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Syltern J. Scandinavian perspectives on life support at the border of viability. Front Pediatr 2024; 12:1394077. [PMID: 38720944 PMCID: PMC11076765 DOI: 10.3389/fped.2024.1394077] [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: 02/29/2024] [Accepted: 03/26/2024] [Indexed: 05/12/2024] Open
Abstract
Advances in neonatal medicine have allowed us to rescue extremely preterm infants. However, both long-term vulnerability and the burden of treatment in the neonatal period increase with decreasing gestational age. This raises questions about the justification of life support when a baby is born at the border of viability, and has led to a so-called "grey zone", where many professionals are unsure whether provision of life support is in the child's best interest. Despite cultural, political and economic similarities, the Scandinavian countries differ in their approach to periviable infants, as seen in their respective national guidelines and practices. In Sweden, guidelines and practice are more rescue-focused at the lower end of the border of viability, Danish guidelines emphasizes the need to involve parental views in the decision-making process, whereas Norway appears to be somewhere in between. In this paper, I will give an overview of national consensus documents and practices in Norway, Sweden and Denmark, and reflect on the ethical justification for the different approaches.
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Affiliation(s)
- Janicke Syltern
- Department of Neonatology, St. Olavs Hospital University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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Farooqi A, Hakansson S, Serenius F, Kallen K, Björklund L, Normann E, Domellöf M, Ådén U, Abrahamsson T, Elfvin A, Sävman K, Bergström PU, Stephansson O, Ley D, Hellstrom-Westas L, Norman M. One-year survival and outcomes of infants born at 22 and 23 weeks of gestation in Sweden 2004-2007, 2014-2016 and 2017-2019. Arch Dis Child Fetal Neonatal Ed 2023; 109:10-17. [PMID: 37290903 DOI: 10.1136/archdischild-2022-325164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden. DESIGN/SETTING Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions. MAIN OUTCOME One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined. RESULTS 977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4). CONCLUSION Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA.
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Affiliation(s)
- Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
| | - Stellan Hakansson
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Pediatrics, Swedish Neonatal Quality Register, Umeå Universitet, Umea, Sweden
| | - Fredrik Serenius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Karin Kallen
- Department of Reproductive Epidemiology, Lund University, Lund, Sweden
| | - Lars Björklund
- Departments of Clinical Sciences and Pediatrics, Skåne University Hospital Lund, Lund, Sweden
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences-Pediatrics, Umeå universitet Medicinska fakulteten, Umea, Sweden
| | - Ulrika Ådén
- Woman and Child Health, Karolinska Institute, Stockholm, Sweden
| | - Thomas Abrahamsson
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, Linkoping, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Karin Sävman
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Petra Um Bergström
- Clinical Science and Education at Sodersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Olof Stephansson
- Departments of Medicine and Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - David Ley
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | | | - Mikael Norman
- Neonatal Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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Poupore NS, Chen T, Nguyen SA, Redden L, Teufel Ii RJ, Pecha PP, Carroll WW. Regional differences of tracheostomy in extremely premature neonates across the United States. Int J Pediatr Otorhinolaryngol 2022; 163:111374. [PMID: 36356392 DOI: 10.1016/j.ijporl.2022.111374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify regional differences in tracheostomy rates and mortality in extremely premature neonates. METHODS The 1997-2019 Kids' Inpatient Databases (KID) were queried to identify children who completed 27 weeks gestation (27-wk) or less and 23 weeks gestation (23-wk) or less. Multivariable logistic regressions compared odds of tracheostomy and mortality by region (Midwest (MW), Northeast (NE), South (S), and West (W)) while controlling for demographic variables and comorbidities. Trend analyses were performed using Poisson Regressions. RESULTS There were 2433 27-wk or less infants and 259 23-wk or less who received a tracheostomy. The MW was the only region where higher odds of tracheostomy were seen for 27-wk or less (aOR 1.25 [95%CI 1.12-1.39]) and 23-wk or less (aOR 1.68 [95%CI 1.24-2.27]) neonates when compared to all other regions combined. The S and MW had the highest increase in tracheostomy rates of 27-wk or less (β = 5.1, r = 0.77, p = 0.025; β = 3.8, r = 0.93, p = 0.001), and the MW had the highest increased rate of tracheostomy for 23-wk or less (β = 1.9, r = 0.97, p = 0.008). There were no higher mortality odds by region in 27-wk or less. Mortality was the highest in the S for 23-wk or less (20.8%, p = 0.015). CONCLUSIONS This study identified regional differences in tracheostomy rates in extremely premature infants. Extremely premature neonates in the MW had higher odds of receiving a tracheostomy with comparable mortality rates to other regions. Further research is needed to analyze regional practice differences that may impact the decision to perform a tracheostomy.
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Affiliation(s)
- Nicolas S Poupore
- Medical University of South Carolina, Department of Otolaryngology - Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA; University of South Carolina School of Medicine Greenville, 607 Grove Road, Greenville, SC, 29605, USA.
| | - Tiffany Chen
- Medical University of South Carolina, Department of Otolaryngology - Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA; Hackensack Meridian School of Medicine, 340 Kingsland Street, Nutley, NJ, 07110, USA
| | - Shaun A Nguyen
- Medical University of South Carolina, Department of Otolaryngology - Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA
| | - Lydia Redden
- Medical University of South Carolina, Department of Otolaryngology - Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA
| | - Ronald J Teufel Ii
- Medical University of South Carolina, Department of Pediatrics, 135 Rutledge Avenue, MSC 561, Charleston, SC, 29425, USA
| | - Phayvanh P Pecha
- Medical University of South Carolina, Department of Otolaryngology - Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA
| | - William W Carroll
- Medical University of South Carolina, Department of Otolaryngology - Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA
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Lianou L, Petropoulou C, Lipsou N, Bouza H. Difference in Mortality and Morbidity Between Extremely and Very Low Birth Weight Neonates. Neonatal Netw 2022; 41:257-262. [PMID: 36002278 DOI: 10.1891/nn-2021-0015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/25/2022]
Abstract
Purpose: The aim of the present study was to evaluate the mortality and morbidity of extremely low (ELBW < 1,000 g) and very low birth weight neonates (VLBW: 1,000-1,500 g) hospitalized in a referral NICU of a Children's hospital. Design: A retrospective study was conducted in records of the Neonatal Unit of a tertiary care Children's hospital in Greece from January 2009 to March 2019. Sample: All neonates with birth weight ≤1,500 grams, who were all outborn, were reviewed. Main Outcome Variable: Mortality and morbidity, including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, early onset sepsis, late onset sepsis, retinopathy of prematurity (ROP), ROP treated with laser and neurological findings were investigated. Results: A total of 444 neonates (52 percent males) were analyzed. Among them, 187 (42 percent) were ELBW and 257 (58 percent) were VLBW. The mean gestational age was lower in ELBW neonates compared to VLBW (26.3 ± 2.3 vs. 29.7 ± 2.4 weeks, respectively; p < .001). Mortality was significantly higher in ELBW compared to VLBW neonates (26.7 percent vs. 7.0 percent, p < .001). Morbidity was significantly higher in ELBW compared to VLBW for respiratory distress syndrome (p < .001), bronchopulmonary dysplasia (p < .001), intraventricular hemorrhage (p < .001), periventricular leukomalacia (p < .001), necrotizing enterocolitis (p = .05), early onset sepsis (p < .001) and late onset sepsis (p = 0.001). Similarly, the incidence of ROP and ROP treated with laser was higher in ELBW compared to VLBW neonates (p < .001). Severe neurological findings during follow-up were more prevalent in ELBW compared to VLBW neonates. Finally, the incidence of eye disorders was higher in ELBW compared to VLBW (p = .05). Conclusion: Our results confirmed that ELBW have higher mortality and morbidity than VLBW neonates. Efforts should be made in order to ameliorate perinatal and neonatal care to reduce the burden of prematurity.
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Lundgren P, Morsing E, Hård A, Rakow A, Hellström‐Westas L, Jacobson L, Johnson M, Holmström G, Nilsson S, Smith LE, Sävman K, Hellström A. National cohort of infants born before 24 gestational weeks showed increased survival rates but no improvement in neonatal morbidity. Acta Paediatr 2022; 111:1515-1525. [PMID: 35395120 PMCID: PMC9454067 DOI: 10.1111/apa.16354] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 12/04/2022]
Abstract
AIM To describe survival and neonatal morbidities in infants born before 24 weeks of gestation during a 12-year period. METHODS Data were retrieved from national registries and validated in medical files of infants born before 24 weeks of gestation 2007-2018 in Sweden. Temporal changes were evaluated. RESULTS In 2007-2018, 282 live births were recorded at 22 weeks and 460 at 23 weeks of gestation. Survival to discharge from hospital of infants born alive at 22 and 23 weeks increased from 20% to 38% (p = 0.006) and from 45% to 67% (p < 0.001) respectively. Caesarean section increased from 12% to 22% (p = 0.038) for infants born at 22 weeks. Neonatal morbidity rates in infants alive at 40 weeks of postmenstrual age (n = 399) were unchanged except for an increase in necrotising enterocolitis from 0 to 33% (p = 0.017) in infants born at 22 weeks of gestation. Bronchopulmonary dysplasia was more common in boys than girls, 90% versus 82% (p = 0.044). The number of infants surviving to 40 weeks doubled over time. CONCLUSION Increased survival of infants born before 24 weeks of gestation resulted in increasing numbers of very immature infants with severe neonatal morbidities likely to have a negative impact on long-term outcome.
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Affiliation(s)
- Pia Lundgren
- The Sahlgrenska Centre for Pediatric Ophthalmology ResearchDepartment of Clinical NeuroscienceInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Eva Morsing
- Department of PediatricsClinical Sciences LundLund UniversityLundSweden
| | - Anna‐Lena Hård
- The Sahlgrenska Centre for Pediatric Ophthalmology ResearchDepartment of Clinical NeuroscienceInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Alexander Rakow
- Department of Women’s and Children’s HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | | | - Lena Jacobson
- The Sahlgrenska Centre for Pediatric Ophthalmology ResearchDepartment of Clinical NeuroscienceInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Division of Eye and VisionDepartment of Clinical NeuroscienceKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Mats Johnson
- Gillberg Neuropsychiatry CentreSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Gerd Holmström
- Department of Surgical Sciences/OphthalmologyUppsala UniversityUppsalaSweden
| | - Staffan Nilsson
- Mathematical SciencesChalmers University of TechnologyGothenburgSweden
- Institute of BiomedicineSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Lois E. Smith
- Department of OphthalmologyBoston Children’s HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Karin Sävman
- Region Västra GötalandDepartment of NeonatologyThe Queen Silvia Children´s HospitalSahlgrenska University HospitalGothenburgSweden
- Institute of Neuroscience and PhysiologyDepartment of Psychiatry and NeurochemistrySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Ann Hellström
- The Sahlgrenska Centre for Pediatric Ophthalmology ResearchDepartment of Clinical NeuroscienceInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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6
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Morsing E, Lundgren P, Hård AL, Rakow A, Hellström-Westas L, Jacobson L, Johnson M, Nilsson S, Smith LEH, Sävman K, Hellström A. Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation. Acta Paediatr 2022; 111:1167-1175. [PMID: 35318709 PMCID: PMC9454084 DOI: 10.1111/apa.16316] [Citation(s) in RCA: 7] [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: 12/16/2021] [Revised: 02/11/2022] [Accepted: 02/24/2022] [Indexed: 12/29/2022]
Abstract
AIM This study investigated childhood diagnoses in children born extremely preterm before 24 weeks of gestation. METHODS Diagnoses of neurodevelopmental disorders and selected somatic diagnoses were retrospectively retrieved from national Swedish registries for children born before 24 weeks from 2007 to 2018. Their individual medical files were also examined. RESULTS We studied 383 children born at a median of 23.3 (range 21.9-23.9) weeks, with a median birthweight of 565 (range 340-874) grams. Three-quarters (75%) had neurodevelopmental disorders, including speech disorders (52%), intellectual disabilities (40%), attention deficit hyperactivity disorder (30%), autism spectrum disorders (24%), visual impairment (22%), cerebral palsy (17%), epilepsy (10%) and hearing impairment (5%). More boys than girls born at 23 weeks had intellectual disabilities (45% vs. 27%, p < 0.01) and visual impairment (25% vs. 14%, p < 0.01). Just over half of the cohort (55%) received habilitation care. The majority (88%) had somatic diagnoses, including asthma (63%) and failure to thrive/short stature (39%). CONCLUSION Most children born before 24 weeks had neurodevelopmental disorders and/or additional somatic diagnoses in childhood and were referred to habilitation services. Clinicians should be aware of the multiple health and developmental problems affecting these children. Resources are needed to identify their long-term support needs at an early stage.
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Affiliation(s)
- Eva Morsing
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Pia Lundgren
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna-Lena Hård
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alexander Rakow
- Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | - Lena Jacobson
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Mats Johnson
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Nilsson
- Department of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lois E H Smith
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karin Sävman
- Region Västra Götaland, Department of Neonatology, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann Hellström
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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The proactive approach to mother-infant dyads at 22-24 weeks of gestation: Perspectives from a Swedish center. Semin Perinatol 2022; 46:151536. [PMID: 34844786 DOI: 10.1016/j.semperi.2021.151536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The care of infants born at the lowest extreme of gestation requires dedication, skill, and experience. Most centers apply a selective approach where intensive care at these gestational ages is being offered to a varying proportion of infants depending on the views and experiences of the medical community, the individual physician, and the parents. Consequently, the outcomes differ dramatically with survival rates at 22-23 weeks ranging from 0 to greater than 50%. This paper presents the approach in a center with a long tradition of providing a comprehensive and uniformly active care to all mother-infant dyads from 22+0 weeks of gestation. Important features outlined include prenatal maternal referral and transfer, delivery room management, and initial intensive care.
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8
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Greisen G. The mortality of immature infants, who decides? Acta Paediatr 2022; 111:9-10. [PMID: 34674308 DOI: 10.1111/apa.16130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Gorm Greisen
- Department of Intensive Care of Newborns and Small Children Rigshospitalet University Hospital of Copenhagen Copenhagen Denmark
- Institute of Clinical Medicine University of Copenhagen Copenhagen Denmark
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9
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Berger JN, Elgin TG, Dagle JM, Klein JM, Colaizy TT. Survival and short-term respiratory outcomes of <750 g infants initially intubated with 2.0 mm vs. 2.5 mm endotracheal tubes. J Perinatol 2022; 42:202-208. [PMID: 34675371 PMCID: PMC8529572 DOI: 10.1038/s41372-021-01227-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/17/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare survival and short-term respiratory outcomes of infants weighing <750 g initially intubated with 2.0 mm versus 2.5 mm endotracheal tube (ETT). STUDY DESIGN Retrospective, observational cohort study. RESULTS Of 149 inborn infants weighing <750 g admitted to the NICU, 69 (46%) were intubated with 2.0 mm ETT, 78 with 2.5 mm ETT (53%), and 2 infants never required intubation. Infants intubated with 2.0 mm ETT were more premature (median gestational age (GA) 23 weeks (22, 24) vs. 24 weeks (24, 25) p < 0.0001), smaller (median birth weight 545 g (450, 616) vs. 648 g (579, 700), p < 0.0001), and more frequently intubated at delivery (96% vs. 68%, p < 0.00001). Survival to discharge was similar 77%, 53/69 and 87%, 68/78 (p = 0.09). Adjusted for GA, there were no significant differences in ventilator days (p = 0.7338) or Grade 3 BPD. CONCLUSIONS Premature infants born at a median GA of 23 weeks and median birth weight of 545 g can be successfully managed with 2.0 mm ETT.
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Affiliation(s)
| | - Timothy G. Elgin
- grid.214572.70000 0004 1936 8294University of Iowa, Stead Family Department of Pediatrics, Iowa City, IA USA
| | - John M. Dagle
- grid.214572.70000 0004 1936 8294University of Iowa, Stead Family Department of Pediatrics, Iowa City, IA USA
| | - Jonathan M. Klein
- grid.214572.70000 0004 1936 8294University of Iowa, Stead Family Department of Pediatrics, Iowa City, IA USA
| | - Tarah T. Colaizy
- grid.214572.70000 0004 1936 8294University of Iowa, Stead Family Department of Pediatrics, Iowa City, IA USA
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10
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Boland RA, Cheong JLY, Doyle LW. Changes in long-term survival and neurodevelopmental disability in infants born extremely preterm in the post-surfactant era. Semin Perinatol 2021; 45:151479. [PMID: 34493405 DOI: 10.1016/j.semperi.2021.151479] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Extremely preterm birth before 28 weeks' gestation accounts for less than 1% of births in high-income countries but is associated with high rates of perinatal and infant mortality, and of neurodevelopmental disability in surviving children. Survival rates have increased over time, both overall, and within each week of gestational age since the introduction of exogenous surfactant into clinical care in the early 1990s. However, rates of major neurodevelopmental disability in survivors, whether they be in early childhood or at school-age, have not clearly improved in parallel with the increases in survival. An important strategy to improve survival free of major neurodevelopmental disability is to birth extremely preterm infants in a tertiary perinatal center, where specialist obstetric care for the mother and ongoing intensive care for the infant can both be provided without the potential morbidities associated with postnatal transfer.
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Affiliation(s)
- Rosemarie A Boland
- Clinical Sciences, Murdoch Children's Research, 50 Flemington Road, Parkville, VIC 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia; Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Parkville, VIC, Australia.
| | - Jeanie L Y Cheong
- Clinical Sciences, Murdoch Children's Research, 50 Flemington Road, Parkville, VIC 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia; Neonatal Services, Royal Women's Hospital, Parkville, VIC, Australia
| | - Lex W Doyle
- Clinical Sciences, Murdoch Children's Research, 50 Flemington Road, Parkville, VIC 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Neonatal Services, Royal Women's Hospital, Parkville, VIC, Australia
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11
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Schwaberger B, Urlesberger B, Schmölzer GM. Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review. CHILDREN-BASEL 2021; 8:children8100882. [PMID: 34682147 PMCID: PMC8534639 DOI: 10.3390/children8100882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.
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Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada
- Correspondence: ; Tel.: +1-780-735-4660
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12
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Elternzentrierte ethische Entscheidungsfindung für Frühgeborene im Grenzbereich der Lebensfähigkeit – Reflexion über die Bedeutung probabilistischer Prognosen als Entscheidungsgrundlage. Ethik Med 2021. [DOI: 10.1007/s00481-021-00653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungFrühgeborene im Grenzbereich der Lebensfähigkeit befinden sich in einer prognostischen Grauzone. Das bedeutet, dass deren Prognose zwar schlecht, aber nicht hoffnungslos ist, woraus folgt, dass nach Geburt lebenserhaltende Behandlungen nicht obligatorisch sind. Die Entscheidung für oder gegen lebenserhaltende Maßnahmen ist wertbeladen und für alle Beteiligten enorm herausfordernd. Sie sollte eine zwischen Eltern und Ärzt*innen geteilte Entscheidung sein, wobei sie unbedingt mit den Präferenzen der Eltern abgestimmt sein sollte. Bei der pränatalen Beratung der Eltern legen die behandelnden Ärzt*innen üblicherweise numerische Schätzungen der Prognose vor und nehmen in der Regel an, dass die Eltern ihre Behandlungspräferenzen davon ableiten. Inwieweit probabilistische Daten die Entscheidungen der Eltern in prognostischen Grauzonen tatsächlich beeinflussen, ist noch unzureichend untersucht. In der hier vorliegenden Arbeit wird eine Studie reflektiert, in welcher die Hypothese geprüft wurde, dass numerisch bessere oder schlechtere kindliche Prognosen die Präferenzen werdender Mütter für lebenserhaltende Maßnahmen nicht beeinflussen. In dieser Studie zeigte sich, dass die elterlichen Behandlungspräferenzen eher von individuellen Einstellungen und Werten als von Überlegungen zu numerischen Ergebnisschätzungen herzurühren scheinen. Unser Verständnis, welche Informationen werdende Eltern, die mit einer extremen Frühgeburt konfrontiert sind, wünschen und brauchen, ist noch immer unvollständig. Bedeutende medizinische Entscheidungen werden keineswegs nur rational und prognoseorientiert gefällt. In der vorliegenden Arbeit wird diskutiert, welchen Einfluss der Prozess der Entscheidungsfindung auf das Beratungsergebnis haben kann und welche Implikationen sich aus den bisher vorliegenden Studienergebnissen ergeben – klinisch-praktisch, ethisch und wissenschaftlich.
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Söderström F, Normann E, Jonsson M, Ågren J. Outcomes of a uniformly active approach to infants born at 22-24 weeks of gestation. Arch Dis Child Fetal Neonatal Ed 2021; 106:413-417. [PMID: 33452221 DOI: 10.1136/archdischild-2020-320486] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/11/2020] [Accepted: 12/11/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine survival and outcomes in infants born at 22-24 weeks of gestation in a centre with a uniformly active approach to management of extremely preterm infants. STUDY DESIGN Single-centre retrospective cohort study including infants born 2006-2015. Short-term morbidities assessed included retinopathy of prematurity, necrotising enterocolitis, patent ductus arteriosus, intraventricular haemorrhage, periventricular malacia and bronchopulmonary dysplasia. Neurodevelopmental outcomes assessed included cerebral palsy, visual impairment, hearing impairment and developmental delay. RESULTS Total survival was 64% (143/222), ranging from 52% at 22 weeks to 70% at 24 weeks. Of 133 (93%) children available for follow-up at 2.5 years corrected age, 34% had neurodevelopmental impairment with 11% classified as moderately to severely impaired. Treatment-requiring retinopathy of prematurity, severe bronchopulmonary dysplasia, visual impairment and developmental delay correlated with lower gestational age. CONCLUSIONS A uniformly active approach to all extremely preterm infants results in survival rates that are not distinctly different across the gestational ages of 22-24 weeks and more than 50% survival even in infants at 22 weeks. The majority were unimpaired at 2.5 years, suggesting that such an approach does not result in higher rates of long-term adverse neurological outcome.
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Affiliation(s)
- Fanny Söderström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Backes CH, Rivera BK, Pavlek L, Beer LJ, Ball MK, Zettler ET, Smith CV, Bridge JA, Bell EF, Frey HA. Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2021; 224:158-174. [PMID: 32745459 DOI: 10.1016/j.ajog.2020.07.051] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care). DATA SOURCES PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020. STUDY ELIGIBILITY CRITERIA Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori. STUDY APPRAISAL AND SYNTHESIS METHODS Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I2 statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model. RESULTS Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I2=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I2=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I2=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported. CONCLUSION The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.
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Affiliation(s)
- Carl H Backes
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH; Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH.
| | - Brian K Rivera
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Leanne Pavlek
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lindsey J Beer
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Eli T Zettler
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Research Institute, Seattle, WA
| | - Jeffrey A Bridge
- Suicide Prevention and Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Edward F Bell
- Department of Pediatrics, University of Iowa; Iowa City, IA
| | - Heather A Frey
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
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De Proost L, Verweij EJT, Ismaili M'hamdi H, Reiss IKM, Steegers EAP, Geurtzen R, Verhagen AAE. The Edge of Perinatal Viability: Understanding the Dutch Position. Front Pediatr 2021; 9:634290. [PMID: 33598441 PMCID: PMC7882530 DOI: 10.3389/fped.2021.634290] [Citation(s) in RCA: 10] [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: 11/27/2020] [Accepted: 01/08/2021] [Indexed: 11/17/2022] Open
Abstract
The current Dutch guideline on care at the edge of perinatal viability advises to consider initiation of active care to infants born from 24 weeks of gestational age on. This, only after extensive counseling of and shared decision-making with the parents of the yet unborn infant. Compared to most other European guidelines on this matter, the Dutch guideline may be thought to stand out for its relatively high age threshold of initiating active care, its gray zone spanning weeks 24 and 25 in which active management is determined by parental discretion, and a slight reluctance to provide active care in case of extreme prematurity. In this article, we explore the Dutch position more thoroughly. First, we briefly look at the previous and current Dutch guidelines. Second, we position them within the Dutch socio-cultural context. We focus on the Dutch prioritization of individual freedom, the abortion law and the perinatal threshold of viability, and a culturally embedded aversion of suffering. Lastly, we explore two possible adaptations of the Dutch guideline; i.e., to only lower the age threshold to consider the initiation of active care, or to change the type of guideline.
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Affiliation(s)
- L. De Proost
- Department of Medical Ethics, Philosophy and History of Medicine, Rotterdam, Netherlands
- Department of Neonatology, Rotterdam, Netherlands
- Department of Obstetrics and Gynecology, Rotterdam, Netherlands
| | - E. J. T. Verweij
- Department of Obstetrics and Gynecology, Rotterdam, Netherlands
- Department of Obstetrics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - H. Ismaili M'hamdi
- Department of Medical Ethics, Philosophy and History of Medicine, Rotterdam, Netherlands
| | | | | | - R. Geurtzen
- Department of Neonatology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, Netherlands
| | - A. A. E. Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Ireland S, Larkins S, Ray R, Woodward L. Negativity about the outcomes of extreme prematurity a persistent problem - a survey of health care professionals across the North Queensland region. Matern Health Neonatol Perinatol 2020; 6:2. [PMID: 32368347 PMCID: PMC7189572 DOI: 10.1186/s40748-020-00116-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Extremely preterm babies are at risk of significant mortality and morbidity due to their physiological immaturity. At periviable gestations decisions may be made to either provide resuscitation and intensive care or palliation based on assessment of the outlook for the baby and the parental preferences. Health care professionals (HCP) who counsel parents will influence decision making depending on their individual perceptions of the outcome for the baby. This paper aims to explore the knowledge and attitudes towards extremely preterm babies of HCP who care for women in pregnancy in a tertiary, regional and remote setting in North Queensland. Methods A cross sectional electronic survey of HCP was performed. Perceptions of survival, severe disability and intact survival data were collected for each gestational age from 22 to 27 completed weeks gestation. Free text comment enabled qualitative content analysis. Results Almost all 113 HCP participants were more pessimistic than the actual outcome data suggests. HCP caring for women antenatally were the most pessimistic for survival (p = 0.03 at 23 weeks, p = 0.02 at 25,26 and 27 weeks), severe disability (p = 0.01 at 24 weeks) and healthy outcomes (p = 0.01 at 24 weeks), whilst those working in regional and remote centres were more negative than those in tertiary unit for survival (p = 0.03 at 23,24,25 weeks). Perception became less negative as gestational age increased. Conclusion Pessimism of HCP may be negatively influencing decision making and will negatively affect the way in which parents perceive the chances of a healthy outcome for their offspring.
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Affiliation(s)
- Susan Ireland
- The neonatal unit, Townsville University Hospital, Angus Smith Drive, Douglas, Queensland 4814 Australia.,2Department Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Sarah Larkins
- 2Department Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Robin Ray
- 2Department Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Lynn Woodward
- 2Department Medicine and Dentistry, James Cook University, Townsville, Australia
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17
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Outcomes at 18 to 22 Months of Corrected Age for Infants Born at 22 to 25 Weeks of Gestation in a Center Practicing Active Management. J Pediatr 2020; 217:52-58.e1. [PMID: 31606151 DOI: 10.1016/j.jpeds.2019.08.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/26/2019] [Accepted: 08/12/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the outcomes in actively managed extremely preterm infants after admission to a neonatal intensive care unit. STUDY DESIGN Retrospective cohort of 255 infants born at 22-25 weeks of gestation between 2006 and 2015 at a single study institution. Infants were excluded for congenital anomaly, death in delivery room, or parental request for palliation (n = 7). Neurodevelopmental outcomes were analyzed for 169 of 214 survivors (78.9%) at 18-22 months of corrected age. Outcomes were evaluated using the Mann-Whitney U, χ2, or Fisher exact test, where appropriate. In addition, cognitive scores of the Bayley Scales of Infant-Toddler Development (3rd edition) were assessed using generalized estimating equations. RESULTS Seventy infants born at 22-23 weeks of gestation (22 weeks, n = 20; 23 weeks, n = 50) and 178 infants born at 24-25 weeks of gestation (24 weeks, n = 79; 25 weeks, n = 99 infants) were included. Survival to hospital discharge of those surviving to NICU admission was 78% (55/70; 95% CI, 69%-88%) at 22-23 weeks and 89% (159/178; 95% CI, 84%-93% at 24-25 weeks; P = .02). No or mild neurodevelopmental impairment in surviving infants was 64% (29/45; 95% CI, 50%-77%) at 22-23 weeks and 76% (94/124; 95% CI, 68%-83%; P = .16) at 24-25 weeks. CONCLUSIONS Although survival was lower in infants born at 22-23 weeks than at 24-25 weeks of gestation, the majority of survivors in both groups had positive outcomes with no or mild neurodevelopmental impairments. Further evaluation of school performance is warranted.
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18
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Bourke J, Wong K, Srinivasjois R, Pereira G, Shepherd CCJ, White SW, Stanley F, Leonard H. Predicting Long-Term Survival Without Major Disability for Infants Born Preterm. J Pediatr 2019; 215:90-97.e1. [PMID: 31493909 DOI: 10.1016/j.jpeds.2019.07.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/07/2019] [Accepted: 07/23/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe the long-term neurodevelopmental and cognitive outcomes for children born preterm. STUDY DESIGN In this retrospective cohort study, information on children born in Western Australia between 1983 and 2010 was obtained through linkage to population databases on births, deaths, and disabilities. For the purpose of this study, disability was defined as a diagnosis of intellectual disability, autism, or cerebral palsy. The Kaplan-Meier method was used to estimate the probability of disability-free survival up to age 25 years by gestational age. The effect of covariates and predicted survival was examined using parametric survival models. RESULTS Of the 720 901 recorded live births, 12 083 children were diagnosed with disability, and 5662 died without any disability diagnosis. The estimated probability of disability-free survival to 25 years was 4.1% for those born at gestational age 22 weeks, 19.7% for those born at 23 weeks, 42.4% for those born at 24 weeks, 53.0% for those born at 25 weeks, 78.3% for those born at 28 weeks, and 97.2% for those born full term (39-41 weeks). There was substantial disparity in the predicted probability of disability-free survival for children born at all gestational ages by birth profile, with 5-year estimates of 4.9% and 10.4% among Aboriginal and Caucasian populations, respectively, born at 24-27 weeks and considered at high risk (based on low Apgar score, male sex, low sociodemographic status, and remote region of residence) and 91.2% and 93.3%, respectively, for those at low risk (ie, high Apgar score, female sex, high sociodemographic status, residence in a major city). CONCLUSIONS Apgar score, birth weight, sex, socioeconomic status, and maternal ethnicity, in addition to gestational age, have pronounced impacts on disability-free survival.
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Affiliation(s)
- Jenny Bourke
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Ravisha Srinivasjois
- Department of Neonatology and Paediatrics, Joondalup Health Campus, Perth, Australia; School of Paediatrics and Child Health, University of Western Australia, Perth, Australia; School of Public Health, Curtin University, Perth, Australia; School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Gavin Pereira
- Telethon Kids Institute, The University of Western Australia, Perth, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Carrington C J Shepherd
- Telethon Kids Institute, The University of Western Australia, Perth, Australia; Ngangk Yira Research Centre for Aboriginal Health and Social Equity, Murdoch University, Murdoch, Australia
| | - Scott W White
- Maternal Fetal Medicine Service, King Edward Memorial Hospital, Subiaco, Australia; Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Australia
| | - Fiona Stanley
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Australia.
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Godeluck A, Gérardin P, Lenclume V, Mussard C, Robillard PY, Sampériz S, Benhammou V, Truffert P, Ancel PY, Ramful D. Mortality and severe morbidity of very preterm infants: comparison of two French cohort studies. BMC Pediatr 2019; 19:360. [PMID: 31623604 PMCID: PMC6796444 DOI: 10.1186/s12887-019-1700-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/29/2019] [Indexed: 01/28/2023] Open
Abstract
Background In Reunion Island, a French overseas department, the burden of preterm birth and perinatal mortality exceed those observed in mainland France, despite similar access to standard perinatal care. The purpose of the study was to compare the outcome of two cohorts of NICU-admitted very preterm infants born between 24 and 31 weeks of gestation (WG): the registry-based OGP (Observatoire de la Grande Prématurité, Reunion Island, 2008–2013) cohort, and the nationwide EPIPAGE-2 (mainland France, 2011) observational cohort. Methods The primary outcome was adverse neonatal outcomes defined as a composite indicator of in-hospital mortality or any of three following severe morbidities: bronchopulmonary dysplasia (BPD), necrotising enterocolitis, or severe neurological injury (periventricular leukomalacia or grade III-IV intraventricular haemorrhages). Logistic regression modelling adjusting for confounders was performed. Results A total of 1272 very preterm infants from the Reunionese OGP cohort and 3669 peers from the mainland EPIPAGE-2 cohort were compared. Adverse neonatal outcomes were more likely observed in the OGP cohort (32.6% versus 26.6%, p < 0.001), as result of both increased in-hospital mortality across all gestational age strata and increased BPD among the survivors of the 29–31 WG stratum. After adjusting for gestational age, gender and multiple perinatal factors, the risk of adverse neonatal outcomes was higher in the OGP cohort than in the EPIPAGE-2 cohort across all gestational age strata. Conclusions Despite similar guidelines for standard perinatal care, very preterm infants born in Reunion Island have a higher risk for death or severe morbidity compared with those born in mainland France. Electronic supplementary material The online version of this article (10.1186/s12887-019-1700-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Patrick Gérardin
- INSERM CIC1410 Epidémiologie Clinique, CHU de la Réunion, Saint Pierre, Réunion
| | - Victorine Lenclume
- INSERM CIC1410 Epidémiologie Clinique, CHU de la Réunion, Saint Pierre, Réunion
| | - Corinne Mussard
- INSERM CIC1410 Epidémiologie Clinique, CHU de la Réunion, Saint Pierre, Réunion
| | - Pierre-Yves Robillard
- CHU de la Réunion, Saint Pierre, Réunion.,Centre d'Etudes Périnatales de l'Océan Indien (CEPOI), Université de la Réunion, EA 7388, Saint-Denis, France
| | | | | | - Patrick Truffert
- CHU Lille, EA 2694 Public Health, Epidemiology and Quality of Care unit, F-59000, Lille, France
| | - Pierre-Yves Ancel
- INSERM U 1153, CHU Cochin Hôtel Dieu, Paris, France.,Université Paris Descartes, Paris, France.,URC - CIC1419 Plurithématique, Cochin Hôtel Dieu, Paris, France
| | - Duksha Ramful
- CHU de la Réunion, Saint Denis, Réunion. .,INSERM CIC1410 Epidémiologie Clinique, CHU de la Réunion, Saint Pierre, Réunion. .,Postal address: Neonatal and pediatric intensive care unit, Félix Guyon Hospital, CHU de La Réunion, Allée des Topazes, CS 11021, 97400, Saint-Denis Cedex, La Réunion, France.
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Widding U, Hägglöf B, Farooqi A. Parents of preterm children narrate constructive aspects of their experiences. J Clin Nurs 2019; 28:4110-4118. [DOI: 10.1111/jocn.14948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/24/2019] [Accepted: 05/26/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Bruno Hägglöf
- Department of Clinical Sciences: Child and Adolescent Psychiatry Umeå University Hospital Umeå Sweden
| | - Aijaz Farooqi
- Department of Neonatology: Child and Adolescent Medicine Umeå University Hospital Umeå Sweden
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Adams M, Berger TM, Borradori-Tolsa C, Bickle-Graz M, Grunt S, Gerull R, Bassler D, Natalucci G. Association between perinatal interventional activity and 2-year outcome of Swiss extremely preterm born infants: a population-based cohort study. BMJ Open 2019; 9:e024560. [PMID: 30878980 PMCID: PMC6429852 DOI: 10.1136/bmjopen-2018-024560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To investigate if centre-specific levels of perinatal interventional activity were associated with neonatal and neurodevelopmental outcome at 2 years of age in two separately analysed cohorts of infants: cohort A born at 22-25 and cohort B born at 26-27 gestational weeks, respectively. DESIGN Geographically defined, retrospective cohort study. SETTING All nine level III perinatal centres (neonatal intensive care units and affiliated obstetrical services) in Switzerland. PATIENTS All live-born infants in Switzerland in 2006-2013 below 28 gestational weeks, excluding infants with major congenital malformation. OUTCOME MEASURES Outcomes at 2 years corrected for prematurity were mortality, survival with any major neonatal morbidity and with severe-to-moderate neurodevelopmental impairment (NDI). RESULTS Cohort A associated birth in a centre with high perinatal activity with low mortality adjusted OR (aOR 0.22; 95% CI 0.16 to 0.32), while no association was observed with survival with major morbidity (aOR 0.74; 95% CI 0.46 to 1.19) and with NDI (aOR 0.97; 95% CI 0.46 to 2.02). Median age at death (8 vs 4 days) and length of stay (100 vs 73 days) were higher in high than in low activity centres. The results for cohort B mirrored those for cohort A. CONCLUSIONS Centres with high perinatal activity in Switzerland have a significantly lower risk for mortality while having comparable outcomes among survivors. This confirms the results of other studies but in a geographically defined area applying a more restrictive approach to initiation of perinatal intensive care than previous studies. The study adds that infants up to 28 weeks benefited from a higher perinatal activity and why further research is required to better estimate the added burden on children who ultimately do not survive.
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Affiliation(s)
- Mark Adams
- Department of Neonatology, Universitätsspital Zürich, Zürich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University Zürich, Zürich, Schweiz, Switzerland
| | - Thomas M Berger
- Neonatal and Paediatric Intensive Care Unit, Kinderspital Luzern, Luzern, Switzerland
| | | | - Myriam Bickle-Graz
- Department Woman-Mother-Child, University Hospital Lausanne, Lausanne, Switzerland
| | - Sebastian Grunt
- Division of Neuropaediatrics, Development and Rehabilitation, Children’s University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Roland Gerull
- Department of Neonatology, University of Basel Children’s Hospital (UKBB), Basel, Switzerland
| | - Dirk Bassler
- Department of Neonatology, Universitätsspital Zürich, Zürich, Switzerland
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Shafey A, Bashir RA, Shah P, Synnes A, Yang J, Kelly EN. Outcomes and resource usage of infants born at ≤ 25 weeks gestation in Canada. Paediatr Child Health 2019; 25:207-215. [PMID: 32549735 DOI: 10.1093/pch/pxz002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 11/26/2018] [Accepted: 12/11/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives To determine the outcomes and resource usage of infants born at ≤ 25 weeks gestational age (GA). Methods Retrospective study of infants born between April 2009 and September 2011 at ≤ 25 weeks' GA in all neonatal intensive care units in Canada with follow-up in the neonatal follow-up clinics. Short-term morbidities, neurodevelopmental impairment, significant neurodevelopmental impairment, and resource utilization of infants born at ≤ 24 weeks were compared with neonates born at 25 weeks. Results Of 803 neonates discharged alive, 636 (80.4%) infants born at ≤ 25 weeks' GA were assessed at 18 to 24 months. Caesarean delivery, lower birth weight, and less antenatal steroid exposure were more common in infants born ≤ 24 weeks as compared with 25 weeks. They had significantly higher incidences of ductus arteriosus ligation, severe intracranial hemorrhage, retinopathy of prematurity as well as longer length of stay, central line days, days on respiratory support, days on total parenteral nutrition, days on antibiotics, and need for postnatal steroids. Neurodevelopmental impairment rates were 68.9, 64.5, and 55.6% (P=0.01) and significant neurodevelopmental impairment rates were 39.3, 29.6, and 20.9% (P<0.01) for infants ≤ 23, 24, and 25 weeks GA, respectively. Postdischarge service referrals were higher for those ≤ 23 weeks. Nonsurviving infants born at 25 weeks GA had higher resource utilization during admission than infants born less than 25 weeks. Conclusions Adverse outcomes and resource usage were significantly higher among infants born ≤ 24 weeks GA as compared with 25 weeks GA.
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Affiliation(s)
- Amy Shafey
- Department of Pediatrics, University of Toronto, Toronto, Ontario
| | | | - Prakesh Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario.,Maternal-Infant Care Research Center, Mount Sinai Hospital, Toronto, Ontario
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Junmin Yang
- Maternal-Infant Care Research Center, Mount Sinai Hospital, Toronto, Ontario
| | - Edmond N Kelly
- Department of Pediatrics, University of Toronto, Toronto, Ontario
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Outcomes following a comprehensive versus a selective approach for infants born at 22 weeks of gestation. J Perinatol 2019; 39:39-47. [PMID: 30353079 DOI: 10.1038/s41372-018-0248-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/20/2018] [Accepted: 09/28/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine outcomes at two institutions with different approaches to care among infants born at 22 weeks of gestation. STUDY DESIGN Retrospective, cohort study (2006-2015). Enrollment was limited to mother-infant dyads at 22 weeks of gestation. Proactive care was defined as provision of antenatal corticosteroids and neonatal resuscitation and intensive care. One center (Uppsala, Sweden; UUCH) provided proactive care to all mother-infant dyads (comprehensive center); the other center (Nationwide Children's Hospital, USA; NCH) initiated or withheld treatment based on physician and family preferences (selective center). Differences in outcomes between the two centers were evaluated. RESULT Among 112 live-born infants at 22 weeks of gestation, those treated at UUCH had in-hospital survival rates higher than those at NCH (21/40, 53% vs. 6/72, 8%; P < 0.01). Among the subgroup of infants receiving proactive care (UUCH: 40/40, 100%; NCH: 16/72, 22%) survival was higher at UUCH than at NCH (21/40, 53% vs. 3/16, 19%; P < 0.05). CONCLUSION Even when mother-infant dyads were provided proactive care at NCH (selective center), survival was lower than infants provided proactive care at UUCH (comprehensive center). Differences between the approaches to care at the two centers at 22 weeks of gestation merits further investigation.
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Challenging the gestational age for the limit of viability: proactive care. J Perinatol 2019; 39:1-3. [PMID: 30478270 DOI: 10.1038/s41372-018-0271-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 11/08/2022]
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Diguisto C, Foix L'Helias L, Morgan AS, Ancel PY, Kayem G, Kaminski M, Perrotin F, Khoshnood B, Goffinet F. Neonatal Outcomes in Extremely Preterm Newborns Admitted to Intensive Care after No Active Antenatal Management: A Population-Based Cohort Study. J Pediatr 2018; 203:150-155. [PMID: 30270165 DOI: 10.1016/j.jpeds.2018.07.072] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/06/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the association between active antenatal management and neonatal outcomes in extremely preterm newborns admitted to a neonatal intensive care unit (NICU). STUDY DESIGN This population-based cohort study was conducted in 25 regions of France. Infants born in 2011 between 220/7 and 266/7 weeks of gestation and admitted to a NICU were included. Infants with lethal congenital malformations or death in the delivery room were excluded. A multilevel multivariable analysis was performed, accounting for clustering by mother (multiple pregnancies) and hospital plus individual characteristics, to estimate the association between the main exposure of no active antenatal management (not receiving antenatal corticosteroids, magnesium sulfate, or cesarean delivery for fetal indications) and a composite outcome of death or severe neonatal morbidity (including severe forms of brain or lung injury, retinopathy of prematurity, and necrotizing enterocolitis). RESULTS Among 3046 extremely preterm births, 783 infants were admitted to a NICU. Of these, 138 (18%) did not receive active antenatal management. The risk of death or severe morbidity was significantly higher for infants without active antenatal management (crude OR, 2.60; 95% CI, 1.44-4.66). This finding persisted after adjustment for gestational age (OR, 2.08; 95% CI, 1.19-3.62) and all confounding factors (OR, 1.86; 95% CI, 1.09-3.20). CONCLUSIONS The increased risk of severe neonatal outcomes for extremely preterm babies admitted to a NICU without optimal antenatal management should be considered in individual-level decision making and in the development of professional guidelines for the management of extremely preterm births.
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Affiliation(s)
- Caroline Diguisto
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Maternité Olympe de Gouges, Regional Univeristy Hospital, François Rabelais University, Tours, France.
| | - Laurence Foix L'Helias
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Service de Néonatologie Hopital Armand Trousseau, APHP, Pierre et Marie Curie University, Paris, France
| | - Andrei S Morgan
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Institute for Women's Health, University College London, London, United Kingdom
| | - Pierre-Yves Ancel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu Hopital APHP, Paris, France
| | - Gilles Kayem
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Service de Gynécologie Obstétrique, Trousseau, APHP, Pierre et Marie Curie University, Paris, France
| | - Monique Kaminski
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Franck Perrotin
- Maternité Olympe de Gouges, Regional Univeristy Hospital, François Rabelais University, Tours, France
| | - Babak Khoshnood
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Francois Goffinet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Maternity Unit of Port Royal, Paris Descartes University, Cochin Broca Hotel Dieu Hospitals, DHU Risk in Pregnancy, Cochin Hotel Dieu University Hospital, Assistance Publique des Hopitaux de Paris, Paris, France
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Wilkinson D, Hayden D. In Search of Consistency: Scandinavian Approaches to Resuscitation of Extremely Preterm Infants. Pediatrics 2018; 142:S603-S606. [PMID: 30171149 PMCID: PMC6379056 DOI: 10.1542/peds.2018-0478n] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
Guidelines around the resuscitation of extremely preterm infants have been developed, in part, to ensure consistency in decision-making between hospitals and health professionals. However, such guidelines can also be used to highlight other forms of inconsistency: between countries and between practices in different areas of medicine. In this article, we highlight the ethical advantages (and disadvantages) of consistency. We argue that an internationally uniform approach to ethically complex decisions is neither likely nor desirable.
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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; and
| | - Dean Hayden
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Australia
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Domellöf M, Jonsson B. The Swedish Approach to Management of Extreme Prematurity at the Borderline of Viability: A Historical and Ethical Perspective. Pediatrics 2018; 142:S533-S538. [PMID: 30171138 DOI: 10.1542/peds.2018-0478c] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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
Sweden has a long tradition of being at the forefront of the management of extremely preterm infants. In this article, we explore the historical background, ethical discussions, and evidence from national surveys combined with data from quality registers that form the background of the current Swedish guidelines for the care of extremely preterm infants. The current Swedish national guidelines suggest providing active care for preterm infants from 23 weeks' gestation and considering active care from 22 weeks' gestation. The survival of infants in gestational weeks 22 and 23 has increased and now exceed 50% and 60%, respectively; importantly, the Swedish proactive approach to care at the border of viability has not resulted in an increased proportion of functional impairment among survivors.
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Affiliation(s)
- Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden; and
| | - Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Berger A, Kiechl-Kohlendorfer U, Berger J, Dilch A, Kletecka-Pulker M, Urlesberger B, Wald M, Weissensteiner M, Salzer H. Update: Erstversorgung von Frühgeborenen an der Grenze der Lebensfähigkeit. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0532-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Affiliation(s)
- Helmut Hummler
- Division of Neonatology; Department of Pediatrics; Sidra Medical and Research Center; Doha Qatar
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31
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Humberg A, Härtel C, Paul P, Hanke K, Bossung V, Hartz A, Fasel L, Rausch TK, Rody A, Herting E, Göpel W. Delivery mode and intraventricular hemorrhage risk in very-low-birth-weight infants: Observational data of the German Neonatal Network. Eur J Obstet Gynecol Reprod Biol 2017; 212:144-149. [PMID: 28363188 DOI: 10.1016/j.ejogrb.2017.03.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/21/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Very-low-birth-weight infants (VLBWI) are frequently delivered by cesarean section (CS). However, it is unclear at what gestational age the benefits of spontaneous delivery outweigh the perinatal risks, i.e. intraventricular hemorrhage (IVH) or death. OBJECTIVES To assess the short-term outcome of VLBWI on IVH according to mode of delivery in a population-based cohort of the German Neonatal Network (GNN). STUDY DESIGN A total cohort of 2203 singleton VLBWI with a birth weight <1500g and gestational age between 22 0/7 and 36 6/7 weeks born and discharged between 1st of January 2009 and 31st of December 2015 was available for analysis. VLBWI were stratified into three categories according to mode of delivery: (1) planned cesarean section (n=1381), (2) vaginal delivery (n=632) and (3) emergency cesarean section (n=190). Outcome was assessed in univariate and logistic regression analyses. RESULTS Prevalence of IVH was significantly higher in the vaginal delivery (VD) (26.6%) and emergency CS group (31.1%) as compared to planned CS (17.2%), respectively. In a logistic regression analysis including known risk factors for IVH, vaginal delivery (OR 1.725 [1.325-2.202], p≤0.001) and emergency cesarean section (OR 1.916 [1.338-2.746], p≤0.001) were independently associated with IVH risk. In the subgroup of infants >30 weeks of gestation prevalence for IVH was not significantly different in VD and planned CS (5.3% vs. 4.4%). CONCLUSIONS Our observational data demonstrate that elective cesarean section is associated with a reduced risk of IVH in preterm infants <30 weeks gestational age when presenting with preterm labor.
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Affiliation(s)
- Alexander Humberg
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany.
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Pia Paul
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Kathrin Hanke
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Verena Bossung
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Annika Hartz
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Laura Fasel
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Tanja K Rausch
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany; Institute of Medical Biometry and Statistics, University of Luebeck, University Medical Center of Schleswig-Holstein, Campus Luebeck, Germany
| | - Achim Rody
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Egbert Herting
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
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Monier I, Ancel PY, Ego A, Guellec I, Jarreau PH, Kaminski M, Goffinet F, Zeitlin J. Gestational age at diagnosis of early-onset fetal growth restriction and impact on management and survival: a population-based cohort study. BJOG 2017; 124:1899-1906. [DOI: 10.1111/1471-0528.14555] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2016] [Indexed: 12/01/2022]
Affiliation(s)
- I Monier
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Antoine Beclere Maternity Unit; Department of Obstetrics and Gynaecology; South Paris University Hospitals; AP-HP; Paris France
| | - P-Y Ancel
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
| | - A Ego
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Clinical Research Centre (CICO3); Grenoble University Hospital; Grenoble France
| | - I Guellec
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Paediatric and Neonatal Intensive Care Unit; Armand-Trousseau Hospital; AP-HP; Paris France
| | - P-H Jarreau
- Department of Neonatal Medicine and Intensive Care Unit of Port-Royal; Cochin University Hospital; AP-HP; DHU Risks in Pregnancy; Paris France
| | - M Kaminski
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
| | - F Goffinet
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Port-Royal Maternity Unit; Department of Obstetrics and Gynaecology; Cochin University Hospital; AP-HP; Paris France
| | - J Zeitlin
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
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Younge N, Goldstein RF, Bann CM, Hintz SR, Patel RM, Smith PB, Bell EF, Rysavy MA, Duncan AF, Vohr BR, Das A, Goldberg RN, Higgins RD, Cotten CM. Survival and Neurodevelopmental Outcomes among Periviable Infants. N Engl J Med 2017; 376:617-628. [PMID: 28199816 PMCID: PMC5456289 DOI: 10.1056/nejmoa1605566] [Citation(s) in RCA: 349] [Impact Index Per Article: 49.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Data reported during the past 5 years indicate that rates of survival have increased among infants born at the borderline of viability, but less is known about how increased rates of survival among these infants relate to early childhood neurodevelopmental outcomes. METHODS We compared survival and neurodevelopmental outcomes among infants born at 22 to 24 weeks of gestation, as assessed at 18 to 22 months of corrected age, across three consecutive birth-year epochs (2000-2003 [epoch 1], 2004-2007 [epoch 2], and 2008-2011 [epoch 3]). The infants were born at 11 centers that participated in the National Institute of Child Health and Human Development Neonatal Research Network. The primary outcome measure was a three-level outcome - survival without neurodevelopmental impairment, survival with neurodevelopmental impairment, or death. After accounting for differences in infant characteristics, including birth center, we used multinomial generalized logit models to compare the relative risk of survival without neurodevelopmental impairment, survival with neurodevelopmental impairment, and death. RESULTS Data on the primary outcome were available for 4274 of 4458 infants (96%) born at the 11 centers. The percentage of infants who survived increased from 30% (424 of 1391 infants) in epoch 1 to 36% (487 of 1348 infants) in epoch 3 (P<0.001). The percentage of infants who survived without neurodevelopmental impairment increased from 16% (217 of 1391) in epoch 1 to 20% (276 of 1348) in epoch 3 (P=0.001), whereas the percentage of infants who survived with neurodevelopmental impairment did not change significantly (15% [207 of 1391] in epoch 1 and 16% [211 of 1348] in epoch 3, P=0.29). After adjustment for changes in the baseline characteristics of the infants over time, both the rate of survival with neurodevelopmental impairment (as compared with death) and the rate of survival without neurodevelopmental impairment (as compared with death) increased over time (adjusted relative risks, 1.27 [95% confidence interval {CI}, 1.01 to 1.59] and 1.59 [95% CI, 1.28 to 1.99], respectively). CONCLUSIONS The rate of survival without neurodevelopmental impairment increased between 2000 and 2011 in this large cohort of periviable infants. (Funded by the National Institutes of Health and others; ClinicalTrials.gov numbers, NCT00063063 and NCT00009633 .).
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Affiliation(s)
- Noelle Younge
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Ricki F Goldstein
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Carla M Bann
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Susan R Hintz
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Ravi M Patel
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - P Brian Smith
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Edward F Bell
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Matthew A Rysavy
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Andrea F Duncan
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Betty R Vohr
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Abhik Das
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Ronald N Goldberg
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - Rosemary D Higgins
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
| | - C Michael Cotten
- From the Department of Pediatrics, Duke University, Durham (N.Y., R.F.G., P.B.S., R.N.G., C.M.C.), and the Statistics and Epidemiology Unit, RTI International, Research Triangle Park (C.M.B., A.D.) - both in North Carolina; the Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA (S.R.H.); the Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (R.M.P.); the Department of Pediatrics, University of Iowa, Iowa City (E.F.B., M.A.R.); the Department of Pediatrics, University of Wisconsin, Madison (M.A.R.); the Department of Pediatrics, University of Texas Medical School at Houston, Houston (A.F.D.); the Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.)
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Holsti A, Adamsson M, Hägglöf B, Farooqi A, Serenius F. Chronic Conditions and Health Care Needs of Adolescents Born at 23 to 25 Weeks' Gestation. Pediatrics 2017; 139:peds.2016-2215. [PMID: 28108580 DOI: 10.1542/peds.2016-2215] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We examined chronic conditions, functional limitations, and special health care needs in extremely preterm children (EPT; 23-25 weeks' gestation) born between 1992 and 1998 at 2 Swedish tertiary care centers that offered regional and active perinatal care to all live-born EPT infants. METHODS Of 134 surviving EPT children, 132 (98%) were assessed at 10 to 15 years of age alongside 103 term-born controls. Identification of children with functional limitations and special health care needs was based on a questionnaire administered to parents. Categorization of medical diagnoses and developmental disabilities was based on child examinations, medical record reviews, and parent questionnaires. RESULTS In logistic regression analyses adjusting for social risk factors and sex, the EPT children had significantly more chronic conditions than the term-born controls, including functional limitations (64% vs 6%; odds ratio [OR], 15; 95% confidence interval [CI], 6.1-37.2; P < .001), compensatory dependency needs (60% vs 29%; OR, 3.8; 95% CI, 2.2-6.6; P < .001), and services above those routinely required by children (64% vs 25%; OR, 5.4; 95% CI, 3.0-9.6; P < .001). Specific diagnoses and disabilities for the EPT group versus controls included cerebral palsy (9.1% vs 0%; P < .001), asthma (21.2% vs 6.8%; P = 001), IQ < -2 SD (31.1% vs 4.9%; P < .001), poor motor skills without neurosensory impairment (21.9% vs 1.9%; P < .001), and psychiatric conditions (15.2% vs 1.9%; P < .001). CONCLUSIONS Adolescents born EPT have considerable long-term health and educational needs. Few had severe impairments that curtailed major activities of daily life.
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Affiliation(s)
| | | | - Bruno Hägglöf
- Child and Adolescent Psychiatry, Institute of Clinical Sciences, University of Umeå, Umeå, Sweden; and
| | | | - Fredrik Serenius
- Units of Pediatrics and.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Park JH, Chang YS, Sung S, Ahn SY, Park WS. Trends in Overall Mortality, and Timing and Cause of Death among Extremely Preterm Infants near the Limit of Viability. PLoS One 2017; 12:e0170220. [PMID: 28114330 PMCID: PMC5256888 DOI: 10.1371/journal.pone.0170220] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/01/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To investigate the trends in mortality, as well as in the timing and cause of death, among extremely preterm infants at the limit of viability, and thus to identify the clinical factors that contribute to decreased mortality. Methods We retrospectively reviewed the medical records of 382 infants born at 23–26 weeks’ gestation; 124 of the infants were born between 2001 and 2005 (period I) and 258 were born between 2006 and 2011 (period II). We stratified the infants into two subgroups–“23–24 weeks” and “25–26 weeks”–and retrospectively analyzed the clinical characteristics and mortality in each group, as well as the timing and cause of death. Univariate and multivariate logistic regression analyses were done to identify the clinical factors associated with mortality. Results The overall mortality rate in period II was 16.7% (43/258), which was significantly lower than that in period I (30.6%; 38/124). For overall cause of death, there were significantly fewer deaths due to sepsis (2.4% [6/258] vs. 8.1% [10/124], respectively) and air-leak syndrome (0.8% [2/258] vs. 4.8% (6/124), respectively) during period II than during period I. Among the clinical factors of time period, 1-and 5-min Apgar score, antenatal steroid identified significant by univariate analyses. 5-min Apgar score and antenatal steroid use were significantly associated with mortality in multivariate analyses. Conclusion Improved mortality rate attributable to fewer deaths due to sepsis and air leak syndrome in the infants with 23–26 weeks’ gestation was associated with higher 5-minute Apgar score and more antenatal steroid use.
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Affiliation(s)
- Jae Hyun Park
- Department of Pediatrics, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sein Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- * E-mail: ,
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Holsti A, Adamsson M, Serenius F, Hägglöf B, Farooqi A. Two-thirds of adolescents who received active perinatal care after extremely preterm birth had mild or no disabilities. Acta Paediatr 2016; 105:1288-1297. [PMID: 27275954 DOI: 10.1111/apa.13499] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 03/27/2016] [Accepted: 06/07/2016] [Indexed: 11/27/2022]
Abstract
AIM Active perinatal care (APC) increases the survival of extremely preterm (EPT) infants, but may increase the rate of disabilities. We examined neurodevelopmental outcomes in adolescents aged 10-15 years who were born EPT and received APC in two Swedish tertiary care centres. METHODS Cognitive function was assessed using the Wechsler Intelligence Scale for Children, and neurosensory impairments were assessed by reviewing the case records and a standard parent health questionnaire. The outcomes were compared to term-born controls. RESULTS We assessed 132 EPT adolescents and 103 controls. The rates of cerebral palsy, moderate to severe visual impairment and moderate to severe hearing impairment were 9%, 4% and 6%, respectively, for the EPT children and zero for the controls. Serious cognitive impairment was present in 31% of the EPT adolescents and 5% of the controls. Combining impairments across domains showed that 34% of EPT adolescents had moderate and severe disabilities compared with 5% of the controls. Impairments were more common at 23-24 weeks of gestational age (43%) than at 25 weeks (28.4%). CONCLUSION Two-thirds (66%) of adolescents born EPT who received APC had mild or no disabilities. Our results are relevant for healthcare providers and clinicians counselling families.
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Affiliation(s)
- A Holsti
- Institute of Clinical Sciences; Department of Pediatrics; University of Umeå; Umeå Sweden
| | - M Adamsson
- Institute of Clinical Sciences; Department of Pediatrics; University of Umeå; Umeå Sweden
| | - F Serenius
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - B Hägglöf
- Institute of Clinical Sciences, Child and Adolescent Psychiatry; University of Umeå; Umeå Sweden
| | - A Farooqi
- Institute of Clinical Sciences; Department of Pediatrics; University of Umeå; Umeå Sweden
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Zegers MJ, Hukkelhoven CWPM, Uiterwaal CSPM, Kollée LAA, Groenendaal F. Changing Dutch approach and trends in short-term outcome of periviable preterms. Arch Dis Child Fetal Neonatal Ed 2016; 101:F391-6. [PMID: 26728314 DOI: 10.1136/archdischild-2015-308803] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 11/30/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND In 2006, the Dutch guideline for active treatment of extremely preterm neonates advised to lower the gestational age threshold for active intervention from 26 0/7 to 25 0/7 weeks gestation. OBJECTIVE To evaluate the association between the guideline modification and early neonatal outcome. DESIGN National cohort study, using prospectively collected data from The Netherlands Perinatal Registry. PATIENTS The study population consisted of 9713 infants with a gestational age between 24 0/7 and 29 6/7 weeks, born between 2000 and 2011. Three gestational age subgroups were analysed: 24 0/7 to 24 6/7 weeks (n=269), 25 0/7 to 25 6/7 weeks (n=852) and 26 0/7 to 29 6/7 weeks (n=8592). MAIN OUTCOME MEASURES Neonatal intensive care unit (NICU) admission, live births, neonatal in-hospital mortality, morbidity and favourable outcome (no mortality or morbidity) before (2000-2005; period 1) and after (2007-2011; period 2) introduction of the modified guideline, using χ(2) tests and univariable and multivariable logistic regression analyses. RESULTS In the second period, the proportion of live births and NICU admissions increased and the proportion of neonatal and in-hospital mortality decreased significantly in all subgroups. Morbidity in surviving infants of 25 weeks increased significantly, although the association between guideline modification and morbidity became non-significant after case-mix adjustment. Overall, favourable outcome did not change significantly after guideline modification in all subgroups when adjusted for variation in case-mix. CONCLUSIONS Overall, the trend in mortality gradually declined at all gestational ages, starting before 2006. This suggests that the guideline modification was a formalisation of already existing daily practice.
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Affiliation(s)
- Maria J Zegers
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Cuno S P M Uiterwaal
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Louis A A Kollée
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Limit of viability: The Swiss experience. Arch Pediatr 2016; 23:944-50. [PMID: 27476994 DOI: 10.1016/j.arcped.2016.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/09/2016] [Accepted: 06/24/2016] [Indexed: 11/22/2022]
Abstract
Progress made in the field of perinatology over the past four decades has led to unprecedented low mortality rates for extremely low birth weight infants. However, because rates of important short-term complications and neurodevelopmental impairment among survivors have remained high, the best approach to borderline viable infants continues to be debated. Not surprisingly, guidelines from various national medical societies for the care of infants born at the limit of viability vary considerably. In 2002, the first Swiss recommendations for the care of borderline viable infants were published. They had been developed by a multidisciplinary team of experts from the fields of obstetrics, pediatrics, and neonatology. Despite the availability of national guidelines, center-to-center outcome variability has since persisted, suggesting that care for the most immature infants is not only evidence-based and guideline-driven but also strongly influenced by local neonatal intensive care unit (NICU) culture. In 2011, revised national recommendations for perinatal care at the limit of viability between 22 and 26 completed weeks of gestation were published. It remains to be seen whether this has led to more uniform outcomes across the Swiss centers in the years that followed.
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Widding U, Farooqi A. “I thought he was ugly”: Mothers of extremely premature children narrate their experiences as troubled subjects. FEMINISM & PSYCHOLOGY 2016. [DOI: 10.1177/0959353516636149] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article explores the ways in which mothers of extremely premature children make sense of their negative feelings towards their newborn child and their strategies for performing “proper motherhood”. The analysis was guided by discursive psychology and the feminist debate on attachment, mother–infant bonding, and “good motherhood”. The empirical material was created within a sub-study that set out to explore mothers’ and fathers’ experiences of having a premature child and was part of a project investigating the need for support for premature children and their families. Parents were interviewed about the pregnancy, their experiences of the birth and hospital period, the process of going home, the experiences of pre-school and school, and thoughts about the future. The stories of four mothers, which dealt with negative feelings towards their child and the guilt and distress related to this, were selected for analysis. The mothers handled their troubled positions as subjects unable to feel “motherly love” by referring to notions of attachment and bonding, and good motherhood as being loving and caring. Yet, the mothers also talked about motherhood as being socially constructed, as duties that can be performed without the “right motherly feelings”, and as something that men could also perform.
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Executive Functioning and Learning Skills of Adolescent Children Born at Fewer than 26 Weeks of Gestation. PLoS One 2016; 11:e0151819. [PMID: 26999522 PMCID: PMC4801389 DOI: 10.1371/journal.pone.0151819] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 03/06/2016] [Indexed: 11/25/2022] Open
Abstract
Aims To assess the cognitive and behavioral aspects of executive functioning (EF) and learning skills in extremely preterm (EPT) children compared with term control children aged 10 to 15 years. Methods A total of 132 of 134 (98% of all eligible survivors) EPT children born at the 2 Swedish regional tertiary care centers from 1992 to 1998 (mean age = 12 years, mean birth weight = 718 g, and mean gestational age = 24.4 weeks) and 103 matched term controls were assessed. General intelligence was assessed using the Wechsler Intelligence Scale for Children (WISC-III-R), and cognitive aspects of EF were analyzed using EF-sensitive subscales of the WISC-III-R and Tower test of the Delis-Kaplan Executive Function Scale (D-KEFS). Behaviors related to EF and learning skills were assessed using the Five to Fifteen questionnaire, which is a validated parent and teacher instrument. Academic performance in school was assessed by teachers’ responses on Achenbach’s Teachers Report Form. Analyses performed included multivariate analyses of covariance (ANCOVA and MANCOVA) and logistic regression analyses. Results The EPT children displayed significant deficits in cognitive aspects of EF compared with the controls, exhibiting decreases on the order of 0.9 SD to 1.2 SD for tasks of verbal conceptual reasoning, verbal and non-verbal working memory, processing speed and planning ability (P <0.001 for all). After excluding the children with major neurosensory impairment (NSI) or a Full Scale intelligence quotient (FSIQ) of < 70, significant differences were observed on all tests. Compared with controls, parents and teachers of EPT children reported significantly more EF-related behavioral problems. MANCOVA of teacher-reported learning skills in children with FSIQ >70 and without major NSI revealed no interactions, but significant main effects were observed for the behavioral composite executive function score, group status (EPT vs control) and FSIQ, for which all effect sizes were medium to large. The corresponding findings of MANCOVA of the parent-reported learning skills were very similar. According to the teachers’ ratings, the EPT children were less well adjusted to the school environment. Conclusion EPT children born in the 1990s who received active perinatal care are at an increased risk of executive dysfunction, even after excluding children with significant neurodevelopmental disabilities. Even mild to moderate executive dysfunctions has a significant impact on learning skills. These findings suggest the need for timely interventions that address specific cognitive vulnerabilities and executive dysfunctions.
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Neuropsychological Outcomes in Extremely Preterm Preschoolers Exposed to Tiered Low Oxygen Targets: An Observational Study. J Int Neuropsychol Soc 2016; 22:322-31. [PMID: 26646724 DOI: 10.1017/s1355617715001186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
An observational study of neuropsychological outcomes at preschool age of tiered lowered oxygen (O2) saturation targets in extremely preterm neonates. We studied 111 three-year-olds born <28 weeks' gestational age. Fifty-nine participants born in 2009-2010 during a time-limited quality improvement initiative each received three-tiered stratification of oxygen rates (83-93% until age 32 weeks, 85-95% until age 35 weeks, and 95% after age 35 weeks), the TieredO2 group. Comparisons were made with 52 participants born in 2007-2008 when pre-initiative saturation targets were non-tiered at 89-100%, the Non-tieredO2 group. Neuropsychological domains included general intellectual, executive, attention, language, visuoperceptual, visual-motor, and fine and gross motor functioning. Descriptive and inferential analyses were conducted. Group comparisons were not statistically significant. Descriptively, the TieredO2 group had better general intellectual, executive function, visual-motor, and motor performance and the Non-tieredO2 group had better language performance. Cohen's d and confidence intervals around d were in similar direction and magnitude across measures. A large effect size was found for recall of digits-forward in participants born at 23 and 24 weeks' gestation, d=0.99 and 1.46, respectively. Better TieredO2 outcomes in all domains except language suggests that the tiered oxygen saturation target method is not harmful and merits further investigation through further studies. Benefit in auditory attention appeared greatest in those born at 23 and 24 weeks. Participants in the tiered oxygen saturation group also had fewer ventilation days and a lower incidence of bronchopulmonary dysplasia, perhaps explanatory for these neuropsychological outcomes at age 3.
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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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Perinatal factors associated with active intensive treatment at the border of viability: a population-based study. J Perinatol 2015; 35:705-11. [PMID: 25973945 DOI: 10.1038/jp.2015.48] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 02/16/2015] [Accepted: 03/31/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this national population-based study was to identify perinatal and neonatal factors associated with active intensive treatment (AIT) of infants born at the periviable period of 22 to 24 weeks of gestation. STUDY DESIGN Data from the Israel national very low-birth weight infant database on 2207 infants born alive in 1995 to 2010 at gestational age (GA) 22 to 24 weeks were evaluated. AIT was defined as endotracheal intubation in the delivery room or mechanical ventilation in the neonatal intensive care unit. Multivariable logistic regression analyses were used to identify the independent effect of demographic and perinatal factors on AIT for each gestational week. RESULT Of the 2207 infants born at 22 to 24 weeks GA, 1643 (74.4%) received AIT and 564 (25.6%) received comfort care. AIT increased from 25.5% at 22 weeks to 62.7 and 93.5% at 23 and 24 weeks GA, respectively, reflecting a 4.66 (95% confidence interval (CI) 3.32 to 6.54)- and 29.8 (95% CI 19.9 to 44.6)-fold odds for AIT at 23 and 24 weeks GA, respectively, compared with 22-week GA infants. Perinatal treatments associated with AIT included maternal tocolytic therapy (odds ratio (OR) 1.51, 95% CI 1.04 to 2.20), prenatal steroid therapy, both partial (OR 3.30, 95% CI 2.14 to 5.10) and complete (OR 3.17, 95% CI 1.91 to 5.26) and cesarean delivery (OR 2.68, 95% CI 1.88 to 3.83). Each unit increase in birth weight z-score was associated with an OR of 1.58 (95% CI 1.30 to 1.92) for AIT. At 22 weeks GA, maternal tocolytic treatment was associated with higher odds of AIT. In the 23 and 24-week GA infants, maternal infertility treatment, antenatal steroids, cesarean delivery and higher-birth weight z-scores were significantly associated with AIT. Among 23-week GA infants, AIT decreased significantly in the period 2006 to 2010 compared with 1995 to 2000 (OR 0.51, 95% CI 0.34 to 0.77). CONCLUSION An active approach in obstetric management of pregnancies appears to impact the neonatologists' decision to undertake AIT treatment in infants born at the border of viability. The higher odds for AIT associated with obstetric interventions might contribute to the reported beneficial effect of antenatal steroids and cesarean delivery on the survival of infants born at the border of viability.
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Crane JMG, Magee LA, Lee T, Synnes A, von Dadelszen P, Dahlgren L, De Silva DA, Liston R. Maternal and perinatal outcomes of pregnancies delivered at 23 weeks' gestation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:214-224. [PMID: 26001868 DOI: 10.1016/s1701-2163(15)30307-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation. METHODS This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity. RESULTS A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found. CONCLUSION Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.
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Affiliation(s)
- Joan M G Crane
- Department of Obstetrics and Gynecology, Eastern Health, Memorial University of Newfoundland, St. John's NL
| | - Laura A Magee
- Department of Medicine, University of British Columbia, Vancouver BC; Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Department of School of Population and Public Health, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC
| | - Tang Lee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver BC
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Department of School of Population and Public Health, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC
| | - Leanne Dahlgren
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
| | - Dane A De Silva
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Department of School of Population and Public Health, University of British Columbia, Vancouver BC
| | - Robert Liston
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
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Glass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg 2015; 120:1337-51. [PMID: 25988638 PMCID: PMC4438860 DOI: 10.1213/ane.0000000000000705] [Citation(s) in RCA: 416] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Premature birth is a significant cause of infant and child morbidity and mortality. In the United States, the premature birth rate, which had steadily increased during the 1990s and early 2000s, has decreased annually for 7 years and is now approximately 11.39%. Human viability, defined as gestational age at which the chance of survival is 50%, is currently approximately 23 to 24 weeks in developed countries. Infant girls, on average, have better outcomes than infant boys. A relatively uncomplicated course in the intensive care nursery for an extremely premature infant results in a discharge date close to the prenatal estimated date of confinement. Despite technological advances and efforts of child health experts during the last generation, the extremely premature infant (less than 28 weeks gestation) and extremely low birth weight infant (<1000 g) remain at high risk for death and disability with 30% to 50% mortality and, in survivors, at least 20% to 50% risk of morbidity. The introduction of continuous positive airway pressure, mechanical ventilation, and exogenous surfactant increased survival and spurred the development of neonatal intensive care in the 1970s through the early 1990s. Routine administration of antenatal steroids during premature labor improved neonatal mortality and morbidity in the late 1990s. The recognition that chronic postnatal administration of steroids to infants should be avoided may have improved outcomes in the early 2000s. Evidence from recent trials attempting to define the appropriate target for oxygen saturation in preterm infants suggests arterial oxygen saturation between 91% and 95% (compared with 85%-89%) avoids excess mortality; however, final analyses of data from these trials have not been published, so definitive recommendations are still pending. The development of neonatal neurocritical intensive care units may improve neurocognitive outcomes in this high-risk group. Long-term follow-up to detect and address developmental, learning, behavioral, and social problems is critical for children born at these early gestational ages.The striking similarities in response to extreme prematurity in the lung and brain imply that agents and techniques that benefit one organ are likely to also benefit the other. Finally, because therapy and supportive care continue to change, the outcomes of extremely low birth weight infants are ever evolving. Efforts to minimize injury, preserve growth, and identify interventions focused on antioxidant and anti-inflammatory pathways are now being evaluated. Thus, treating and preventing long-term deficits must be developed in the context of a "moving target."
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Affiliation(s)
- Hannah C Glass
- From the *Department of Neurology and Pediatrics, UCSF Benioff Children's Hospital, San Francisco, California; †Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; ‡Department of Pediatric Anesthesiology, The Alfred I. duPont Hospital for Children, Wilmington, Delaware; §Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; ∥Department of Anesthesiology and Perioperative Care, University of California, San Francisco, San Francisco, California; and ¶Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Serenius F, Blennow M, Maršál K, Sjörs G, Källen K. Intensity of perinatal care for extremely preterm infants: outcomes at 2.5 years. Pediatrics 2015; 135:e1163-72. [PMID: 25896833 DOI: 10.1542/peds.2014-2988] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the association between intensity of perinatal care and outcome at 2.5 years' corrected age (CA) in extremely preterm (EPT) infants (<27 weeks) born in Sweden during 2004-2007. METHODS A national prospective study in 844 fetuses who were alive at the mother's admission for delivery: 707 were live born, 137 were stillborn. Infants were assigned a perinatal activity score on the basis of the intensity of care (rates of key perinatal interventions) in the infant's region of birth. Scores were calculated separately for each gestational week (gestational age [GA]-specific scores) and for the aggregated cohort (aggregated activity scores). Primary outcomes were 1-year mortality and death or neurodevelopmental disability (NDI) at 2.5 years' CA in fetuses who were alive at the mother's admission. RESULTS Each 5-point increment in GA-specific activity score reduced the stillbirth risk (adjusted odds ratio [aOR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) and the 1-year mortality risk (aOR: 0.84; 95% CI: 0.78-0.91) in the primary population and the 1-year mortality risk in live-born infants (aOR: 0.86; 95% CI: 0.79-0.93). In health care regions with higher aggregated activity scores, the risk of death or NDI at 2.5 years' CA was reduced in the primary population (aOR: 0.69; 95% CI: 0.50-0.96) and in live-born infants (aOR: 0.68; 95% CI: 0.48-0.95). Risk reductions were confined to the 22- to 24-week group. There was no difference in NDI risk between survivors at 2.5 years' CA. CONCLUSIONS Proactive perinatal care decreased mortality without increasing the risk of NDI at 2.5 years' CA in EPT infants. A proactive approach based on optimistic expectations of a favorable outcome is justified.
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Affiliation(s)
- Fredrik Serenius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Umeå University, Umeå, Sweden;
| | - Mats Blennow
- Department of Pediatrics, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Karel Maršál
- Department of Obstetrics and Gynecology, Lund University, Lund, Sweden
| | - Gunnar Sjörs
- Department of Pediatrics, Uppsala University Hospital, Uppsala, Sweden; and
| | - Karin Källen
- Centre for Reproductive Epidemiology, Lund University, Lund, Sweden
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48
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Arnold CC, Eichenwald EC. Proactive care at the edge of viability: making the gray zone less gray? Pediatrics 2015; 135:e1288-9. [PMID: 25896836 DOI: 10.1542/peds.2015-0536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Cody C Arnold
- University of Texas Medical School, Houston, Texas; and Children's Memorial Hermann Hospital, Houston, Texas
| | - Eric C Eichenwald
- University of Texas Medical School, Houston, Texas; and Children's Memorial Hermann Hospital, Houston, Texas
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Kaneko M, Yamashita R, Kai K, Yamada N, Sameshima H, Ikenoue T. Perinatal morbidity and mortality for extremely low-birthweight infants: A population-based study of regionalized maternal and neonatal transport. J Obstet Gynaecol Res 2015; 41:1056-66. [DOI: 10.1111/jog.12686] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Masatoki Kaneko
- Graduate School of Nursing Science; University of Miyazaki; Miyazaki Japan
- Department of Obstetrics and Gynecology, Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Rie Yamashita
- Department of Obstetrics and Gynecology, Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Katsuhide Kai
- Department of Obstetrics and Gynecology, Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Naoshi Yamada
- Department of Obstetrics and Gynecology, Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Hiroshi Sameshima
- Department of Obstetrics and Gynecology, Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Tsuyomu Ikenoue
- Department of Obstetrics and Gynecology, Faculty of Medicine; University of Miyazaki; Miyazaki Japan
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Lando A, Kure Østergaard K, Greisen G. Comparing minimally invasive and proactive initial management of extremely preterm infants. Acta Paediatr 2014; 103:827-32. [PMID: 24750177 PMCID: PMC4271678 DOI: 10.1111/apa.12661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/17/2014] [Accepted: 04/15/2014] [Indexed: 11/28/2022]
Abstract
AIM In 2005, we changed our minimally invasive departmental policy for infants born before 26 weeks of gestation to a proactive approach. This included structured guidelines as well as intubation and surfactant in the delivery room, if the parents agreed. The aim of this study was to evaluate the effect of this change of policy. METHOD We compared the Ages and Stages Questionnaire (ASQ) scores, mortality rates and use of mechanical ventilation before (1999-2003) and after (2005-2011) the introduction of the new policy. RESULTS Twenty-two per cent of 61 infants in the before group had an ASQ z-score of <-2 standard deviation at 18 months' corrected age, compared with 26% of 55 infants in the after group. Mortality decreased from 46% to 36% (p = 0.06) and the use of mechanical ventilation at any time during admission increased from 64% to 87% (p < 0.0001). CONCLUSION We demonstrated that changing our policy to a proactive approach to the initial care of infants born before 26 weeks did not result in a major increase in psychomotor deficit. However, the use of mechanical ventilation increased significantly and survival tended to improve.
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Affiliation(s)
- A Lando
- Department of Neonatology The Juliane Marie Centre University Hospital Copenhagen, Rigshospitalet Copenhagen Denmark
| | - K Kure Østergaard
- Department of Neonatology The Juliane Marie Centre University Hospital Copenhagen, Rigshospitalet Copenhagen Denmark
| | - G Greisen
- Department of Neonatology The Juliane Marie Centre University Hospital Copenhagen, Rigshospitalet Copenhagen Denmark
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