From Iowa: Cautious Optimism?

Abstract

I n their report from the University of Iowa Hospitals and Clinics, Watkins et al 1 give what may be viewed as hopeful information on the outcomes of infants born between 22 and 25 weeks of completed gestation. Although limited to a single site, and retrospective in nature, their cohort represents perhaps the largest of infants born in this periviable period (n = 255). Indeed, the cohort of infants born at 22-23 weeks of gestation is the largest such cohort from North America, Australia, or Europe (n = 70), with a remarkable survival to hospital discharge of 78%. Their further demonstration of improved outcomes at 18-22 months of adjusted age, with better than 60% of survivors having no or mild neurodevelopmental impairment, certainly exceeds published norms. 2,3 These figures alone may cause many to beg for what the secret to their success might be. They provide some clues: the consistent provision of antenatal steroids (ANS) by obstetricians and the unwavering active resuscitation of babies by neonatologists, or neonatology fellows, when requested by parents. We are told that all these babies were inborn, assisted by high-frequency ventilation, and cared for in a specialized environment within, but separate from, the remainder of the neonatal intensive care unit (NICU) and by a special dedicated staff. However, other factors also must have contributed over the 10 years of the study's reflection, and these should be published in greater detail. Since the report by Rysavy et al 4 in 2015, the variability in resuscitation and survival of babies from 22-25 weeks of gestation has been well documented. This variability exists elsewhere in the world and is contributed to by many factors. At times resource limitations are cited, 5 as may be guidelines from professional societies 2-although what such guidelines should state remains debatable 6-and attention to perceived infant pain, suffering, and a poor quality of life both in the NICU and, for the many who survive with impairments, throughout their lives. 2,3 The study by Watkins et al would suggest that at least the latter 3 concerns are not insurmountable. And, in America, the resource use matter may be moot, especially given the very small proportion of births occurring between 22-25 weeks of gestation (here note there were only 20 infants born at 22 weeks and 50 at 23 weeks over the 10 years of the Iowa cohort). Yet these results urge caution. If there was an increasing survival and decreasing morbidity over the 10 years reported,