Outcomes of Preterm Infants following Discussions about Withdrawal or Withholding of Life Support

Social Determinants of Health and Redirection of Care for Infants Born Extremely Preterm

Importance

Redirection of care refers to withdrawal, withholding, or limiting escalation of treatment. Whether maternal social determinants of health are associated with redirection of care discussions merits understanding.

Objective

To examine associations between maternal social determinants of health and redirection of care discussions for infants born extremely preterm.

Design, Setting, and Participants

This is a retrospective analysis of a prospective cohort of infants born at less than 29 weeks' gestation between April 2011 and December 2020 at 19 National Institute of Child Health and Human Development Neonatal Research Network centers in the US. Follow-up occurred between January 2013 and October 2023. Included infants received active treatment at birth and had mothers who identified as Black or White. Race was limited to Black and White based on service disparities between these groups and limited sample size for other races. Maternal social determinant of health exposures were education level (high school nongraduate or graduate), insurance type (public/none or private), race (Black or White), and ethnicity (Hispanic or non-Hispanic).

Main Outcomes and Measures

The primary outcome was documented discussion about redirection of infant care. Secondary outcomes included subsequent redirection of care occurrence and, for those born at less than 27 weeks' gestation, death and neurodevelopmental impairment at 22 to 26 months' corrected age.

Results

Of the 15 629 infants (mean [SD] gestational age, 26 [2] weeks; 7961 [51%] male) from 13 643 mothers, 2324 (15%) had documented redirection of care discussions. In unadjusted comparisons, there was no significant difference in the percentage of infants with redirection of care discussions by race (Black, 1004/6793 [15%]; White, 1320/8836 [15%]) or ethnicity (Hispanic, 291/2105 [14%]; non-Hispanic, 2020/13 408 [15%]). However, after controlling for maternal and neonatal factors, infants whose mothers identified as Black or as Hispanic were less likely to have documented redirection of care discussions than infants whose mothers identified as White (Black vs White adjusted odds ratio [aOR], 0.84; 95% CI, 0.75-0.96) or as non-Hispanic (Hispanic vs non-Hispanic aOR, 0.72; 95% CI, 0.60-0.87). Redirection of care discussion occurrence did not differ by maternal education level or insurance type.

Conclusions and Relevance

For infants born extremely preterm, redirection of care discussions occurred less often for Black and Hispanic infants than for White and non-Hispanic infants. It is important to explore the possible reasons underlying these differences.

Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?-a narrative review

Background and Objective

The morbidity and mortality of infants born extremely preterm varies substantially across networks, within countries and throughout the globe. Most of the literature tends to focus on the management at birth and choices around active resuscitation of extremely preterm infants. Withdrawal and withholding of life sustaining treatment (WWLST) is an important and central process in the neonatal intensive care unit (NICU) and practices vary substantially. As such, our objective in this review was to explore whether end of life decisions also contribute to variations in the morbidity and mortality of periviable infants.

Methods

This narrative literature review is based on studies from the last 15 years found using several searches of medical databases (OVID Medline, Scopus and Cochrane Systematic Reviews) performed between March 2021 and December 2023.

Key Content and Findings

Just as outcomes in periviable infants vary, the rates of and processes behind WWLST differ in the periviable population. Variation increases as gestational age decreases. Parental involvement is crucial to share decision making but the circumstances and rates of parental involvement differ. Strict guidelines in end-of-life care may not be appropriate, however there is a need for more targeted guidance for periviable infants as a specific population. The current literature available relating to periviable infants or WWLST is minimal, with many datasets rapidly becoming outdated.

Conclusions

Further research is needed to establish the role of WWLST in variation of periviable infants' outcomes. The unification of data, acquisition of more recent datasets and inclusion of variables relating to end-of-life decisions in data collection will aid in this process.

Resuscitation in the “Periviable” Period—Commentary of Opposing Views

The periviable period is defined as delivery between 20 0/7 weeks and 25 6/7 weeks of gestation. It has long been considered a “gray area,” as there are still no clear guidelines on initial resuscitation and subsequent treatment of the newborn. This lack of guidance compounds the uncertainty in decision-making in low- and middle-income countries with limited resources. The decision to treat or not has far-reaching economic, social, cultural, and sometimes even religious implications for the parents and family. This review explores the perspectives of parents, caregivers, and policymakers in detail to utilize the existing evidence better. We present arguments for and against resuscitation in the periviable period, discussing concerns surrounding neurodevelopmental outcomes, cost, parental concerns, nonuniformity of evidence, and ethical considerations. A large survival gap exists between developed and developing countries, and the infrastructure and clinical care network in low- and middle-income country are not strong enough to provide adequate support for these infants and their families. Antenatal factors, socioeconomic and cultural issues, center capacity, and resuscitation capacity of birthing centers should be considered when making decisions. The neonatologists are expected to be impartial, provide information, and not advise based on their beliefs and outlook; while preserving the autonomy of parents. The only way forward is for parents and caregivers to work together to develop a logical and ethical approach that can be accepted as national and institutional policies.

Survival and Long-Term Outcomes of Children Who Survived after End-of-Life Decisions in a Neonatal Intensive Care Unit

OBJECTIVE

To investigate long-term outcomes of infants who survive despite life-and-death discussions with families and a decision to withdraw or withhold life-sustaining interventions (WWLST) in one neonatal intensive care unit.

STUDY DESIGN

Medical records for neonatal intensive care unit admissions from 2012 to 2017 were reviewed for presence of WWLST discussions or decisions, as well as the 2-year outcome of all children who survived. WWLST discussions were prospectively recorded in a specific book; follow-up to age 2 years was determined by retrospective chart review.

RESULTS

WWLST discussions occurred for 266 of 5251 infants (5%): 151 (57%) were born at term and 115 (43%) were born preterm. Among these discussions, 164 led to a WWLST decision (62%) and 130 were followed by the infant's death (79%). Of the 34 children (21%) surviving to discharge after WWLST decisions, 10 (29%) died before 2 years of age and 11 (32%) required frequent medical follow-up. Major functional limitations were common among survivors, but 8 were classified as functionally normal or with mild-to-moderate functional limitations.

CONCLUSIONS

When a WWLST decision was made in our cohort, 21% of the infants survived to discharge. By 2 years of age, the majority of these infants had died or had major functional limitations. This highlights the uncertainty of WWLST decisions during neonatal intensive care and the importance of ensuring that parents are informed of all possibilities. Additional studies including longer-term follow-up and ascertaining the family's views will be important.

Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills

Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.

CARFS7: A guide and proforma for reading a preterm neonate's EEG

OBJECTIVES

The important role of the EEG in preterm and term babies in investigating brain function and seizures, predicting outcomes, evaluating therapeutic interventions and decision-making is being increasingly acknowledged. Development of the brain in the last trimester of pregnancy results in rapid changes in the EEG patterns in this period. Acquiring and interpreting the EEG of a preterm baby can be challenging. The aim of this study was to develop a proforma titled CARFS⁷ (Continuity, Amplitude, Reactivity, Frequency, Synchrony, Symmetry, Sleep, Sharps, Shapes, Size and Seizures) to enable neurologists to read EEGs of premature babies with greater confidence, ease and accuracy and produce a report more easily repeatable and homogenous among operators.

METHODS

The CARFS⁷proforma was developed based on a literature review and the personal experience of the authors. The parameters of the EEG evaluated and scored in the proforma are Continuity, Amplitude, Reactivity/Variability, Frequency, Synchrony, Symmetry, Sleep, Sharps, Shapes/Patterns, Size and Seizures. We also assessed the interrater reliability of the proposed scoring system incorporated in the proforma.

RESULTS

CARFS⁷ proforma incorporates a number of parameters that help evaluate the preterm EEG. The interrater reliability of the proposed scoring system in the CARFS⁷proforma was high.

CONCLUSIONS

CARFS⁷ is a user friendly proforma for reading EEGs in the preterm infant. Interrater reliability using Cohen's k shows high agreement between two child neurologists who independently rated the EEGs of 25 premature babies using this proforma. CARFS⁷ has the potential to provide, accurate, reproducible and valuable information on brain function in the preterm infant in clinical practice.

High-Risk Neighborhoods and Neurodevelopmental Outcomes in Infants Born Preterm

OBJECTIVE

To study the association between neighborhood risk and moderate to severe neurodevelopmental impairment (NDI) at 22-26 months corrected age in children born at <34 weeks of gestation. We hypothesized that infants born preterm living in high-risk neighborhoods would have a greater risk of NDI and cognitive, motor, and language delays.

STUDY DESIGN

We studied a retrospective cohort of 1291 infants born preterm between 2005 and 2016, excluding infants with congenital anomalies. NDI was defined as any one of the following: a Bayley Scales of Infant and Toddler Development-III Cognitive or Motor composite score <85, bilateral blindness, bilateral hearing impairment, or moderate-severe cerebral palsy. Maternal addresses were geocoded to identify census block groups and create high-risk versus low-risk neighborhood groups. Bivariate and regression analyses were run to assess the impact of neighborhood risk on outcomes.

RESULTS

Infants from high-risk (n = 538; 42%) and low-risk (n = 753; 58%) neighborhoods were compared. In bivariate analyses, the risk of NDI and cognitive, motor, and language delays was greater in high-risk neighborhoods. In adjusted regression models, the risks of NDI (OR, 1.43; 95% CI, 1.04-1.98), cognitive delay (OR, 1.62; 95% CI, 1.15-2.28), and language delay (OR, 1.58; 95% CI, 1.15-2.16) were greater in high-risk neighborhoods. Breast milk at discharge was more common in low-risk neighborhoods and was protective of NDI in regression analysis.

CONCLUSIONS

High neighborhood risk provides an independent contribution to preterm adverse NDI, cognitive, and language outcomes. In addition, breast milk at discharge was protective. Knowledge of neighborhood risk may inform the targeted implementation of programs for socially disadvantaged infants.

Infant mode of death in the neonatal intensive care unit: A systematic scoping review

OBJECTIVE

To characterize literature that describes infant mode of death and to clarify how limitation of life-sustaining treatment (LST) is defined and rationalized.

STUDY DESIGN

Eligible studies were peer-reviewed, English-language, and included number of infant deaths by mode out of all infant deaths in the NICU and/or delivery room.

RESULT

58 included studies were primarily published in the last two decades from North American and European centers. There was variation in rates of infant mode of death by study, with some showing an increase in deaths following limitation of LST over time. Limitation of LST was defined by the intervention withheld/withdrawn, the relationship between the two practices, and prior frameworks. Themes for limiting LST included diagnoses, low predicted survival and/or quality of life, futility, and suffering.

CONCLUSION

Limitation of LST is a common infant mode of death, although rates, study definitions, and clinical rationale for this practice are variable.

Ethics of care for the micropreemies. Just because we can, should we?

Debates about treatment for the tiniest premature babies focus on three different approaches - universal non-resuscitation, selective resuscitation, and universal resuscitation. Doctors, hospitals, and professional societies differ on which approach is preferable. The debate is evolving as studies show that survival rates for babies born at 22 and 23 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. The doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Centers that offer and encourage treatment cite evidence that many babies born at 22 weeks can survive, that most survivors have good neurodevelopmental outcomes, and that NICU care for tiny babies is cost-effective compared to many common and uncontroversial treatments. The debate touches on many fundamental ethical issues that have been present in neonatology since its inception as a medical specialty.

Ethical implications of the shifting borderline of viability

Survival rates for babies born at 22 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. Thus, parents will be given very different advice at different centers for babies born at the borderline of viability. Those doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Yet there is strong evidence that many babies born at 22 weeks can survive, most survivors have good neurodevelopmental outcomes, and neonatal intensive care for tiny babies is cost-effective compared to many common and uncontroversial treatments. Given this growing body of evidence, policies discouraging or forbidding treatment of babies born at 22 weeks will require stronger ethical justification than has been given to date.

Ethical issues in treatment of babies born at 22 weeks of gestation

Many centres now report that more than half of babies born at 22 weeks survive and most survivors are neurocognitively intact. Still, many centres do not offer life-sustaining treatment to babies born this prematurely. Arguments for not offering active treatment reflect concerns about survival rates, rates of neurodevelopmental impairment and cost. In this essay, I examine each of these arguments and find them ethically problematic. I suggest that current data ought to lead to two changes. First, institutional culture should change at institutions that do not offer treatment to babies born at 22 weeks. Second, we need more research to understand best practices for these tiny babies.

Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates

OBJECTIVE

To identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates.

DESIGN

Observational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST.

RESULTS

Of 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74).

CONCLUSIONS

Among infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.

Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units

OBJECTIVE

To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs).

STUDY DESIGN

We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation.

RESULTS

Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death.

CONCLUSIONS

From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.

Clinicians' Self-Reported Practices Related to End-of-Life Care for Infants in NICUs in Jordan

OBJECTIVE

To examine how clinical decisions are made at the end of life for infants born with specific fatal and disabling conditions in NICUs in Jordan from the perspectives of neonatal health care providers.

DESIGN

A cross-sectional survey of neonatal nurses and physicians.

SETTING

Twenty-four NICUs in Jordan.

PARTICIPANTS

Participants included 213 nurses and 75 physicians who provided direct care for infants in NICUs.

METHODS

Using the EURONIC questionnaire, we asked participants to recall the last experiences of end-of-life decision making in which they were involved. The participants described factors and outcomes related to those experiences, and we used descriptive and inferential statistics to examine these factors.

RESULTS

In 83% of the recalled situations, the physicians in charge of the infants' care or who were on duty were the primary decision makers. Parents, nurses, ethics committees, and NICU heads were less involved. The infants' primary diagnoses were significantly associated with the nature of decisions regarding end-of-life care (p < .001). Age, importance of religion, having their own children, and involvement in research activities were factors that significantly predicted nurses' perceived levels of involvement in decision making (χ²[4] = 23.140, p < .001).

CONCLUSION

Our results suggest the need to improve clinical approaches to decision making regarding end-of-life care for infants in NICUs in Jordan to be more family focused and team based. This process should include parents, physicians, neonatal nurses, and ethics committees.

The clinical management and outcomes of extremely preterm infants in Japan: past, present, and future

There is a wide variation in neonatal mortality rates across regions and countries. Japan has one of the lowest neonatal mortality rates in the world; in particular, the mortality rate of extremely preterm infants (i.e., those born before 26 weeks of gestation) is much lower in Japan than in other developed countries. In addition, Japan has low incidences of intraventricular hemorrhage, necrotizing enterocolitis, and late-onset sepsis, a very high incidence of retinopathy of prematurity, and a relatively high incidence of chronic lung disease. In Japan, general perinatal medical centers (PMCs), which are PMCs that offer the highest levels of care, are required to have an obstetric department with maternal-fetal intensive care units as well as a neonatal or pediatric department with neonatal intensive care units (NICU), in order to promote antenatal rather than neonatal maternal transfer of high-risk cases. The limit of viability of extremely preterm infants is 22 weeks of gestation, and approximately half of them are estimated to receive active resuscitation. The clinical management of extremely preterm infants in Japan are characterized by (I) circulatory management that is guided by neonatologist-performed echocardiography, (II) relatively invasive respiratory management, (III) nutritional management, which entails the promotion of breast milk feeding, early enteral feeding, routine glycerin enema, and the administration of probiotics, (IV) neurological management by means of minimal handling, sedation of ventilated infants, and serial brain ultrasounds, and (V) infection control with the assistance of serial C-reactive protein (CRP) monitoring. Thus, this review provides a brief description of the development of neonatology in Japan, introduces the unique features of Japanese clinical management of extremely preterm infants, and overviews their outcomes.

Withdrawal of life-sustaining therapy

PURPOSE OF REVIEW

The aim of this review is to examine literature relating to the withdrawal of life-sustaining therapy (WLST).

RECENT FINDINGS

Discussions regarding end-of-life issues in adults and children are not occurring comprehensively. Discussions relating to the WLST in the pediatric population varies by institution and may vary by race, age, health insurance, diagnosis, and severity of illness. Completing advance directives prior to placement of life-sustaining treatments is not consistent practice. With the WLST, differences in perspectives exist between medical specialties, within one specialty at different levels of training, and in physicians' ethical and psychological responses to the WLST. The timing of WLST appears to be influenced by ICU strain and communication issues. Study outcomes differ regarding the functionally favorable survival of patients who have had WLST. Universal guidelines for the WLST may not address individual patient circumstances.

SUMMARY

Discussions of end-of-life issues early in the course of a patient's health care will contribute to the healthcare team's understanding and respect of the patient's wishes. This article addresses the withdrawal of left ventricular assist devices; attending physicians and physicians in training perspectives of WLST; do physicians distinguish between withholding and WLST; the timing of WLST; guidelines for the process of WLST; and pediatrics and end-of-life decisions.

Pediatric Palliative Care in Infants and Neonates

The application of palliative and hospice care to newborns in the neonatal intensive care unit (NICU) has been evident for over 30 years. This article addresses the history, current considerations, and anticipated future needs for palliative and hospice care in the NICU, and is based on recent literature review. Neonatologists have long managed the entirety of many newborns' short lives, given the relatively high mortality rates associated with prematurity and birth defects, but their ability or willingness to comprehensively address of the continuum of interdisciplinary palliative, end of life, and bereavement care has varied widely. While neonatology service capacity has grown worldwide during this time, so has attention to pediatric palliative care generally, and neonatal-perinatal palliative care specifically. Improvements have occurred in family-centered care, communication, pain assessment and management, and bereavement. There remains a need to integrate palliative care with intensive care rather than await its application solely at the terminal phase of a young infant's life-when s/he is imminently dying. Future considerations for applying neonatal palliative care include its integration into fetal diagnostic management, the developing era of genomic medicine, and expanding research into palliative care models and practices in the NICU.