Elsevier

Seminars in Perinatology

Volume 27, Issue 6, December 2003, Pages 458-470
Seminars in Perinatology

Ethical considerations in the management of infants born at extremely low gestational age

https://doi.org/10.1053/j.semperi.2003.10.005Get rights and content

Abstract

With ongoing improvements in technology and the understanding of neonatal physiology, there has been increasing debate regarding the gestational age and birth weight limits of an infants’ capability of sustaining life outside the womb and how this is to be determined. The objective of this review was to address this issue with an analysis of current data (following the introduction of surfactant therapy in 1990) from published studies of survival in extremely low gestational age infants. We found that survival was possible at 22 completed weeks of gestation but only in < 4% of live births reported. Survival increased from 21% at 23 weeks gestational age to 46% at 24 weeks gestational age. Historically, despite continual advances in neonatology, the mortality at 22 weeks has not improved over the past three decades. Combining the data from studies on survival with evidence from developmental biology, we believe that it is not worthwhile to pursue aggressive support of infants born at < 23 weeks gestational age. Given the complicated issues related to morbidity and mortality in infants born at 22 to 25 weeks gestational age and the ethical implications of the available evidence, we propose the need for a consensus derived framework to help in decision-making.

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.

References (85)

  • M.P. Sweet et al.

    Two-year outcome of infants weighing 600 grams or less at birth and born 1994 through 1998

    Obstet Gynecol

    (2003)
  • A.G. Philip

    Neonatal mortality rateis further improvement possible?

    J Pediatr

    (1995)
  • R.O. Bahado-Singh et al.

    Prenatal prediction of neonatal outcome in the extremely low-birth-weight infant

    Am J Obstet Gynecol

    (1998)
  • S.J. Kilpatrick et al.

    Outcome of infants born at 24–26 weeks’ gestation: I. Survival and cost

    Obstet Gynecol

    (1997)
  • D.G. Batton et al.

    The impact of fetal compromise on outcome at the border of viability

    Am J Obstet Gynecol

    (1998)
  • S.B. Effer et al.

    Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study

    Br J Obstet Gynecol

    (2002)
  • D.K. Stevenson et al.

    Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994

    Am J Obstet Gynecol

    (1998)
  • D. El-Metwally et al.

    Survival and neonatal morbidity at the limits of viability in the mid 1990s22 to 25 weeks

    J Pediatr

    (2000)
  • R.E. Piecuch et al.

    Outcome of infants born at 24–26 weeks’ gestation: II. Neurodevelopmental outcome

    Obstet Gynecol

    (1997)
  • J.S. Monro

    A premature infant weighing less than one pound at birth who survived and developed normally

    Can Med Assoc J

    (1939)
  • M.C. Allen et al.

    The limit of viability-neonatal outcome of infants born at 22 to 25 weeks’ gestation

    N Engl J Med

    (1993)
  • N. Hussain et al.

    Pre-discharge outcomes of 22–27 weeks gestational age infants born at tertiary care centers in Connecticut implications for perinatal management

    Conn Med

    (1998)
  • K. Costeloe et al.

    The EPICure studyoutcomes to discharge from hospital for infants born at the threshold of viability

    Pediatrics

    (2000)
  • J.A. Lemons et al.

    Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network

    Pediatrics

    (2001)
  • M.A. Kohn et al.

    Optimal gestational age and birth-weight cutoffs to predict neonatal morbidity

    Med Decis Making

    (2000)
  • D.E. deMello et al.

    Embryonic and early fetal development of human lung vasculature and its functional implications

    Pediatr Dev Pathol

    (2000)
  • J.P. Barbet et al.

    Histological assessment of gestational age in human embryos and fetuses

    Am J Forensic Med Pathol

    (1988)
  • M. DiMaio et al.

    Structural maturation of the human fetal lungA morphometric study of the development of air-blood barriers

    Pediatr Res

    (1989)
  • G.R. Alexander et al.

    US birth weight/gestational age-specific neonatal mortality1995–1997 rates for whites, hispanics, and blacks

    Pediatrics

    (2003)
  • The Vermont-Oxford Trials Network: very low birth weight outcomes for 1990. Investigators of the Vermont-Oxford Trials Network Database Project

    Pediatrics

    (1993)
  • M. Hack et al.

    Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Network

    Pediatrics

    (1991)
  • J.D. Horbar et al.

    Trends in mortality and morbidity for very low birth weight (VLBW) infantsThe Vermont Oxford Network Experience, 1991–1999

    Pediatric Research

    (2001)
  • B.L. Koops et al.

    Neonatal mortality risk in relation to birth weight and gestational ageupdate

    J Pediatr

    (1982)
  • Fetal extrauterine survivabilityReport of the Committee on Fetal and Extrauterine Survivability to the New York State task Force on Life and the Law

    (1988)
  • D.L. Streiner et al.

    Attitudes of parents and health care professionals toward active treatment of extremely premature infants

    Pediatrics

    (2001)
  • M.R. Sanders et al.

    Perceptions of the limit of viabilityneonatologists’ attitudes toward extremely preterm infants

    J Perinatol

    (1995)
  • M.R. Sanders et al.

    Impact of the perception of viability on resource allocation in the neonatal intensive care unit

    J Perinatol

    (1998)
  • S. Saigal et al.

    Differences in preferences for neonatal outcomes among health care professionals, parents, and adolescents

    JAMA

    (1999)
  • J. Oei et al.

    Attitudes of neonatal clinicians towards resuscitation of the extremely premature infantan exploratory survey

    J Paediatr Child Health

    (2000)
  • T.F. McElrath et al.

    Contemporary trends in the management of delivery at 23 weeks’ gestation

    Am J Perinatol

    (2002)
  • B. Cummings et al.

    Neonatologists’ opinions regarding resuscitation of extremely premature infants in Connecticut and Rhode Island

    Conn Med

    (2002)
  • Fetuses and Newborn Infants at the Threshold of Viability

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