Ethical considerations in the management of infants born at extremely low gestational age
Section snippets
Survival of extremely-low-gestational-age infants
The survival of low birth weight babies predates modern neonatal intensive care units (NICUs).2 However, subsequent to the development of surfactant therapy, the survival of large numbers of extremely premature infants has become routine. Until recently, reports of short- and long-term outcomes have been largely retrospective, single center studies with small populations.3, 4 Moreover, direct comparisons of survival reports are hampered by lack of uniformity in reporting data including analyses
Influence of site of delivery on survival
Does the site of delivery have an impact on the survival or quality of life in survivors? Hack noted that there are wide variations in survival among developed and developing countries.11 Even among the developed countries like the United States, there are variations in outcome related to the site of the infant’s birth. Yeast recently revisited this issue in a comparison of live births and neonatal mortality (death < 28 days) in the state of Missouri for the periods 1982–1986 vs. 1990–1994.36
Early outcome: (0–3 years)
A number of studies have reported on neurodevelopmental outcomes in survivors of extremely low gestational age infants. A summary of the reports of infants born after 1990 classified by gestational age at birth is shown in Table 3. One of the largest and best designed studies on developmental and functional outcomes in infants was recently reported from the NICHD.40 Fourteen hundred and eighty (1,480) surviving infants born between 1993–1994 with birth weights 500–1000 g, were evaluated for
Evidence-based ethics
What are the ethical implications of the evolving data on survival and morbidities for families and health care providers caring for these extremely premature infants? Earlier generations of health care providers had only single center studies, their own hospital’s results and their “hopes” for improved outcomes for these tiniest of patients to guide their decision-making. However, practicing neonatologists and families are now empowered by an evolving literature of short- and intermediate-term
What should we do with this evolving information?
Given the currently available information on the survival and intermediate-term neurodevelopmental outcomes of extremely premature infants, our efforts should focus upon improving short- and long-term outcomes for infants for whom we currently care, not on altering the lower limit of viability. As part of these efforts, we should ensure that families are given useful information both prior to and after delivery to enhance their decisional capabilities and to empower them to advocate for their
Acknowledgements
We acknowledge the contributions of Dr Marilyn Sanders, who was instrumental in initiating this review and was extremely helpful in reviewing the manuscript.
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Cited by (20)
Limit of viability: The Swiss experience
2016, Archives de PediatrieCitation Excerpt :Over the same time period, obstetricians and neonatologists continued to push the limit of viability to lower and lower gestational ages: survival of infants with a gestational age of only 22 0/7 weeks [3] or a birth weight of only 280 g [4] has now been reported. However, this success came at a price and the burden of intensive care imposed on borderline viable infants who ultimately do not survive, and high rates of neurosensory impairment among survivors [5–9] have raised serious ethical questions [10–13]. Consequently, many national medical societies have responded to these concerns with the publication of guidelines to support ethical decision-making in the care of infants born at the limit of viability [14–20].
Ethical Decision Making in the Resuscitation of Extremely Premature Infants: The Health Care Professional's Perspective
2011, Journal of Obstetrics and Gynaecology CanadaMothers' mood and perceptions regarding their preterm infants' behavioral state following a feeding intervention
2010, Journal of Neonatal NursingEthics of maintaining extremely preterm infants
2007, Paediatrics and Child Health