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Daisy CC, Fonseca C, Schuh A, Millikan S, Boyd C, Thomas L, Brennan KG, LoRe D, Famuyide M, Myers P, Ostilla LA, Feltman DM, Andrews B. The Landscape of Resource Utilization After Resuscitation of 22-, 23-, and 24-Weeks' Gestation Infants. J Pediatr 2024; 270:114033. [PMID: 38552951 DOI: 10.1016/j.jpeds.2024.114033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/13/2024] [Accepted: 03/26/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To compare estimated healthcare resources needed to care for 22 through 24 weeks' gestation infants. STUDY DESIGN This multicenter, retrospective cohort study included 1505 live in-born and out-born infants 22 through 24 weeks' gestational age at delivery from 6 pediatric tertiary care hospitals from 2011 through 2020. Median neonatal intensive care unit (NICU) length of stay (LOS) for each gestational age was used as a proxy for hospital resource utilization, and the number of comorbidities and medical technology use for each infant were used as estimates of future medical care needs. Data were analyzed using Kruskal-Wallis with Nemenyi's posthoc test and Fisher's exact test. RESULTS Of the identified newborns, 22-week infants had shorter median LOS than their 23- and 24-week counterparts due to low survival rates. There was no significant difference in LOS for surviving 22-week infants compared with surviving 23-week infants. Surviving 22-week infants had similar proportions of comorbidities and medical technology use as 23-week infants. CONCLUSIONS Compared with 23- and 24-week infants, 22-week infants did not use a disproportionate amount of hospital resources. Twenty-two-week infants should not be excluded from resuscitation based on concern for increased hospital care and medical technology requirements. As overall resuscitation efforts and survival rates increase for 22-week infants, future research will be needed to assess the evolution of these results.
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Affiliation(s)
| | - Camille Fonseca
- Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Allison Schuh
- Department of Pediatrics, The University of Chicago, Chicago, IL
| | | | - Cameron Boyd
- Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Leah Thomas
- The University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Kathleen G Brennan
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Danielle LoRe
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Mobolaji Famuyide
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Patrick Myers
- Department of Pediatrics, Northwestern University, Chicago, IL
| | | | - Dalia M Feltman
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, IL
| | - Bree Andrews
- Department of Pediatrics, The University of Chicago, Chicago, IL
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Boland RA, Cheong JLY, Stewart MJ, Kane SC, Doyle LW. Disparities between perceived and true outcomes of infants born at 23-25 weeks' gestation. Aust N Z J Obstet Gynaecol 2021; 62:255-262. [PMID: 34687048 DOI: 10.1111/ajo.13443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/17/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Decision-making for infants born at 23-25 weeks involves counselling parents about survival and major disability risks. Accurate information is needed for parents to make informed decisions about their baby's care. AIMS To determine if perinatal clinicians had accurate perceptions of outcomes of infants born at 23-25 weeks' gestation, and if accuracy had changed over a decade. MATERIALS AND METHODS A web-based survey was sent to midwives, nurses, neonatologists, and obstetricians working in tertiary and non-tertiary hospitals, and the neonatal retrieval service in the state of Victoria in 2020. A similar survey had been completed in 2010. Clinicians' estimates of survival and major neurodevelopmental disability rates were compared with true rates for actively managed infants overall, and by infant birthplace and gestational age, and professional workplace and discipline. Accuracy of outcomes was compared between eras. RESULTS Overall, 165 surveys were received. Participants underestimated survival (absolute mean difference [%] -14.4%; [95% confidence interval (CI) -16.6 to -12.3]; P < 0.001) and overestimated major disability (absolute mean difference 32.7%; [95% CI 29.7 to 35.8]; P < 0.001) rates overall, and at each week of gestation, and were worse for outborn compared with inborn infants. Perceptions of clinicians in tertiary centres were similar to those of non-tertiary clinicians. Nurses/midwives were more pessimistic, and paediatricians were more optimistic. Clinicians' perceptions of outcome were less accurate in 2020 than in 2010. CONCLUSIONS Most perinatal clinicians underestimate survival and overestimate major disability of infants born at 23-25 weeks' gestation, which may translate into overly pessimistic counselling of parents.
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Affiliation(s)
- Rosemarie A Boland
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeanie L Y Cheong
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Michael J Stewart
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stefan C Kane
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Maternal Fetal Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Lex W Doyle
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Cavolo A, Dierckx de Casterlé B, Naulaers G, Gastmans C. Physicians' Attitudes on Resuscitation of Extremely Premature Infants: A Systematic Review. Pediatrics 2019; 143:peds.2018-3972. [PMID: 31076541 DOI: 10.1542/peds.2018-3972] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Whether to resuscitate extremely premature infants (EPIs) is a clinically and ethically difficult decision to make. Indications and practices vary greatly across different countries and institutions, which suggests that resuscitation decisions may be influenced more by the attitudes of the individual treating physicians. Hence, gaining in-depth insight into physicians' attitudes improves our understanding of decision-making regarding resuscitation of EPIs. OBJECTIVE To better understand physicians' attitudes toward resuscitation of EPIs and factors that influence their attitudes through a systematic review of the empirical literature. DATA SOURCES Medline, Embase, Web of Science, and Scopus. STUDY SELECTION We selected English-language articles in which researchers report on empirical studies of physicians' attitudes toward resuscitation of EPIs. DATA EXTRACTION The articles were repeatedly read, themes were identified, and data were tabulated, compared, and analyzed descriptively. RESULTS Thirty-four articles were included. In general, physicians were more willing to resuscitate, to accept parents' resuscitation requests, and to refuse parents' nonresuscitation requests as gestational age (GA) increased. However, attitudes vary greatly for infants at GA 23 to 24 weeks, known as the gray zone. Although GA is the primary factor that influences physicians' attitudes, a complex interplay of patient- and non-patient-related factors also influences their attitudes. LIMITATIONS Analysis of English-only articles may limit generalizability of the results. In addition, authors of only 1 study used a qualitative approach, which may have led to a biased reductionist approach to understanding physicians' attitudes. CONCLUSIONS Although correlations between GA and attitudes emerged, the results suggested a more complex interplay of factors influencing such attitudes.
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Affiliation(s)
- Alice Cavolo
- Interfaculty Centre for Biomedical Ethics and Law,
| | | | - Gunnar Naulaers
- Section of Pregnancy, Foetus and Newborn, Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
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Wilkinson D, Verhagen E, Johansson S. Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands. Pediatrics 2018; 142:S574-S584. [PMID: 30171144 PMCID: PMC6379058 DOI: 10.1542/peds.2018-0478i] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands. METHODS We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed. RESULTS The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses. CONCLUSIONS In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.
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Affiliation(s)
- Dominic Wilkinson
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom; .,John Radcliffe Hospital, Oxford, United Kingdom
| | - Eduard Verhagen
- Dept of Pediatrics, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Stefan Johansson
- Department of Clinical Science and Education, Södersjukhuset (Karolinska Institutet SÖS), Stockholm, Sweden,Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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Haward MF, Gaucher N, Payot A, Robson K, Janvier A. Personalized Decision Making: Practical Recommendations for Antenatal Counseling for Fragile Neonates. Clin Perinatol 2017; 44:429-445. [PMID: 28477670 DOI: 10.1016/j.clp.2017.01.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Emphasis has been placed on engaging parents in processes of shared decision making for delivery room management decisions of critically ill neonates whose outcomes are uncertain and unpredictable. The goal of antenatal consultation should rather be to adapt to parental needs and empower them through a personalized decision-making process. This can be done by acknowledging individuality and diversity while respecting the best interests of neonates. The goal is for parents to feel like they have agency and ability and are good parents, before birth, at birth, and after, either in the NICU or until the death of their child.
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, New York, NY 10467, USA
| | - Nathalie Gaucher
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada
| | - Antoine Payot
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada
| | - Kate Robson
- Canadian Premature Babies Foundation, Toronto, Ontario M4N 3M5, Canada
| | - Annie Janvier
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Department of Pediatrics and Clinical Ethics, Sainte-Justine Hospital, University of Montreal, 3175 Chemin Côte-Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada.
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Boland RA, Davis PG, Dawson JA, Doyle LW. What are we telling the parents of extremely preterm babies? Aust N Z J Obstet Gynaecol 2016; 56:274-81. [DOI: 10.1111/ajo.12448] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/13/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Rosemarie Anne Boland
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
- Paediatric Infant Perinatal Emergency Retrieval; Royal Children's Hospital; Parkville Victoria Australia
| | - Peter Graham Davis
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
- Newborn Research Centre; Royal Women's Hospital; Parkville Victoria Australia
| | - Jennifer Anne Dawson
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
- Newborn Research Centre; Royal Women's Hospital; Parkville Victoria Australia
| | - Lex William Doyle
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
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Gallagher K, Aladangady N, Marlow N. The attitudes of neonatologists towards extremely preterm infants: a Q methodological study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F31-6. [PMID: 26178462 PMCID: PMC4717384 DOI: 10.1136/archdischild-2014-308071] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/11/2015] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The attitudes and biases of doctors may affect decision making within Neonatal Intensive Care. We studied the attitudes of neonatologists in order to understand how they prioritise different factors contributing to decision making for extremely preterm babies. DESIGN Twenty-five neonatologists (11 consultants and 14 senior trainees) participated in a Q methodological study about decision making that involved the ranking of 53 statements from agree to disagree in a unimodal shaped grid. Results were explored by person factor analysis using principle component analysis. RESULTS The model of best fit comprised 23 participants contributing a three-factor model, which represented three different attitudes towards decision making and accounted for 59% of the variance. Fourteen statements were ranked in statistically significant similar positions by 23 participants; consensus statements included placing the baby and family at the centre of care, limitation of intervention based upon perceived risk and non-mandatory intervention at birth. Factor 1 participants (n=12) believed that treatment should not be limited based on gestational age and technology should be used to improve treatment. Five factor 2 participants identified strongly with a limit of 24 weeks for treatment, one of whom being polar opposite, believing in treatment at all costs at all gestations. The remaining six factor 3 participants identified strongly with statements that treatment should be withheld on quality of life grounds. CONCLUSIONS This study has identified differences in attitudes towards decision making between individual neonatologists and trainees that may impact how decisions are communicated to families.
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Affiliation(s)
- Katie Gallagher
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - Narendra Aladangady
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK,Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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Perinatal practice in extreme premature delivery: variation in Dutch physicians' preferences despite guideline. Eur J Pediatr 2016; 175:1039-46. [PMID: 27251669 PMCID: PMC4930484 DOI: 10.1007/s00431-016-2741-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/19/2016] [Accepted: 05/25/2016] [Indexed: 11/04/2022]
Abstract
UNLABELLED Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians' preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24(+0/7) weeks of gestational age (GA). Obstetricians' and neonatologists' opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24(+0/7) weeks and intensive care over 26(+0/7) weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, "small for gestational age" fetus, and incomplete course of corticosteroids. CONCLUSION There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. WHAT IS KNOWN • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 (+0/7) weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.
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Branger B, Rouger V, Berlie I, Beucher A, Flamant C, N'guyen The Tich S, Garcia J, Brossier JP, Montcho Y, Hanf M, Roze JC. [Monitoring network for vulnerable children in the Pays de la Loire ("Grandir ensemble" - Cohort LIFT): 10 years of activity 2003-2013]. Arch Pediatr 2014; 22:171-80. [PMID: 25547193 DOI: 10.1016/j.arcped.2014.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/14/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Vulnerable children are at-risk newborns including premature infants and some children with pathologies presented by fear anomalies and deficiencies, most particularly neurological. Monitoring is based on the detection of these abnormalities and their early management. The organization of this monitoring system is based on a network of doctors, mostly pediatricians, trained regularly. The objective of this review was to assess the resources, means, and results of 10 years of follow-up. METHODS The Pays de la Loire network includes 24 maternity wards and 13 neonatal departments. Annual admissions are around 5000 newborns to approximately 45,000 annual births. Upon discharge of newborns, born prematurely at 34 weeks of gestation (WG) or less, or term infants with neurological problems, parents are asked to have their child monitored by a referring doctor. During the consultation, a reference document is filled out by the doctor and sent to the project manager for data collection and specific compensation for private practitioners. Standardized questionnaires were used such as the ASQ (Ages and Stage Questionnaire) completed by parents, the developmental quotient (DQ) with the Lézine Brunet-Revised test (BLR), the intelligence quotient (IQ) with the Wechsler Preschool and Primary Scale of Intelligence (WIPPSI III) completed by psychologists employed in the network, and a questionnaire completed by the teacher at 5 years of age. RESULTS The network started on 1st March 2003, and 28th February 2013, after 10 years of inclusion, 10,800 children had been included. This population accounts for 2.4% of all annual births: 1.1% were included for prematurity less than 33 weeks and 0.25% were term-born infants. The characteristics of children are presented with gestational age, birth weight, and obstetric and neonatal pathologies. The percentage of these children followed was 80% at 2 years and 63% at 5 years. At 2 years, the results are presented according to gestational age with approximately 60% of children without disabilities at 25-26 WG, 73% at 27-28 WG, 77% at 29-30 WG, and 86% at 31-32 WG. Absorptions are diverse and vary according to the age of the child with physical therapy, psychomotor skill work, speech therapy, hearing and vision consultations, and psychology/psychiatry. Assessment tools were refined by specific analyses: the ASQ 24 months (completed by parents) was deemed valid and predictive with respect to IQ (abandoned in 2012), and the grid completed by the teacher was found to predict abnormalities in 5 years. CONCLUSION The Pays de la Loire monitoring network has met its initial objective, namely to detect disabilities early and provide practical help to parents in a population of vulnerable children. Benefits for professionals and other children not followed in the network were observed, with an increase in pediatricians' skills. The benefits of the evaluation results are more difficult to assess with the care than neonatal care in obstetrics. The sustainability of such a network seems assured for healthcare professionals, provided that funding is maintained by the health authorities.
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Affiliation(s)
- B Branger
- « Sécurité naissance-naître ensemble » des Pays de la Loire, 2, rue de la Loire, 1, allée Baco, 44200 Nantes, France.
| | - V Rouger
- « Grandir ensemble », CHU, 44093 Nantes, France
| | - I Berlie
- CAMSP, CHU, 49333 Angers, France
| | | | | | | | - J Garcia
- Maternité, centre hospitalier, 44600 Saint-Nazaire, France
| | - J-P Brossier
- Réseau « Sécurité naissance-naître ensemble » des Pays de la Loire, néonatologie, centre hospitalier, 85925 La Roche-sur-Yon, France
| | - Y Montcho
- Centre hospitalier, 72000 Le Mans, France
| | - M Hanf
- Centre d'investigation clinique - épidémiologie clinique, CHU de Nantes, Nantes, France
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Simard M, Gagné AM, Lambert RD, Tremblay Y. A transdisciplinary approach to the decision-making process in extreme prematurity. BMC Res Notes 2014; 7:450. [PMID: 25023324 PMCID: PMC4107558 DOI: 10.1186/1756-0500-7-450] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 07/03/2014] [Indexed: 11/10/2022] Open
Abstract
Background A wide range of dilemmas encountered in the health domain can be addressed more efficiently by a transdisciplinary approach. The complex context of extreme prematurity, which is raising important challenges for caregivers and parents, warrants such an approach. Methods In the present work, experts from various disciplinary fields, namely biomedical, epidemiology, psychology, ethics, and law, were enrolled to participate in a reflection. Gathering a group of experts could be very demanding, both in terms of time and resources, so we created a web-based discussion forum to facilitate the exchanges. The participants were mandated to solve two questions: “Which parameters should be considered before delivering survival care to a premature baby born at the threshold of viability?” and “Would it be acceptable to give different information to parents according to the sex of the baby considering that outcome differences exist between sexes?” Results The discussion forum was performed over a period of nine months and went through three phases: unidisciplinary, interdisciplinary and transdisciplinary, which required extensive discussions and the preparation of several written reports. Those steps were successfully achieved and the participants finally developed a consensual point of view regarding the initial questions. This discussion board also led to a concrete knowledge product, the publication of the popularized results as an electronic book. Conclusions We propose, with our transdisciplinary analysis, a relevant and innovative complement to existing guidelines regarding the decision-making process for premature infants born at the threshold of viability, with an emphasis on the respective responsabilities of the caregivers and the parents.
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Affiliation(s)
| | | | | | - Yves Tremblay
- Obstetrics, Gynecology & Reproduction, Faculty of Medicine, and Centre de Recherche en Biologie de la Reproduction, Laval University; Centre Hospitalier Universitaire de Québec (CHUQ) Research Center, Rm T-1-49, 2705 Laurier Blvd, Quebec City, QC G1V 4G2, Canada.
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Raju TNK, Mercer BM, Burchfield DJ, Joseph GF. 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. J Perinatol 2014; 34:333-42. [PMID: 24722647 DOI: 10.1038/jp.2014.70] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 02/21/2014] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- T N K Raju
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - B M Mercer
- The Society for Maternal-Fetal Medicine and Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - D J Burchfield
- The American Academy of Pediatrics and University of Florida, Gainesville, FL, USA
| | - G F Joseph
- The American College of Obstetricians and Gynecologists, Washington, DC, USA
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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. Am J Obstet Gynecol 2014; 210:406-17. [PMID: 24725732 DOI: 10.1016/j.ajog.2014.02.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 01/01/2023]
Abstract
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.
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Taittonen L, Korhonen PH, Palomäki O, Luukkaala T, Tammela O. Opinions on the counselling, care and outcome of extremely premature birth among healthcare professionals in Finland. Acta Paediatr 2014; 103:262-7. [PMID: 24205845 DOI: 10.1111/apa.12498] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/13/2013] [Accepted: 11/04/2013] [Indexed: 12/01/2022]
Abstract
AIM To study the opinions of paediatric and obstetric personnel on the perinatal treatment and delivery outcome of infants from 22(+0) to 27(+6) weeks' gestation. METHODS An email questionnaire was sent to 2963 professionals in 32 maternity hospitals in Finland. RESULTS The questionnaire survey was completed by 856 (28%) professionals in 30 hospitals. Opinions on outcome were most pessimistic if the infant was very premature. More than a third (37%) assumed no survival at the earliest gestational age, but none dismissed the possibility at 26 weeks' gestation. Paediatric professionals took a more active approach to the treatment of a premature birth and baby than obstetric personnel. Opinions on treatment activity were based firstly on what was best for the baby and secondly on experience. Gynaecologists reported discussing matters regarding premature birth with the parents more often than paediatricians and were much more likely to be influenced by these discussions. CONCLUSION Paediatric personnel showed a more positive attitude and a more active approach to extremely premature deliveries and babies than obstetric personnel. There would appear to be some inconsistency between prenatal counselling and treatment activity after birth at the limit of viability.
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Affiliation(s)
- L Taittonen
- Department of Paediatrics; Vaasa Central Hospital; Vaasa Finland
| | - PH Korhonen
- Department of Paediatrics; Tampere University Hospital; Tampere Finland
- Tampere Center for Child Health Research; University of Tampere; Tampere Finland
| | - O Palomäki
- Department of Obstetrics and Gynaecology; Tampere University Hospital; Tampere Finland
| | - T Luukkaala
- The Science Center, Pirkanmaa Hospital District and The School of Health Sciences; University of Tampere; Tampere Finland
| | - O Tammela
- Department of Paediatrics; Tampere University Hospital; Tampere Finland
- Tampere Center for Child Health Research; University of Tampere; Tampere Finland
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Silberberg AA, Gallo JE. Managing end-of-life decisions in critical infants: a survey of neonatologists in Cordoba, Argentina. Acta Paediatr 2013; 102:e475-7. [PMID: 23808648 DOI: 10.1111/apa.12333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/12/2013] [Accepted: 06/25/2013] [Indexed: 11/29/2022]
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Condie J, Caldarelli L, Tarr L, Gray C, Rodriquez T, Lantos J, Meadow W. Have the boundaries of the 'grey zone' of perinatal resuscitation changed for extremely preterm infants over 20 years? Acta Paediatr 2013; 102:258-62. [PMID: 23211016 DOI: 10.1111/apa.12119] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/14/2012] [Accepted: 11/30/2012] [Indexed: 12/01/2022]
Abstract
AIM To determine the boundaries of the grey zone of discretionary resuscitation over the past 20 years. BACKGROUND As the likelihood of survival improves over time, the BW- and GA-specific boundaries of discretionary nonresuscitation should fall. HYPOTHESIS Between 1988 and 2008 reductions in BW- and GA-specific mortality would drive a parallel reduction in BW and GA boundaries of discretionary resuscitation. METHODS We determined the likelihood of resuscitation and survival to NICU discharge for all infants born <700 g or <26 gestational weeks from 1988 to 2008. In addition, for 1988, 1993, 1998, 2003 and 2008, we determined the BW and GA for the 10 smallest infants who were resuscitated, and the 10 largest infants who were not resuscitated. We excluded any infant born with congenital anomaly. RESULTS Mortality fell from 80% in 1988 to 28% in 2008, and as expected, the percentage who were resuscitated rose from 63% in 1988-93 to 95% in 2004-2008. However, unexpectedly, over the 20-year study period, the smallest infants who were resuscitated despite extreme immaturity did not change (450-550 g and 23-24 weeks) and the largest infants not resuscitated did not change (600-700 g and 23-24 weeks. CONCLUSION Neither the BW nor GA boundaries of the grey zone of discretionary resuscitation have fallen over the past 20 years. Factors guiding resuscitation at the border of viability are complex and incompletely understood.
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Affiliation(s)
- J Condie
- Department of Pediatrics; The University of Chicago; Chicago; IL; USA
| | - L Caldarelli
- Department of Pediatrics; The University of Chicago; Chicago; IL; USA
| | - L Tarr
- Department of Pediatrics; The University of Chicago; Chicago; IL; USA
| | - C Gray
- Department of Pediatrics; The University of Chicago; Chicago; IL; USA
| | - T Rodriquez
- Department of Pediatrics; The University of Chicago; Chicago; IL; USA
| | - J Lantos
- Department of Pediatrics; Children's Mercy Hospital; Kansas City; MO; USA
| | - W Meadow
- Department of Pediatrics; The University of Chicago; Chicago; IL; USA
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Seaton SE, King S, Manktelow BN, Draper ES, Field DJ. Babies born at the threshold of viability: changes in survival and workload over 20 years. Arch Dis Child Fetal Neonatal Ed 2013; 98:F15-20. [PMID: 22516474 PMCID: PMC3479086 DOI: 10.1136/fetalneonatal-2011-301572] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the care given to the babies born at the threshold of viability over the last 20 years using regional and national data. DESIGN Population-based retrospective study. SETTING Former 'Trent' health region. PARTICIPANTS Babies born between 1 January 1991 and 31 December 2010 at 22(+0) to 25(+6) weeks gestational age. MAIN OUTCOME MEASURE Survival and use of respiratory support. METHODS Data of all babies born between 1 January 1991 and 31 December 2010 with a gestational age of 22(+0) to 25(+6) weeks and admitted to a neonatal unit were extracted from The Neonatal Survey. Use of respiratory support in terms of ventilation and continuous positive airway pressure (CPAP) for this group of babies was calculated as a proportion of the total used by the whole neonatal intensive care population within the defined study area. RESULTS The proportion of babies surviving to discharge increased significantly over time in those born at 24 and 25 weeks (p<0.01) but failed to achieve statistical significance for those at 23 weeks (p=0.08). No babies born at 22 weeks survived. The babies born at 22-25 weeks accounted for 26.3% of all ventilation and 21.5% of CPAP given. CONCLUSION Our work concurs with the current UK guidelines. There could be advantages in focusing the care of babies born at 23 weeks to a small number of intensive care units to allow specialist expertise to develop in all aspects of the management of these babies. However, focusing care will not necessarily improve survival or reduce morbidity.
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Affiliation(s)
- Sarah E Seaton
- Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester LE1 6TP, UK.
| | - Sophie King
- Health Sciences, University of Leicester, Leicester, UK
| | | | | | - David J Field
- Health Sciences, University of Leicester, Leicester, UK
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Guinsburg R, Branco de Almeida MF, Dos Santos Rodrigues Sadeck L, Marba STM, Suppo de Souza Rugolo LM, Luz JH, de Andrade Lopes JM, Martinez FE, Procianoy RS. Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists. J Perinatol 2012; 32:913-9. [PMID: 22460546 DOI: 10.1038/jp.2012.28] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.
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Affiliation(s)
- R Guinsburg
- Department of Pediatrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
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Simic M, Amer-Wåhlin I, Maršál K, Källén K. Effect of various dating formulae on sonographic estimation of gestational age in extremely preterm infants. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:179-185. [PMID: 21953817 DOI: 10.1002/uog.10101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Gestational age (GA) is one of the most important obstetric factors and prediction of date of delivery is usually based on ultrasonographic fetal measurements. Our aim was to determine whether applying three different dating formulae to a cohort of extremely preterm infants influenced the estimation of their GA. METHODS This was a study of 513 infants delivered before 27 gestational weeks, included in a Swedish national population study (EXPRESS), with information available on mid-trimester ultrasonographically measured biparietal diameter and femur length. We applied using these parameters three dating formulae, the Persson & Weldner formula, commonly used in Sweden, the Hadlock formula and the Mul formula, and compared their GA estimates to the clinically reported GA (recorded at delivery) and the last menstrual period (LMP)-based GA. RESULTS The mean reported GA was 173.2 days, corresponding well to the GA according to the Persson & Weldner dating formula (173.3). The mean GA according to LMP, the Hadlock formula and the Mul formula were 176.8, 175.3 and 175.6 days, respectively. The Hadlock and Mul GA estimates differed significantly from that based on the Persson & Weldner formula (both P-values < 10(-6)). Among 68 pregnancies with a reported duration of 22 weeks, 33 (49%) had a duration of 23 weeks or more when GA was calculated according to LMP and 22 (32%) when GA was calculated according to the Hadlock formula. CONCLUSION Estimated GA among infants delivered before 27 gestational weeks varied significantly depending on the dating formula used to calculate the estimated date of delivery; this might influence the clinical management of extremely preterm fetuses and infants.
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Affiliation(s)
- M Simic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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Wali UJ, Andrews V, Banerjee S. Abdominal trauma in pregnancy. Injury 2012; 43:1223. [PMID: 21939969 DOI: 10.1016/j.injury.2011.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 07/11/2011] [Indexed: 02/02/2023]
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Andrews B, Lagatta J, Chu A, Plesha-Troyke S, Schreiber M, Lantos J, Meadow W. The nonimpact of gestational age on neurodevelopmental outcome for ventilated survivors born at 23-28 weeks of gestation. Acta Paediatr 2012; 101:574-8. [PMID: 22277021 DOI: 10.1111/j.1651-2227.2012.02609.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM It has long been known that survival of preterm infants strongly depends upon birth weight and gestational age. This study addresses a different question - whether the gestational maturity improves neurodevelopmental outcomes for ventilated infants born at 23-28 weeks who survive to neonatal intensive care unit (NICU) discharge. METHODS We performed a prospective cohort study of 199 ventilated infants born between 23 and 28 weeks of gestation. Neurodevelopmental impairment was determined using the Bayley Scales of Infant Development-II at 24 months. RESULTS As expected, when considered as a ratio of all births, both survival and survival without neurodevelopmental impairment were strongly dependent on gestational age. However, the percentage of surviving infants who displayed neurodevelopmental impairment did not vary with gestational age for any level of neurodevelopmental impairment (MDI or PDI <50, <60, <70). Moreover, as a higher percentage of ventilated infants survived to NICU discharge at higher gestational ages, but the percentage of neurodevelopmental impairment in NICU survivors was unaffected by gestational age, the percentage of all ventilated births who survived with neurodevelopmental impairment rose - not fell - with increasing gestation age. CONCLUSION For physicians, parents and policy-makers whose primary concern is the presence of neurodevelopmental impairment in infants who survive the NICU, reliance on gestational age appears to be misplaced.
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Affiliation(s)
- Bree Andrews
- Department of Pediatrics, The University of Chicago, IL 60637, USA
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