Policy Change for Infants Born at the “Cusp of Viability”: A Canadian NICU Experience

Mahgoub, Linda; Manen, Max van; Byrne, Paul; Tyebkhan, Juzer

doi:10.1542/peds.2014-0904

Cited by 11 publications

(7 citation statements)

References 25 publications

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“…Outcome statistics that are derived from populations that include large numbers of infants who did not receive active treatment may seem to support decisions to forgo future treatment, resulting in a “self-fulfilling” prognosis. 36–38 For transparency and accuracy, it is important to take into account whether the infants included in outcome statistics received active treatment when using those data to counsel families. 39 …”

Section: Discussionmentioning

confidence: 99%

Between-Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants

et al. 2015

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BACKGROUND Between-hospital variation in outcomes among extremely preterm infants is largely unexplained and may reflect differences in hospital practices regarding the initiation of active lifesaving treatment as compared with comfort care after birth. METHODS We studied infants born between April 2006 and March 2011 at 24 hospitals included in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Data were collected for 4987 infants born before 27 weeks of gestation without congenital anomalies. Active treatment was defined as any potentially lifesaving intervention administered after birth. Survival and neurodevelopmental impairment at 18 to 22 months of corrected age were assessed in 4704 children (94.3%). RESULTS Overall rates of active treatment ranged from 22.1% (interquartile range [IQR], 7.7 to 100) among infants born at 22 weeks of gestation to 99.8% (IQR, 100 to 100) among those born at 26 weeks of gestation. Overall rates of survival and survival without severe impairment ranged from 5.1% (IQR, 0 to 10.6) and 3.4% (IQR, 0 to 6.9), respectively, among children born at 22 weeks of gestation to 81.4% (IQR, 78.2 to 84.0) and 75.6% (IQR, 69.5 to 80.0), respectively, among those born at 26 weeks of gestation. Hospital rates of active treatment accounted for 78% and 75% of the between-hospital variation in survival and survival without severe impairment, respectively, among children born at 22 or 23 weeks of gestation, and accounted for 22% and 16%, respectively, among those born at 24 weeks of gestation, but the rates did not account for any of the variation in outcomes among those born at 25 or 26 weeks of gestation. CONCLUSIONS Differences in hospital practices regarding the initiation of active treatment in infants born at 22, 23, or 24 weeks of gestation explain some of the between-hospital variation in survival and survival without impairment among such patients. (Funded by the National Institutes of Health.)

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Section: Discussionmentioning

confidence: 99%

Between-Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants

et al. 2015

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“…A ctive resuscitation of infants born at 22 or 23 weeks of gestation is a matter of intense debate. Some neonatal intensive care units (NICUs) are presently changing their policies and offering treatment to these preterm infants born at the border of viability, 1 whereas other NICUs are now withholding treatment that they offered 10 years ago. 2 This contrast is highlighted by a recent study by Rysavy et al, 3 in which interquartile ranges for active treatment of infants born at 22 weeks of gestation were 8% to 100% within 24 hospitals in the United States.…”

mentioning

confidence: 99%

Survival Among Infants Born at 22 or 23 Weeks’ Gestation Following Active Prenatal and Postnatal Care

et al. 2016

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IMPORTANCE Rates of survival for infants born at the border of viability are still low and vary considerably among neonatal intensive care units. OBJECTIVE To determine whether higher survival rates and better short-term outcomes for infants born at 22 or 23 weeks' gestation may be achieved by active prenatal and postnatal care. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of 106 infants born at 22 or 23 weeks of gestation at a level III neonatal intensive care unit at EXPOSURES Active prenatal and postnatal care.MAIN OUTCOMES AND MEASURES Survival until hospital discharge and survival without neonatal or short-term severe complications (defined as high-grade intraventricular hemorrhage, surgery for abdominal complications, bronchopulmonary dysplasia, or retinopathy of prematurity). RESULTSOf 106 liveborn infants (45 born at 22 weeks and 61 born at 23 weeks and 6 days), 20 (19%) received palliative care (17 born at 22 weeks and 3 born at 23 weeks), and 86 (81%) received active care (28 born at 22 weeks and 58 born at 23 weeks). Of the 86 infants who received active care (mean [SD] maternal age, 32 [6] years), 58 (67%) survived until hospital discharge (17 born at 22 weeks and 41 born at 23 weeks). Eighty-five infants survived without severe complications, with 1 infant born at 22 weeks excluded because of missing data (6 of 27 [22%] born at 22 weeks, and 16 of 58 [28%] born at 23 weeks). Survival was predicted by the Apgar score after 5 minutes (odds ratio, 0.62 [95% CI, 0.46-0.84]) and birth weight (odds ratio, 0.001 [95% CI, 0.00-0.40]). CONCLUSIONS AND RELEVANCE One in 4 infants born at the border of viability and offered active care survived without severe complications. This finding should be considered for individualized parental approaches and decision making. Active follow-up information is required to determine childhood outcomes.

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“…58,59 We developed a guideline to facilitate the SDM process with parents regarding the early care of EPI; beyond GA, it considers the medical prognosis and the parents' perspective as key. We based our guideline development process on the steps outlined in the AGREE II tool.…”

Section: Discussionmentioning

confidence: 99%

Shared decision making for infants born at the threshold of viability: a prognosis-based guideline

et al. 2016

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Policy Change for Infants Born at the “Cusp of Viability”: A Canadian NICU Experience

Cited by 11 publications

References 25 publications

Between-Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants

Between-Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants

Survival Among Infants Born at 22 or 23 Weeks’ Gestation Following Active Prenatal and Postnatal Care

Shared decision making for infants born at the threshold of viability: a prognosis-based guideline

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