Outcomes following a comprehensive versus a selective approach for infants born at 22 weeks of gestation

Backes, Carl H.; Söderström, Fanny; Ågren, Johan; Sindelar, Richard; Bartlett, Christopher W.; Rivera, Brian K.; Mitchell, Courtney; Frey, Heather A.; Shepherd, Edward G.; Nelin, Leif D.; Normann, Erik

doi:10.1038/s41372-018-0248-y

Cited by 46 publications

(31 citation statements)

References 35 publications

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“…P reterm birth is difficult to predict and prevent. Although the long-term health outcomes for preterm infants have improved over time, extremely preterm birth has continued to be an issue in terms of optimal antenatal and postnatal management, [1][2][3][4][5] resource allocation and costs, 6 quality of care, 7 and long-term health outcomes. 8,9 Given these uncertainties, and compounded by changes in reproductive epidemiology, 10,11 it is important to evaluate international variations and time trends for the management and outcomes of extremely preterm birth.…”

mentioning

confidence: 99%

Association Between Year of Birth and 1-Year Survival Among Extremely Preterm Infants in Sweden During 2004-2007 and 2014-2016

Norman

Hallberg

Abrahamsson

et al. 2019

JAMA

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mentioning

confidence: 99%

Association Between Year of Birth and 1-Year Survival Among Extremely Preterm Infants in Sweden During 2004-2007 and 2014-2016

Norman

Hallberg

Abrahamsson

et al. 2019

JAMA

Self Cite

220

128

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“…However, because this definition is less stringent than the Centers for Disease Control/National Health Safety Network definition, this distinction cannot easily be ascertained. The fact that delayed time to administration resulted in increased mortality even with inclusion of this large subset of infants with CONS sepsis is notable, because multiple prior large studies in neonates have shown no association between CONS bacteremia/sepsis and mortality, [4][5][6][7][8] and no survival benefit to early empiric antibiotic treatment in infants identified to have CONS bacteremia. 9,10 The authors declare no conflicts of interest.…”

Section: Every Minute Counts: the Urgency Of Identifyingmentioning

confidence: 91%

“…the authors should make that clear. In addition, in view of the study by Backes et al, 7 there are numerous facets of actively providing comprehensive care that will require attention for similar outcomes to be seen across the US when compared with Sweden or Japan. 8 These include at the very least the universal provision of ANS, a neonatologist at every delivery, immediate intubation, and surfactant administration.…”

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confidence: 99%

From Iowa: Cautious Optimism?

Carter

2020

The Journal of Pediatrics

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I n their report from the University of Iowa Hospitals and Clinics, Watkins et al 1 give what may be viewed as hopeful information on the outcomes of infants born between 22 and 25 weeks of completed gestation. Although limited to a single site, and retrospective in nature, their cohort represents perhaps the largest of infants born in this periviable period (n = 255). Indeed, the cohort of infants born at 22-23 weeks of gestation is the largest such cohort from North America, Australia, or Europe (n = 70), with a remarkable survival to hospital discharge of 78%. Their further demonstration of improved outcomes at 18-22 months of adjusted age, with better than 60% of survivors having no or mild neurodevelopmental impairment, certainly exceeds published norms. 2,3 These figures alone may cause many to beg for what the secret to their success might be. They provide some clues: the consistent provision of antenatal steroids (ANS) by obstetricians and the unwavering active resuscitation of babies by neonatologists, or neonatology fellows, when requested by parents. We are told that all these babies were inborn, assisted by high-frequency ventilation, and cared for in a specialized environment within, but separate from, the remainder of the neonatal intensive care unit (NICU) and by a special dedicated staff. However, other factors also must have contributed over the 10 years of the study's reflection, and these should be published in greater detail. Since the report by Rysavy et al 4 in 2015, the variability in resuscitation and survival of babies from 22-25 weeks of gestation has been well documented. This variability exists elsewhere in the world and is contributed to by many factors. At times resource limitations are cited, 5 as may be guidelines from professional societies 2-although what such guidelines should state remains debatable 6-and attention to perceived infant pain, suffering, and a poor quality of life both in the NICU and, for the many who survive with impairments, throughout their lives. 2,3 The study by Watkins et al would suggest that at least the latter 3 concerns are not insurmountable. And, in America, the resource use matter may be moot, especially given the very small proportion of births occurring between 22-25 weeks of gestation (here note there were only 20 infants born at 22 weeks and 50 at 23 weeks over the 10 years of the Iowa cohort). Yet these results urge caution. If there was an increasing survival and decreasing morbidity over the 10 years reported,

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“…The allocation decision would probably be similar if she was born at 22 weeks. If that were the case, she would have a 23% chance of survival (10-50% depending on where she was born) and 42% chance of long-term neuro-morbidity (Backes et al 2019;Ding et al 2019;Rysavy et al 2015). Her chance of survival is probably similar to Jim's (Arentz et al 2020;Weiss and Murdoch 2020;Zhou et al 2020), but Judy would still live longer.…”

Section: Age and Gestational Age Biasesmentioning

confidence: 99%

Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis?

Haward

Janvier

Moore

et al. 2020

The American Journal of Bioethics

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In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing lifeyears. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.

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Outcomes following a comprehensive versus a selective approach for infants born at 22 weeks of gestation

Cited by 46 publications

References 35 publications

Association Between Year of Birth and 1-Year Survival Among Extremely Preterm Infants in Sweden During 2004-2007 and 2014-2016

Association Between Year of Birth and 1-Year Survival Among Extremely Preterm Infants in Sweden During 2004-2007 and 2014-2016

From Iowa: Cautious Optimism?

Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis?

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