Edge Of Viability Research Articles

Report of an International Conference on the Medical and Ethical Management of the Neonate at the Edge of Viability: A Review of Approaches from Five Countries

Current United States guidelines for neonatal resuscitation note that there is no mandate to resuscitate infants in all situations. For example, the fetus that at the time of delivery is determined to be so premature as to be non-viable need not be aggressively resuscitated. The hypothetical case of an extremely premature infant was presented to neonatologists from the United States and four other European countries at a September 2006 international meeting sponsored by the World Health Organization Collaborating Center in Reproductive Health of Atlanta (currently, the Global Collaborating Center in Reproductive Health). Responses to the case varied by country, due to differences in legal, ethical and related practice parameters, rather than differences in medical technology, as similar medical technology was available within each country. Variations in approach seemed to stem from physicians' perceptions of their ability to remove the neonate from life support if this appeared non-beneficial. There appears to be a desire for greater convergence in practice options and more open discussion regarding the practical problems underlying the variability. Specifically, the conference attendees identified four areas that need to be addressed: (1) lack of international consensus guidelines in viability and therapeutic options, (2) lack of bodies capable of generating these guidelines, (3) variation in laws between countries, and (4) the frequent failure of physicians and families to confront death at the beginning of life.

A Small Bioethical World?

This essay discusses four challenges posed to a global bioethics by articles on: divergent national policies on compensation of egg donors for IVF, efforts to advance the development of international guidelines for the management of neonates on the edge of viability, bioethics training workshops in Uganda, a bioethicist's reflection on a visit to Pakistan. The article then discusses several approaches to developing a global bioethics and how these approaches might meet the four challenges. The essay concludes with discussion of the author's development of a "navigational approach" to policymaking for "fractious" bioethical policy problems and how this compares to other approaches to developing a global bioethics.

Chest compressions and epinephrine during resuscitation of infants born at the border of viability: Yes, no or maybe?

Neonatology, in large part due to its population of babies born at the edge of viability, is rife with bioethical issues. This unique population is at high risk of mortality and considerable neurodevelopmental morbidity. One contentious, ongoing debate concerns whether these extremely low birth weight infants born at the border of viability should, if required by the Neonatal Resuscitation Program guidelines, receive chest compressions and epinephrine as part of their delivery room resuscitation. The present article, through a case presentation and discussion based on the ethical framework of principlism, provides readers with a thoughtful approach to the controversial issue of the provision of chest compressions and epinephrine as part of resuscitation for extremely low birth weight infants born at the border of viability.

The Evolving Science of Care in Perinatal Loss

The Evolving Science of Care in Perinatal Loss

Regulation of treatment of infants at the edge of viability in Italy: the role of the medical profession?

In the last few years there has been intense debate in Italy on administration of life-prolonging treatment to premature babies at the edge of viability. In 2006, a group of...

NNP Education in Neonatal End-of-life Care

To determine from practicing neonatal nurse practitioners (NNPs) their perceived end-of-life (EOL) care learning needs. A needs assessment-based evaluation methodology was used to answer the research questions. A neonatal EOL needs assessment survey was developed, pilot tested, and then mailed to 260 NNPs across the United States. NNPs in clinical practice regarded their education on EOL for neonates and their families as inadequate. Twenty-three percent ranked "delivery room decisions to resuscitate infants considered at edge of viability" as the item for which they most wanted more training. The other top-ranked EOL items included balance between giving parents false hopes and removing all hopes, and communicating and giving bad news to families. Based on these findings, specific neonatal EOL education and communication skill workshops are warranted for graduate nursing core and advance practice continuing education courses. Additionally, there needs to be a mechanism to provide EOL content and support for the NNP already in clinical practice; it is suggested that learning about EOL issues can be integrated into existing (continuing nursing education CNE) educational activities. Further research is needed on what issues, tools, and methods in CNE programs make a difference in the experience of NNPs.

Variation by State in Outcomes Classification for Deliveries Less Than 500 g in the United States

The purpose of this study is to explore state-level fetal death rates and <24 h infant mortality rates for deliveries less than 500 g in order to estimate outcomes classification differences at the edge of viability. We selected singleton deliveries to US resident mothers born <500 g and >20 weeks gestation from the NCHS live birth-infant death and fetal death files for 1999-2002 (n = 37,813). Infant deaths within 24 h of birth were selected to estimate odds of classification as a fetal death versus a live birth/infant death by state. Logistic regression was used to derive odds of classification as a fetal death and to adjust for maternal characteristics, calculating unadjusted and adjusted odds ratios. We identified 37,813 outcomes from 48 states reporting in this birthweight category. Unadjusted odds of classification of outcomes as a fetal death versus a live birth/death within 24 h by state ranged from OR = 0.38 (95% CI = 0.24-0.59) to OR = 2.93 (95% CI = 2.26-3.78); adjusted for maternal age and race, the range narrowed slightly to a OR = 0.31 (95% CI = 0.20-0.48) to aOR = 2.54 (95% CI = 1.96-3.30). Six states were more likely to classify outcomes as a live birth/infant death, while 14 states were more likely to classify as a fetal death, when compared to a large reference state. The remaining states did not differ significantly in their outcomes. The fraction of outcomes classified as fetal deaths varied by state during the years studied. This study suggests fetal death and early infant death outcomes reported for babies less than 500 g reflect differential classification thus influencing the validity of these vital statistics data at the state level. Further studies are needed to explore the factors that influence these differences.

January February 2010 News of the Academy of Neonatal Nursing

Make your plans now for the 7th National Advanced Practice Neonatal Nurses Conference to secure the best rates and discounts, The conference will be held at the Hyatt Regency Embarcadero in San Francisco, March 17–20, 2010. Our conference coordinators have organized an outstanding lineup of speakers and the venue is one of the best in San Francisco! A sample of some of the sessions offered includes “Advanced Nursing Education: What You Need to Know—DNP or Not?”; “Intestinal and Liver Transplantation in Infants and Children: State of the Art”; “Implementation of Cerebral Cooling for Hypoxic-Ischemic Encephalopathy”; “Health Care Provider Work Schedules, Sleep Deprivation, and Patient Safety”; and “Life in the Gray Zone: Moral, Ethical, and Clinical Challenges in Caring for Infants on the Edge of Viability.” Gregory M. Enns, MB, ChB, associate professor at Stanford School of Medicine, and certified by the American Board of Medical Genetics in clinical genetics, and biochemical genetics will present the latest findings on neonatal metabolic disorders and newborn screening. Dr. Enns’ research interests include novel means of diagnosing and treating mitochondrial disorders, with emphasis on antioxidant therapy, lysosomal disorders, and newborn screening by tandem mass spectrometry. His current pursuits include the analysis of glutathione and antioxidant status in patients who have mitochondrial disorders.

Caring for the pregnant woman presenting at periviable gestation: acknowledging the ambiguity and uncertainty

Counseling the periviable pregnant woman presenting at the edge of viability can often be confusing for the patient and frustrating for the clinician. Although neonatal survival rates have improved dramatically over the last few decades, severe morbidity is still common. This is further complicated by the fact that the information provided to the parents regarding the outcomes may not be up to date or completely accurate. The counseling is also frequently influenced by personal beliefs and biases of the medical staff. An evidence-based approach may improve the experience for both the expectant parents and the health care team.

Infant Mortality in Canada

Canada’s infant mortality rates appear to be worsening, but this may be due, at least in part, to inconsistencies in registration of births at the edge of viability, variations in international practices for reporting live births, and related factors. There are striking differences in reported infant mortality rates among provinces and territories and between certain population groups within Canada. Efforts are underway through the Canadian Perinatal Surveillance System, Public Health Agency of Canada, to further improve the reporting of stillbirths and livebirths throughout Canada and to promote accurate reporting of First Nations, Inuit, and Métis births.

Guidelines for Care of Fetal Infants at the Limit of Viability

Viability of the fetal infant is its capability of living. It usually implies a fetus that has reached 500g in weight and 20 gestational weeks. Lower limit of viability is between 23 and 25 weeks’ gestation in developed countries at present. Trends toward intervention at an earlier gestational age may be continuing. However, the term of viability does not simply mean the ability to be born alive, but the capability to grow and to develop normally in the extrauterine environment. There are concerns on what is the best management for fetal infants on the edge of viability. Decisions regarding all aspects of management of the birth and subsequent care of the fetal infant should be based on the fetal and infant’s condition and prognosis and be made jointly by the parents and the physicians. This article will discuss medical, legal, socioeconomic and ethical issues to find the best way in the management of the fetal infants.

Neonatal Resuscitation Guidelines and the Late Preterm Infant

The Neonatal Resuscitation Guidelines have been recently reviewed and released (American Academy of Pediatrics: Neonatal Resuscitation Textbook. 5th edition. Elk Grove, IN: American Academy of Pediatrics; 2006). There are many areas that have applicability to specific populations, such as the infant with meconium-stained amniotic fluid, preterm infants, and infants at the edge of viability. However, there is no specific mention of the late preterm infant. This population does not usually need specific resuscitation measures that are different from other infant populations but may, in fact, require some measure of support after delivery more often than term infants do. The specific changes in the guidelines as well as postresuscitation measures, which are as important as the resuscitation measures themselves, are reviewed in this article. Careful consideration about the best place to provide this increased level of monitoring and intervention, as necessary, is required.

Total parenteral nutrition for premature infants 1,2,3

In the late 1970s the age of viability was approximately 28 weeks’ gestation. Most infants less than 1,000 grams and some less than 1,500 grams were considered nonviable, therefore, resuscitation attempts were less aggressive. Advancing technology has led to improvements in ventilators, intravenous access materials, and surfactant therapy; have all had an impact on lowering the age of viability. It is not unusual today to resuscitate infants as young as 22 weeks’ gestation. One of the major obstacles in the care of babies on the edge of viability is to provide adequate nutritional intake. This article discusses the importance of adequate nutrition, reviews the components of total parenteral nutrition (TPN), and makes suggestions concerning initiation of enteral feedings for premature infants.

RNA virus error catastrophe: direct molecular test by using ribavirin.

RNA viruses evolve rapidly. One source of this ability to rapidly change is the apparently high mutation frequency in RNA virus populations. A high mutation frequency is a central tenet of the quasispecies theory. A corollary of the quasispecies theory postulates that, given their high mutation frequency, animal RNA viruses may be susceptible to error catastrophe, where they undergo a sharp drop in viability after a modest increase in mutation frequency. We recently showed that the important broad-spectrum antiviral drug ribavirin (currently used to treat hepatitis C virus infections, among others) is an RNA virus mutagen, and we proposed that ribavirin's antiviral effect is by forcing RNA viruses into error catastrophe. However, a direct demonstration of error catastrophe has not been made for ribavirin or any RNA virus mutagen. Here we describe a direct demonstration of error catastrophe by using ribavirin as the mutagen and poliovirus as a model RNA virus. We demonstrate that ribavirin's antiviral activity is exerted directly through lethal mutagenesis of the viral genetic material. A 99.3% loss in viral genome infectivity is observed after a single round of virus infection in ribavirin concentrations sufficient to cause a 9.7-fold increase in mutagenesis. Compiling data on both the mutation levels and the specific infectivities of poliovirus genomes produced in the presence of ribavirin, we have constructed a graph of error catastrophe showing that normal poliovirus indeed exists at the edge of viability. These data suggest that RNA virus mutagens may represent a promising new class of antiviral drugs.

Following the Learning Curve: The Evolution of Kinder, Gentler Neonatal Respiratory Technology

Immense progress has been made in all aspects of neonatal critical care during the past 4 decades, particularly in the realm of respiratory support. A historical overview of the evolution of neonatal respiratory support illustrates how technological advances are improving survival and outcome for many sick newborns. Major milestones in this history include continuous positive airway pressure, conventional ventilation, exogenous surfactant, extracorporeal membrane oxygenation, and high frequency ventilation. Changes in clinical and nursing care highlight the significant impact of technological and practice advances on neonatal respiratory morbidity. Although bronchopulmonary dysplasia still occurs, the incidence and severity have decreased. The nature and outcome of the neonatal intensive-care experience has been redefined for many infants; however, great challenges remain in the care of infants on the edge of viability.

Inquiry into serial killer criticises hospital's response

Vital clues that could have pointed to nurse Beverly Allitt being a serial killer were missed during the 58 days she worked on the children's ward at Grantham and Kesteven Hospital in Lincolnshire, according to the report of the independent inquiry into the tragedy. The inquiry, chaired by Sir Cecil Clothier, criticises the hospital's two consultant paediatricians, the ward sister, the clinical services manager, and other middle managers. It paints a picture of a hospital “on the edge of viability,” operating on a shoestring budget. Sir Cecil, however, dismissed staff shortages as “a tangential issue.” * Clothier said that steps taken after children's deaths were feeble (Fig Omitted) Allitt, aged 35, is in Rampton Special Hospital after being given 13 life sentences last May for murdering four children and attacking nine others while working as an enrolled nurse on ward 4 between February and April 1991. The report criticises the hospital's “sloppy” appointments procedures in recruiting Allitt but doubts that she would have been detected as unsuitable at …