Edge Of Viability Research Articles

Evidence Supporting Antenatal Steroids at the Edge of Viability

Evidence Supporting Antenatal Steroids at the Edge of Viability

Disparities in tracheostomies and gastrostomy tubes in infants at the edge of viability.

To assess trends of clinical practice of tracheostomy and gastrostomy tube (G-tube) placement over a 25-year period and to assess the association of both procedures with outcomes in extremely low birth weight (ELBW) infants (<1000 g). We reviewed and analyzed data obtained from the National Inpatient Sample dataset from 1993 to 2018. ELBW infants who received a tracheostomy and or G-tubewere included. Regression analysis was performed to assess the association of tracheostomy and/or G-tube placement with mortality after controlling for confounding variables. A total of 620,061 ELBW infants were identified in the weighted sample. Of them, 221,339 were included. G-tube was placed on 4867 (2.2%) infants, tracheostomy was placed on 1788 (0.8%) infants, and both procedures were placed on 1026 (0.46%). Mortality was highest (26.9%) in infants who received tracheostomy only and lowest (5.5%) in those who had G-tube only and (17.8%) in those who had both procedures with adjusted odds ratios of 7.1 (6.3-7.9), 0.7 (0.6-0.8), and 3.7 (3.1-4.4), respectively. The length of stay (LOS) was highest with the combined procedure (219 ± 171), and lowest in the nonintervention group (88 ± 57). The trend of G-tube placement has increased over the years (p < 0.01) but tracheostomy placement has decreased over time. Tracheostomy is associated with increased mortality in ELBW infants and increased LOS in survivors whereas the placement of both tracheostomy and G-tube is independently associated with decreased mortality. Prospective studies are needed to assess the relationship between clinical presentation, the timing of the procedure, and outcomes.

Association of antenatal steroid exposure with survival among infants receiving postnatal life support at 22 to 25 weeks' gestation.

Commentary on: Ehret, DEY, Edwards, EM, Greenberg, LT, Bernstein, IM, Buzas, JS, Soll, RF, Horbar, JD. Association of Antenatal Steroid Exposure with Survival Among Infants Receiving Postnatal Life Support at 22 to 25 Weeks’ Gestation. JAMA Netw Open. 2018; 1( 6): e183235. https://doi.org/10.1001/jamanetworkopen.2018.3235. The definition for limits of viability has been steadily declining for the past decade with increased survival of infants born at lower gestational ages 1. ACOG and SMFM criteria for periviable birth include infants delivered between 20 0/7 and 25 6/7 weeks of gestation. There are marked differences in reported survival from different centres and countries based on the perinatal care received, including counselling, antenatal steroids, magnesium sulphate use, approach to mode of delivery and resuscitation practices offered at delivery to lower gestational ages 2-4. Current ACOG guidelines recommend clinicians should evaluate aggressiveness of treatment provided to a 22-week gestation infant per family wishes but does not recommend antenatal steroid use 5. There is an urgent need for an accurate, objective and collaborative look at the short- and long-term outcomes of infants born at the edge of viability. This article is a multicenter, observational cohort study evaluating the survival, and survival without major morbidities, in periviable infants that received postnatal life support with or without benefits of ANS exposure. Analysis was done for overall cohort as well as by gestational ages. The study consistently showed that infants who received ANS prior to delivery at all gestational ages had higher survival and lower incidence of major morbidities among survivors. Although the difference in survival was most notable at the lowest gestational ages, the rate of survival without major morbidity remained extremely low. The study also reports that the percentage of infants offered postnatal life support was low for infants born at 22 weeks of gestation, possibly due to differential approaches among providers and lack of consensus. A major strength of this study is its size, possible only with a major national database such as VON, lending strong credibility to the results. A major limitation of the study is its retrospective design, which prevents capture of certain variables. The authors also note that the decision-making burden which lies on the families during the perinatal period, as well as their possibly limited understanding of long-term outcomes, may lead to disparate care provided to some of these infants. Another potential bias could be that these data are collected from NICUs equipped to handle periviable births, which could lead to an overestimation of survival in infants that were outborn. Additionally, there are possible unmeasured confounders related to practices at larger centres with targeted treatment strategies for these particular GA's leading to improved survival. This study does not look at long-term neurodevelopmental outcomes or the economic burdens suffered by these families and by society, which is of paramount importance in such infants with very high risks of short- and long-term consequences. The study concludes that infants that receive ANS with postnatal life support have higher survival and a decrease in major morbidities. However, survival without major morbidity remains low. This study will add vital information to the standardization of the care of infants at the edge of viability. Since clearly a randomized trial is unethical, large prospective cohort studies are needed to further guide practice. https://ebneo.org/2019/02/antenatal-steroid-exposure-survival/ None. None.

Association of Antenatal Steroid Exposure With Survival Among Infants Receiving Postnatal Life Support at 22 to 25 Weeks’ Gestation

Although evidence of antenatal steroids (ANS) efficacy at 22 to 25 weeks' gestation is limited, increasingly these infants are treated with postnatal life support. To estimate the proportion of infants receiving postnatal life support at 22 to 25 weeks' gestation who had exposure to ANS, and to examine if the provision of ANS was associated with a higher rate of survival to hospital discharge and survival without major morbidities. This multicenter observational cohort study consisted of 33 472 eligible infants liveborn at 431 US Vermont Oxford Network member hospitals between January 1, 2012, and December 31, 2016. We excluded infants with recognized syndromes or major congenital anomalies. Of the eligible infants, 29 932 received postnatal life support and were included in the analyses. Data analysis was conducted from July 2017 to July 2018. Antenatal steroids administered to the mother at any time prior to delivery. Survival to hospital discharge, major morbidities among survivors, and the composite of survival to discharge without major morbidities. Among 29 932 infants who received postnatal life support, 51.9% were male, with a mean (SD) gestational age of 24.12 (0.86) weeks and mean (SD) birth weight of 668 (140) g; 26 090 (87.2%) had ANS exposure and 3842 (12.8%) had no ANS exposure. Survival to hospital discharge was higher for infants with ANS exposure (18 717 of 25 892 [72.3%]) compared with infants without ANS exposure (1981 of 3820 [51.9%]); the adjusted risk ratio for 22 weeks was 2.11 (95% CI, 1.68-2.65), for 23 weeks was 1.54 (95% CI, 1.40-1.70), for 24 weeks was 1.18 (95% CI, 1.12-1.25), and for 25 weeks was 1.11 (95% CI, 1.07-1.14). Survival to hospital discharge without major morbidities was higher for infants with ANS exposure (3777 of 25 833 [14.6%]) compared with infants without ANS exposure (347 of 3806 [9.1%]); the adjusted risk ratio for 22 through 25 weeks was 1.67 (95% CI, 1.49-1.87). Concordant receipt of ANS and postnatal life support was associated with significantly higher survival and survival without major morbidities at 22 through 25 weeks' gestation compared with life support alone. Although statistically higher with ANS, survival without major morbidities remains low at 22 and 23 weeks. There is an opportunity to reevaluate national obstetric guidelines, allowing for shared decision making at the edge of viability with concordant obstetrical and neonatal treatment plans.

Parent-Physician Partnership at the Edge of Viability.

In this article, a father and mother thoughtfully reflect on their experiences surrounding the imminent birth of their son Gabriel at the edge of viability. They suggest that physicians should try to understand the values and motivations that will influence parental decisions before reviewing with them the probability of survival and the most likely range of functional outcomes. A neonatologist not clinically involved in Gabriel’s care recounts new lessons learned and previous lessons validated during this collaboration that can help neonatologists establish stronger partnerships with families. When my wife, Miri, developed preterm labor at 21 weeks and 4 days of gestation, we were suddenly thrust into a very unfamiliar world. My wife’s physicians offered us the unthinkable choice of an elective abortion, advising that it was likely that our son would be born before he had a chance to survive or that he would be extremely disabled if he did survive. While in the antepartum unit, every day was a crisis. The doctors did not try to understand the values and motivations underlying our wish to give Gabriel a chance for life. Although we heard statistics that augured a poor chance for a good outcome for Gabriel, we had a difficult time connecting … Address correspondence to Mark L. Hudak, MD, Department of Pediatrics, University of Florida College of Medicine–Jacksonville, LRC 3rd floor, 653-1 W 8th St, Jacksonville, FL 32209. E-mail: mark.hudak{at}jax.ufl.edu

Preterm Birth: At the Edge of Viability. University of Iowa Obstetrics and Gynecology Postgraduate Conference. November 4, 2016

Preterm Birth: At the Edge of Viability. University of Iowa Obstetrics and Gynecology Postgraduate Conference. November 4, 2016

The Newborn at the edge of viability

The Newborn at the edge of viability

Birth at 22 gestational weeks: case report of cognitive resilience

Objective: Children delivered at the edge of viability are at greatest risk of medical and neuropsychological disability, their adverse outcomes overshadowing extremely preterm survivors with more optimal outcomes. We aimed to describe an exceptionally early-born extremely preterm (EEEP) preschooler whose neurobiological, familial, and socioeconomic factors likely influenced her unexpected cognitive resilience. Method: Baby G was a 3-years 10-months-old, English-speaking, Caucasian, singleton girl born weighing 435 g at 225/7 weeks’ gestation to well-educated married parents. Neonatal complications of extremely premature birth included sepsis, severe respiratory distress syndrome, patent ductus arteriosus requiring ligation, necrotizing enterocolitis not requiring surgical intervention, and retinopathy of prematurity. Intellectual and neuropsychological testing was administered. Results: Baby G performed age-appropriately in nearly all domains and did not exhibit intellectual deficits. Her general conceptual ability was above average for both her chronological and adjusted ages. She had below average performance on tests of motor function, working memory, and delayed recall of spatial locations. Standardized parental behavioral questionnaires indicated no concern in emotional or attentional functioning except in relation to mental shifting capacity and signs of anxiety. Conclusion: Report of persistent adverse neurodevelopmental/neuropsychological disabilities following EEEP birth is a counterpoint to the more optimal outcomes in some vulnerable EEEP survivors. This case emphasizes that decisions about aggressive resuscitation and prognostication for infants born EEEP may be enhanced by consideration of individual variability, and of pertinent medical, socioeconomic, and sociodemographic variables that may be more predictive of neuropsychological outcomes than birth weight and gestational age.

Care at edge of viability: Legal and ethical issues

Care at edge of viability: Legal and ethical issues

Outcomes of neonates with birth weight⩽500 g: a 20-year experience.

Ethical dilemmas continue regarding resuscitation versus comfort care in extremely preterm infants. Counseling parents and making decisions regarding the care of these neonates should be based on reliable, unbiased and representative data drawn from geographically defined populations. We reviewed survival and morbidity data for our population at the edge of viability. A retrospective review of our perinatal database was carried out to identify all infants born alive and admitted to the neonatal intensive care unit (NICU) with BW⩽500 g between 1989 and 2009. Data from the initial hospital stay and follow-up at 24 months were collected. Out of 22 672 NICU admissions, 273 were eligible: 212 neonates were reviewed after excluding infants with comfort care. BW ranged from 285 to 500 g (mean 448 g) and gestational age range 22 to 28 weeks (median 24 week). Sixty-one (28.8%) survived until discharge. Only 13.8% males survived compared with 39.2% females (P<0.05). Half (49%) were discharged with home oxygen/monitor. Fifty (82%) patients' charts were available to review at the 24-month follow-up. Thirty-three percent of surviving infants had a normal neurodevelopmental assessment at 24 months. Forty-three percent had weight/head circumference<5th percentile at 24 months. About a third of neonates admitted to NICU with ⩽500 g BW survived, with 33% of those surviving, demonstrating age-appropriate development at a 24-month follow-up visit.

Proactive care at the edge of viability: making the gray zone less gray?

One of the great success stories in neonatology is the gains made in survival of the smallest and most immature infants over the past 25 years.1,2 However, concerns persist that increased survival may be complicated by increased neurodevelopmental impairment (NDI) for infants born at the edge of viability.3,4 This balance between potential for survival and that of severe NDI weighs heavily on counseling for parents threatened with the birth of an extremely preterm infant. In this issue of Pediatrics , Serenius and colleagues from the Extremely Preterm Infant Study in Sweden (EXPRESS) team address this concern directly.5 Acknowledging that for some patients the burdens of intensive care (deaths in the NICU but especially long-term morbidity among survivors) may outweigh benefits, they present data to support a proactive approach beginning in utero, aiming to optimize a “trial of life” for infants born at the edge of viability. The EXPRESS investigators recently reported rates of death and NDI at 2.5 years in a cohort of live fetuses at 22 to 26 weeks’ gestation.6 … Address correspondence to Eric C. Eichenwald, MD, Department of Pediatrics, University of Texas Medical School, Houston, 6431 Fannin St, MSB 3.020, Houston, TX 77030. E-mail: Eric.c.eichenwald{at}uth.tmc.edu

Noworodek skrajnie niedojrzały między życiem a śmiercią. Granice medycznej interwencji

Neonatologia to dosyć młoda specjalizacja w medycynie, która w ostatnim dziesięcioleciu poczyniła ogromne postępy, głównie dzięki możliwościom technicznym i leczniczym. Zwiększyły one szanse utrzymania przy życiu coraz bardziej niedojrzałych noworodków, nawet tych ważących 500 g. Szybko jednak przyszedł moment refleksji, gdy pojawiły się pierwsze wyniki badań wskazujących, że jest to grupa dzieci ze zwiększonym ryzykiem nieprawidłowego rozwoju psychoruchowego. Fakty te postawiły przed lekarzami nowe wyzwania i poszukiwania odpowiedzi na wiele nurtujących ich pytań: czy podtrzymywanie życia w imię jego świętości albo dlatego że jest technicznie możliwe jest uzasadnione? Czy raz rozpoczęte leczenie należy zawsze kontynuować? W pracy autorka podejmuje próbę odpowiedzi na te pytania z perspektywy neonatologa z wieloletnim doświadczeniem zawodowym. Omawia sytuacje noworodków znajdujących się na granicy życia i śmierci, wskazując gdzie są granice medycznej interwencji i co je wyznacza. Na koniec przedstawia etapy procesu podejmowania ostatecznej decyzji zwracając uwagę na trudności i podając praktyczne wskazówki postępowania.

Does diagnosis influence end-of-life decisions in the neonatal intensive care unit?

To determine the influence of physiological status and diagnosis at the time of death on end-of-life care. Retrospective descriptive study in a regional referral level IV neonatal intensive care unit (NICU) of infants who died from 1 January 1999 to 31 December 2008. Infants were categorized based on diagnosis (very preterm, congenital anomalies or other) and level of stability. Primary outcome was level of clinical service provided at end of life (care withheld, care withdrawn or full resuscitation). From 1999 to 2008, there were 414 deaths in the NICU. Congenital anomaly was the leading diagnosis at the time of death, representing 45% of all deaths. Comparing mode of death, very preterm newborns were more likely than infants with congenital anomalies to have received cardio-pulmonary resuscitation (CPR) at the time of death (26% vs 13%, P < 0.01) and were significantly more unstable (75% vs 52%, P < 0.01). Infants aged 22 to 24 weeks were mostly unstable and significantly more likely to receive CPR than infants with any other diagnosis. Over the 10-year period, very preterm infants were more likely to be physiologically unstable and to receive CPR at the time of death than infants with any other diagnosis. This finding was especially true for infants at the edge of viability (22 to 24 weeks). These differences in end-of-life care suggest that the quality of life and medical futility may be viewed differently for the least mature infants.

Shades of Gray: Managing Delivery at the Edge of Viability

The management and counseling of women at risk for delivering fetuses of periviable gestational age (defined as 20 0/7 weeks through 25 6/7 weeks) is

Ethical issues related to caring for low birth weight infants

Currently preterm births are the leading causes of newborn deaths and newborn mortality in developed countries. Infants born prematurely remain vulnerable to many acute complications and long-term disabilities. There is a growing concern surrounding the moral and ethical implications of the complex and technological care being provided to extremely low birth weight infants in neonatal intensive care units in the developed nations. The purpose of this study was to describe the ethical and moral issues that neonatal intensive care nurses experience when caring for low birth weight preterm infants and their families. A phenomenological method design was used to describe the lived experiences of nurses with ethical and moral issues encountered in the neonatal intensive care unit. One-on-one, semi-structured interviews using open-ended questions were used to gather data from the participants. The setting for this study was a 97-bed neonatal intensive care. A total of 16 female nurses were interviewed. Approval to conduct the research study was obtained from the institutional review board of the hospital where the study was conducted. Formal signed consent was obtained from each participant. To ensure confidentiality, each participant was asked to choose a confederate name to be used in the interview and the transcriptions. The thematic analysis identified five recurring themes: (a) at the edge of viability, (b) infant pain and discomfort, (c) crucial decisions, (d) communicating with parents, and (e) letting go. Neonatal intensive care unit nurses indicated that they often had challenges to their own sense of morality as they struggled to protect the infant from pain and unnecessary discomfort, provide care to an infant and their family whom they thought was faced with a lifetime of challenges and poor health, accepting decisions made by parents, and feeling as if parents were not adequately informed about outcomes.

Infants Who Survive Birth at the Edge of Viability

Thepast 20 yearshavewitnessed a dramatic improvement in survival after extremely preterm birth. Currently, most infants born between 25 and 28 weeks’ gestation can survive when provided with delivery room resuscitation followed by neonatal intensive care, including positivepressure ventilation, surfactant replacement, and nutritional support.At least forbabiesbornatorafter 25completedweeks’ gestation, theexpected long-termoutcomeisgoodenoughthat mostneonatologists considerdelivery roomresuscitationand neonatal intensive care obligatory, regardless of the parents’ preference.1 For babies bornbefore 25 completedweeks’ gestation, deciding what care to provide is less straightforward. As compared with more mature infants, the survival rate for babies born in the“grayzone” (approximately23-24weeks’gestation)1 is considerably lower and long-term morbidities affecting health anddevelopment aremore frequent and severe. Intensive care and comfort or palliative care may both be acceptable approaches for neonatologists and parents, and neonatologists are encouraged topursuean individualizedapproach reflecting the preferences of the parents.2 To determine which approach is right for their baby, expectant parents need accurate information about the anticipated sequelae of pretermbirth, should their baby survive the initial resuscitationandneonatalhospitalization.Typically, this information is communicated to parents by neonatologists in the context of an antenatal consultation, andmostneonatologists rely on published data to inform these discussions. Most widely available information describes the probability of survival to age 18 to 22 months, as well as the expected level of cognitive ability and degree of neurosensory impairment in survivors at that age. Although reasonably easy to find in the published literature, extremely preterm infant outcome measures at age 18 to 22 months are relatively poor predictors of a child’s abilities at school age and beyond. Many children scoring less than 70 on the Bayley Scales of Infant Development Mental Development Index at age 18 to 22 months perform in the normal range on cognitive testing at age 8 years.3 Measures in infancy, then, may substantially overestimate the expected degree of long-term impairment. Reports of adult outcomes are also relevant but are particularly limited with respect to babies born at the edge of viability because they reflect outdated neonatal care practices of the presurfactant era, during which only a tiny proportion of “gray zone” babies survived. Compared with outcomes in infancy, school-age outcomesbetter reflect deficits that are likely to be sustained and have an advantage over adult outcomes of reflecting contemporarymedical practices. Fine-grained information about the expectedoutcome for infants bornafter each completedweek of gestation is critical for informing decisions, but such data fromanygivenneonatal intensivecareunit (NICU)orevennetwork of NICUs are limited because extremely pretermbirth is rare, the probability of survival is relatively low, and following up survivors to school age is logistically challenging and costly. In this issueof JAMAPediatrics,Moore andcolleagues4 attempt to fill this gap with their meta-analysis of neurodevelopmental outcomes at 4 to 8 years of age for children born at 22 to 25 weeks’ gestation. Moore et al performed a comprehensive systematic review and included in themeta-analysis studies with school-age outcomes stratified by gestational week, or they obtained primary data from the authors and stratified it themselves.Theprimaryoutcomesweresevereand moderate to severe neurodevelopmental impairment, defined on the basis of IQ, motor, or sensory deficits. Moore et al included only studies with more than 75% follow-up. The final meta-analysis included 8 studies from the United Kingdom, Finland, Germany, Czech Republic, Norway, and New Zealand. For the 441 infants born at 25 weeks’ gestation, Moore et al found that 24% had moderate to severe impairment at age 4 to 8 years. That is, 76% were either mildly impaired or unimpaired, an estimate that is more favorable than previously published 18to 22-month outcomes. For example, based on data from the Eunice Kennedy Shriver National Institute of ChildHealthNeonatal ResearchNetwork,5 about 30% to 40% of surviving infants born at 25weeks’ gestationhaveneurodevelopmental impairment at age 18 to 22 months. The schoolage data presented byMoore and colleagues seem to support the general consensus among US neonatologists that for babies born at or after 25 weeks’ gestation, neonatal resuscitation is not optional. Outcomes for infants born before 25 weeks’ gestation— the “gray zone”—are of particular interest with respect to decision making about use of life-sustaining therapies. For the infants born at 23weeks’ (n = 75) and 24weeks’ (n = 210) gestation,meta-analysis estimates of school-agemoderate to severe impairment rateswere40%and28%, respectively.While manyneonatologists consider the resuscitationof infantsborn at 22 weeks’ gestation to be futile, Moore and colleagues report that 43% of the 12 infants included in the meta-analysis were impairedat school age, that is,more thanhalfwereeither mildly impaired or unimpaired. How should clinicians and parents use this information? First, the outcomes reported by Moore et al must be placed in the context of everyday decision making in the NICU. By definition, school-age outcomes represent only the survivors, a small proportion of all births at 22 to 24 weeks’ gestation. Some infants are too immature to survive, regardless of technological support in the NICU. However, for many, survival is contingent on decisions to initiate resuscitation and Related article page 967 Editorial Opinion

Creating an ethical environment for parents and health providers dealing with the treatment dilemmas of neonates at the edge of viability

Parents who deliver an infant on the edge of viability are often poorly prepared for the many ethical decisions that will confront them. Physicians will give mothers who are in early labor a quick synopsis of what they can do to treat this very preterm infant, but do not always have the time to explain the ethical ramifications of the decisions that will be made. Furthermore, these parents are often in physical and emotional distress, which is not conducive to an important discussion regarding the quality of life of their infant. These periviable infants, born between 22 and 24 weeks, have a great variation in probability of survival with and without morbidity. Parents need to be given statistics and medical probabilities so they can make informed, ethical decisions regarding their child's future. In the middle of an emergency delivery is not the time to have these important ethical discussions. Due to these problems, parents should be given information earlier in the pregnancy in order to be more informed in the event that they have a baby born at the limits of viability.

Management of an Extremely Premature Infant in the Out-of-Hospital Environment

The rate of premature infant mortality has decreased over the last several decades, with an accompanying decrease in the gestational age of premature infants who survive to hospital discharge. Emergency medical services (EMS) providers are sometimes called to provide prehospital care for infants born at the edge of viability. Such extremely premature infants (EPIs) present medical and ethical challenges. In this case report, we describe an infant born at 24 weeks into a toilet by a mother who thought she had miscarried. The EMS providers evaluated the infant as nonviable and placed him in a plastic bag for transport to a local emergency department (ED). The ED staff found the infant to have a bradycardic rhythm, initiated resuscitation, and admitted him to the neonatal intensive care unit. The infant died seven days later. We review the literature for recommendations in resuscitation of EPIs and discuss the ethics regarding their management in the prehospital setting.

At the Edge of Viability: Moral and Ethical Guideline Proposals

The paper proposes moral and ethical guidelines for medical treatment at the edge of viability. The proposed principles are defended on the grounds of a general conceptual framework presented by elucidating the notions of viability, the edge of viability, person, sanctity of human life, dignity, and the slope of dignity protection, as well as the distinction between ethics and morality.

Dilemmas in the Treatment of Premature Infants at the Borderline of Viability

As more reports emerge of improved mortality and morbidity rates in infants born at the edge of viability, there may be need to reassess protocols and recommendations that encourage only comfort care for infants who are born at less than 24 weeks’ gestation. Analysis of those studies that report extremely poor survival of these infants reveals that, all too often, the results are measures of a self-fulfilling prophesy that reflects a predetermined non-aggressive global policy of no resuscitation and minimal investment in intensive care. Furthermore, little distinction is made between high- and low-risk infants of the same gestational age despite repeated studies that indicate that one can identify subpopulations that have as much as a 20–50% increased chance of surviving with little if any long-term neurodevelopmental impairment. Thus, the need to reassess current policies is discussed.