Treatment Choices for Extremely Preterm Infants: An International Perspective

Leeuw, R. de; Cuttini, Marina; Nadai, Michela; Berbik, István; Hansen, Gesine; Kucinskas, Audrunas; Lenoir, Sophie; Levin, Adik; Persson, Jan; Rebagliato, Marisa; Reid, Margaret; Schroell, M; Vonderweid, Umberto de

doi:10.1097/00006254-200105000-00010

Cited by 71 publications

(102 citation statements)

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“…The question focused on CP because it is consistently and clearly reported and is relatively stable among studies. [2][3][4] We felt that this made it a better indicator of knowledge than other, probably more important, aspects of impairment in these infants.…”

Section: Resultsmentioning

confidence: 96%

“…The philosophy of caring for such infants differs between physicians, between hospital centers and between physicians working in different countries. 2,3 Both physicians and nurses routinely underestimate very preterm infants' survival and chances of a good long-term outcome, with nurses being more pessimistic than physicians. 4,5 The extent of resuscitation is known to be related to these estimates of outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Moral distress in the neonatal intensive care unit: caregiver's experience

et al. 2007

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Background: The Neonatal Intensive Care Unit (NICU) can be ethically charged, which can create challenges for health-care workers.Objective: To determine the frequency with which nurses and residents have experienced ethical confrontations and what factors are associated with increased frequency.Design/Methods: An anonymous questionnaire was distributed to nurses in a university center, a high-risk obstetric service, a maternity hospital NICU with 85% in-born patients and an outborn NICU, most of whose preterm admissions are those with surgical complications. Obstetric and pediatric residents in the four universities of the province also received the questionnaire, which included demographics, opinions regarding the gestational age threshold at which resuscitation of a premature infant with bradycardia was appropriate, knowledge of cerebral palsy (CP) outcomes (as an indicator of knowledge about long-term sequelae of prematurity) and questions about ethical confrontation in the NICU.Results: Two hundred and seventy-nine caregivers participated (115 full time nurses and 164 residents). All the distributed questionnaires were completed. Frequent ethical confrontation was reported by 35% of the nurses and 19% of the residents. Among the nurses, moral distress differed significantly between work environments. Nurses working in an out-born NICU and obstetric nurses were more likely to overestimate CP prevalence (P<0.05). Nurses who overestimated CP rates had higher thresholds for resuscitation and were more likely to experience ethical confrontations. Of the residents, 60% were pediatric and 40% obstetric. All groups of residents frequently overestimated the prevalence of CP, and knowledge differed significantly by residency program (P<0.05). The residents who overestimated CP rates had higher thresholds for resuscitation, had more incorrect answers regarding prematurity outcomes and were less likely to have ethical confrontations.Conclusions: A large proportion of nurses and residents report frequent ethical confrontations. Many residents and nurses have limited knowledge of outcomes and high threshold for resuscitation. Ethical confrontation is more common among nurses with poor knowledge about outcomes, and less common in residents with poor knowledge about outcomes.

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Section: Resultsmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

Moral distress in the neonatal intensive care unit: caregiver's experience

et al. 2007

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“…2 A systematic review 3 shows that at p22 weeks, no scientific society recommends active treatment for the mother to protect the fetus beyond offering compassionate care. A general agreement is also evident for week 25 0/7 to 25 6/7 : antenatal steroid administration are recommended, prenatal transport and Cesarean section are indicated to protect the fetus and resuscitation is offered to all infants without fatal anomalies.…”

Section: Introductionmentioning

confidence: 99%

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

et al. 2012

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Objective: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death.Study Design: Prospective cohort of 484 infants with 23 0/7 to 26 6/7 weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of X1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life.Result: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/ neonatal clinical conditions. Conclusion:In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day. Keywords: fetal viability; steroids; cesarean section; cardiopulmonary resuscitation; infant newborn; neonatal mortality Introduction According to the International Liaison Group on Resuscitation, in 2010, 1 for neonates at the margins of viability or those with conditions that predict a high risk of mortality or morbidity, attitudes and practice vary according to region and availability of resources. 2 A systematic review 3 shows that at p22 weeks, no scientific society recommends active treatment for the mother to protect the fetus beyond offering compassionate care. A general agreement is also evident for week 25 0/7 to 25 6/7 : antenatal steroid administration are recommended, prenatal transport and Cesarean section are indicated to protect the fetus and resuscitation is offered to all infants without fatal anomalies. However, there exists a gray area for infants between 23 and 24 weeks, which, in some countries, extends through 25 weeks. 3 The active management of gestations at the limit of viability involves three important clinical decisions: the use of antenatal steroids, delivery method and resuscitation at birth. One prospective cohort study between 1993 and 2007 followed 5476 infants with 23 to 29 weeks gestation admitted for neonatal care. The overall mortality among infants exposed to maternal steroids was lower than in infants not exposed: 19% vs 35% at 24 to 29 weeks and 79% vs 89% at 23 weeks. 4 23, 24, 25 and 26 weeks, respectively. 5 In the same study, 8% of the 125 542 live births with 22 to 31 weeks of gestation had Apgar scores <4 at 5 min, which indicates that resuscitation procedures were frequently needed among preterm infants. However, extensive cardiopulmonary resuscitation at birth

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“…3,[5][6][7][8][9] Important points to be considered are the impact on postneonatal mortality and infant mortality rate. Further evaluation of neurodevelopmental outcome of infants of extremely low birth weight would be critical.…”

mentioning

confidence: 99%

“…15 Clinical practices differ as well, ranging from continuation or discontinuation of treatment up to extreme approaches such as the 'Groningen Regulation' allowing euthanasia on children whose condition does not promise proper development. 6 These practices are strictly related to religious and ethical dilemmas. They extend from the dogma of the 'sanctity' to 'productivity of life', which clearly determines the approach to how these newborns are treated.…”

mentioning

confidence: 99%

Neonatal mortality: the chance for improvement

Gadzinowski

2008

J Perinatol

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Treatment Choices for Extremely Preterm Infants: An International Perspective

Cited by 71 publications

References 0 publications

Moral distress in the neonatal intensive care unit: caregiver's experience

Moral distress in the neonatal intensive care unit: caregiver's experience

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

Neonatal mortality: the chance for improvement

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