the moral distress experienced by nurses, such as debriefing sessions, effective communication, role clarification, and interprofessional education and collaboration.

Long-term outcome at age 7-10 years after extreme prematurity - a prospective, two centre cohort study of children born before 25 completed weeks of gestation (1999-2003)

OBJECTIVE

We aimed to determine the long-term neurodevelopmental outcome in extremely preterm infants of 22-23 completed weeks' gestation as compared to infants of 24 weeks with immediate postnatal life support born in two German tertiary perinatal centres between 1999 and 2003.

METHODS

Children were assessed for cognitive and neurological outcomes at the age of 7-10 years. The test battery included a neurological examination, the Wechsler Intelligence Scale for children (WISC-IV) and the Frostigs Developmental Test of Visual Perception (DTVP-2). Gross motor function was classified according to the GMFCS and functional activity was assessed with the Lincoln Oseretzky Motor Development Scale (LOS KF 18).

RESULTS

Outcome data were available for 79/105 children. 75.9% of the entire study cohort showed no or mild impairment. There was no difference seen between the two gestational age groups. Risk factors for moderate or severe impairment were an intracerebral haemorrhage >II° and/or periventricular leukomalacia or a retinopathy of prematurity >II°. Neither the gestational age (GA) nor the birth weight was associated with long-term outcome.

CONCLUSIONS

Gestational age was not a predictor for long-term impairment of preterm infants born <25 completed weeks' GA. Other prognostic factors should be taken into account for counselling in the grey zone of viability.

Counselling and management for anticipated extremely preterm birth

Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.

Have the boundaries of the 'grey zone' of perinatal resuscitation changed for extremely preterm infants over 20 years?

AIM

To determine the boundaries of the grey zone of discretionary resuscitation over the past 20 years.

BACKGROUND

As the likelihood of survival improves over time, the BW- and GA-specific boundaries of discretionary nonresuscitation should fall.

HYPOTHESIS

Between 1988 and 2008 reductions in BW- and GA-specific mortality would drive a parallel reduction in BW and GA boundaries of discretionary resuscitation.

METHODS

We determined the likelihood of resuscitation and survival to NICU discharge for all infants born <700 g or <26 gestational weeks from 1988 to 2008. In addition, for 1988, 1993, 1998, 2003 and 2008, we determined the BW and GA for the 10 smallest infants who were resuscitated, and the 10 largest infants who were not resuscitated. We excluded any infant born with congenital anomaly.

RESULTS

Mortality fell from 80% in 1988 to 28% in 2008, and as expected, the percentage who were resuscitated rose from 63% in 1988-93 to 95% in 2004-2008. However, unexpectedly, over the 20-year study period, the smallest infants who were resuscitated despite extreme immaturity did not change (450-550 g and 23-24 weeks) and the largest infants not resuscitated did not change (600-700 g and 23-24 weeks.

CONCLUSION

Neither the BW nor GA boundaries of the grey zone of discretionary resuscitation have fallen over the past 20 years. Factors guiding resuscitation at the border of viability are complex and incompletely understood.

The nonimpact of gestational age on neurodevelopmental outcome for ventilated survivors born at 23-28 weeks of gestation

AIM

It has long been known that survival of preterm infants strongly depends upon birth weight and gestational age. This study addresses a different question - whether the gestational maturity improves neurodevelopmental outcomes for ventilated infants born at 23-28 weeks who survive to neonatal intensive care unit (NICU) discharge.

METHODS

We performed a prospective cohort study of 199 ventilated infants born between 23 and 28 weeks of gestation. Neurodevelopmental impairment was determined using the Bayley Scales of Infant Development-II at 24 months.

RESULTS

As expected, when considered as a ratio of all births, both survival and survival without neurodevelopmental impairment were strongly dependent on gestational age. However, the percentage of surviving infants who displayed neurodevelopmental impairment did not vary with gestational age for any level of neurodevelopmental impairment (MDI or PDI <50, <60, <70). Moreover, as a higher percentage of ventilated infants survived to NICU discharge at higher gestational ages, but the percentage of neurodevelopmental impairment in NICU survivors was unaffected by gestational age, the percentage of all ventilated births who survived with neurodevelopmental impairment rose - not fell - with increasing gestation age.

CONCLUSION

For physicians, parents and policy-makers whose primary concern is the presence of neurodevelopmental impairment in infants who survive the NICU, reliance on gestational age appears to be misplaced.

Mortality and adverse neurologic outcomes are greater in preterm male infants

OBJECTIVES

To determine whether male gender has an effect on survival, early neonatal morbidity, and long-term outcome in neonates born extremely prematurely.

METHODS

Retrospective review of the New South Wales and Australian Capital Territory Neonatal Intensive Care Unit Data Collection of all infants admitted to New South Wales and Australian Capital Territory neonatal intensive care units between January 1998 and December 2004. The primary outcome was hospital mortality and functional impairment at 2 to 3 years follow-up.

RESULTS

Included in the study were 2549 neonates; 54.7% were male. Risks of grade III/IV intraventricular hemorrhage, sepsis, and major surgery were found to be increased in male neonates. Hospital mortality (odds ratio 1.285, 95% confidence interval 1.035-1.595) and moderate to severe functional disability at 2 to 3 years of age (odds ratio 1.877, 95% confidence interval 1.398-2.521) were more likely in male infants. Gender differences for mortality and long-term neurologic outcome loses significance at 27 weeks gestation.

CONCLUSIONS

In the modern era of neonatal management, male infants still have higher mortality and poorer long-term neurologic outcome. Gender differences for mortality and long-term neurologic outcome appear to lose significance at 27 weeks gestation.

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.