Periviable Infants Research Articles

Resuscitation of extremely preterm infants - controversies and current evidence.

Despite significant advances in perinatal medicine, the management of extremely preterm infants in the delivery room remains a challenge. There is an increasing evidence for improved outcomes regarding the resuscitation and stabilisation of extremely preterm infants but there is a lack of evidence in the periviable (gestational age 23-25 wk) preterm subgroup. Presence of an experienced team during the delivery of extremely preterm infant to improve outcome is reviewed. Adaptation from foetal to neonatal cardiorespiratory haemodynamics is dependent on establishing an optimal functional residual capacity in the extremely preterm infants, thus enabling adequate gas exchange. There is sufficient evidence for a gentle approach to stabilisation of these fragile infants in the delivery room. Evidence for antenatal steroids especially in the periviable infants, delayed cord clamping, strategies to establish optimal functional residual capacity, importance of temperature control and oxygenation in delivery room in extremely premature infants is reviewed in this article.

Infant Outcomes after Periviable Birth: External Validation of the Neonatal Research Network Estimator with the BEAM Trial.

Objective The objective of this study was to use data from the 20-center beneficial effect of antenatal magnesium sulfate (BEAM) trial to assess the external validity of the Neonatal Research Network (NRN) estimator, a widely employed web-based counseling tool to estimate the probability of an adverse outcome for periviable infants given intensive care. Study Design The probability of different adverse outcomes predicted from the NRN estimator was compared with observed rates at 18 to 22 months for ventilated, nonanomalous infants born at 23 to 25 weeks and assessed in BEAM as in the NRN. Results were assessed using rigorous validation methods for prediction models. Results Among 289 eligible infants, 26% died, 40% died or had profound neurodevelopmental impairment (PNDI), and 71% died or had NDI. The area under the receiver operating characteristic curve was 0.70 (95% confidence interval [CI], 0.63-0.78) for death, 0.64 (95% CI, 0.56-0.71) for death or NDI, and 0.71 (95% CI, 0.65-0.78) for death or PNDI. Observed and predicted rates were somewhat different for death or NDI but quite similar for death and for death or PNDI in different risk groups. Brier scores for accuracy were favorable (0.17-0.22) for all outcomes. Conclusion Our results provide external validation of the NRN estimator for assessing the probability of adverse outcomes at 18 to 22 months for periviable infants given intensive care.

Attitudes towards the resuscitation of periviable infants: a national survey of American Muslim physicians.

To examine the associations between American Muslim physicians' characteristics and intended behaviours towards resuscitation of 22- and 23-week gestation infants. This national survey of physician members of the Islamic Medical Association of North America inquired about physician religiosity, their practice of referring to Islamic resources for bioethical guidance, their preferred model of patient-doctor decision-making and the perceived importance of quality-of-life determinations with respect to medical decision-making. Four vignettes described birth of a 22- and a 23-week gestation infant. Respondents were given estimated survival data for each and asked whether they would attempt resuscitation. A total of 255 of 626 responses received. About 51% and 85% of respondents believed that a 22- and a 23-week gestation infant should be resuscitated, respectively. If parents opposed resuscitation, 44% (22 weeks) and 46% (23 weeks) of respondents still endorsed resuscitating. Respondents who were more religious, referred more often to Islamic bioethical resources and did not believe that quality-of-life determinations were tied to life's value had greater odds of endorsing resuscitation in many of the scenarios. American Muslim physicians have high rates of support for delivery room resuscitation of periviable infants. Their intended behaviour appears to associate with religious values.

Antenatal Counseling Regarding Resuscitation and Intensive Care Before 25 Weeks of Gestation.

The anticipated birth of an extremely low gestational age (,25 weeks) infant presents many difficult questions, and variations in practice continue to exist.Decisions regarding care of periviable infants should ideally be well informed,ethically sound, consistent within medical teams, and consonant with the parents' wishes. Each health care institution should consider having policies and procedures for antenatal counseling in these situations. Family counseling may be aided by the use of visual materials, which should take into consideration the intellectual, cultural, and other characteristics of the family members. Although general recommendations can guide practice, each situation is unique; thus, decision-making should be individualized. In most cases, the approach should be shared decision-making with the family, guided by considering both the likelihood of death or morbidity and the parents' desires for their unborn child. If a decision is made not to resuscitate,providing comfort care, encouraging family bonding, and palliative care support are appropriate.

Periviable Birth

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Periviable Birth

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (eg, antenatal steroid, tocolytic agents, and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation, and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect, and understanding and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation) and the treatment options for the newborn infant. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (eg, antenatal steroid, tocolytic agents, and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation, and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect, and understanding and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists.

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

National Variability in Neonatal Resuscitation Practices at the Limit of Viability

Delivery room management of extremely premature infants is not subjected to professional regulations. In the United States, legal definitions of human viability and statutes regulating elective abortions vary by state, placing providers in an often difficult position regarding whether to attempt resuscitation when faced with the delivery of an infant of 22 to 25 weeks gestation. The objective of this study was to delineate variations in delivery room resuscitation practices of periviable infants in the United States in 2012. Electronic survey was sent to the members of American Academy of Pediatrics Section of Perinatal Medicine. Chi-square, Fisher exact test, and multivariate logistic regression were performed. A total of 758 surveys returned out of which 637 were complete. Overall 68% of providers consider 23-week gestation to be the youngest age that should be resuscitated at parental request, while 25-week gestation is considered by 51% to be the youngest age of obligatory resuscitation even with parental refusal. Responses varied when providers were separated into geographical regions based on the U.S. Census Bureau (p < 0.05). When provided with delivery room scenarios, parental preference significantly affected resuscitation attempts of 22 to 25 weeks, but not 26-week infants. In scenarios of periviable elective terminations, providers' personal belief systems influenced management of aborted fetuses. Regional practice variation exists independent of specific state laws. Parental request is the most important factor to providers resuscitating 22 to 25-week infants. Providers' personal belief systems influence infant management infrequently.

Management of Periviable Newborns in the Nordic Countries

Perinatal and neonatal health care is quite uniform in the Nordic countries in spite of large differences in population densities and transport distances. For the present study data was collected with a questionnaire sent to neonatologists in the five Nordic countries Denmark, Finland, Iceland, Norway, and Sweden. In these countries there are totally approximately 80 level II and 25 level I NICUs. Care of periviable immature infants is strongly centralized with a few exceptions in Norway due to long transport distances. Iceland with one level III NICU only is the only country with national guidelines for management of prematurity, and only Norway has national guidelines for follow-up. In all countries the lower margin of viability is considered as < 23 weeks, although practical handling of these smallest children may vary between countries and within each country. In parts of Sweden proactive management is recommended while other units, for instance in Denmark, practice palliative care at 23 weeks and life support at 24 weeks. Following a consensus conference organized in Norway in 1998 it became common practice to treat babies with gestational age down to 23 weeks, however parental choice and autonomy should be respected. This seems to be in accordance with recent international guidelines. In summary, ELBWI are offered intensive care treatment in all Nordic countries but with some variation between countries concerning rate of referral and degree of centralization of care. Survival rates for these babies are quite high in all the Nordic countries. Keywords: Extreme prematurity, ethics, health care practices, resuscitation, end-of-life decisions

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.

Long-term Health Outcomes of Extremely Premature Infants: In Reply

We appreciate the opportunity to respond to the perceptive questions raised by Drs Kaempf and Tomlinson regarding our article.1 We have read with interest their recent article on counseling of parents of periviable fetuses and infants.2 We understand the dilemma faced by the authors in their inability to reconcile their guidelines for recommending nonintervention of infants <25 weeks' gestation with the positive self-reported health-related quality of life (QoL) of the subjects in our study.We address first their specific questions. Ours is a population-based study of a cohort of 397 live births of extremely low birth weight (ELBW [<1000 g]): 56 (14%) infants died before transfer to the tertiary care center; intensive care was not instituted for or was withdrawn from 61 (15%) infants3; 179 survived to hospital discharge (regional survival: 45%; tertiary care center survival: 53%); and over the subsequent years 13 died, which left 166 available for follow-up. In that early era of neonatal intensive care, antenatal counseling was not as formalized as it is today, because the outcomes of ELBW survivors were largely unknown. Decisions regarding noninitiation and/or withdrawal of intensive care, however, were made in consultation with the parents. The information requested by gestational age (best estimate) is shown in Table 1.The other details requested were provided in Table 1 of our article: 143 (86%) of the subjects participated in the interviews; nearly half of the subjects were in the higher I and II socioeconomic group; 81% were from 2-parent households; only 2% were nonwhite; and all subjects were beneficiaries of the Canadian universal health care system. We do not know whether any of our subjects have read our medical publications. We did send a brief summary of our findings to all parents of the ELBW and control subjects after completion of our previous study at adolescence (mean age: 14 years), but we doubt that our report could have influenced their self-perception 9 years later. Also, the standard gamble technique used by us for obtaining preferences offers an objective approach for measuring subjective phenomena and is less likely to be influenced by preconceived notions.4By and large, the survival of infants <26 weeks' gestational age, but not the proportion of survivors with impairments, has improved significantly in the last decade. We do not claim that our subjects are entirely representative of the current survivors. However, the proportion of participants in our study who were of <26 weeks' gestational age (22%) was not insignificant. We concede that there are limitations in extrapolating our follow-up data to recipients of modern obstetric and neonatal care and have recommended, therefore, that such studies need to be repeated to also account for different social and economic conditions and diverse cultural, racial, and ethnic populations.1Finally, the statement by Kaempf and Tomlinson's critics that our subjects are “happy and well adjusted” and that all infants, therefore, should be resuscitated is a gross oversimplification of our findings. Although the majority of our subjects rated their health-related QoL relatively highly, there were both individuals and families who did not. Therefore, we favor individual de cision-making,5 because many factors that may have influenced the positive self-perception need to be considered. However, several studies support our findings that individuals with disabilities place a high value on their QoL.1 Although no one would “choose” to have a disability, most individuals use whatever mechanisms are available to them to carry on with their lives as best as they can, attesting to the extraordinary resilience of many human beings. The question of why individuals with disabilities rate their QoL as high as they do is intriguing, but equally intriguing, perhaps, is the question of why individuals of normal birth weight without disabilities do not rate their QoL any higher.