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Few treatment decisions in any area of medicine have greater consequences than the decisions made shortly after birth to give intensive care or comfort care to extremely preterm infants. Obstetricians and neonatologists continue to struggle with ethical questions such as “How can we formulate better evidence-based treatment thresholds in judging when intensive care is ethically mandatory, unwarranted, or optional?”1 and “How can parents be best informed and counseled?”
Results of the cohort study by Bader et al, published in this issue of Pediatrics,2 are an important addition to the evidence base for these decisions. Theirs is one of only a few recent population-based studies that are free of the referral biases in virtually all center-based studies. Other important strengths include prospective data collection and entry into a computerized database with error checks. Prenatal and post-natal risk factors were related to predischarge mortality for >99% of the 3768 infants born alive at 23 to 26 weeks’ gestational age (GA) in Israel between 1995 and 2006. A limitation of the study is their lack of analyses to assess the extent to which mortality was affected by center differences or decisions to forego intensive care. In addition, there were no data about longer-term outcomes, including profound impairment, an outcome that some people consider worse than death.3,4
In multivariable regression models, the likelihood of death decreased with not only increasing GA but also higher birth weight (BW), female gender, singleton gestation, and antenatal steroid treatment. These same factors were also associated recently with a reduced mortality rate in large population-based analyses in California5 and center-based analyses in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN).6
Bader et al2 found that the decrease in mortality rate with antenatal steroid treatment and with a higher BW (per 100-g increase) was comparable to that of a 1-week increase in GA. In the California5 and NRN studies,6 this was true for not only higher BW and antenatal steroid treatment but also for female gender and singleton gestation. The reduction in risk of impairment and of profound impairment at 18 to 22 months’ corrected age (postterm) associated with each of these 4 factors was also comparable to a 1-week increase in GA in the NRN study.
Bader et al2 used BW and gender to classify infants into 3 categories on the basis of gender-specific BW percentiles and then developed simple tables for clinicians to use in assessing prognosis. This approach involves some uncertainty in determining appropriate BW standards7 and introduces approximations in grouping infants with different percentiles into the same category. Although this categorization was necessary for prediction tables, the infant’s exact BW can be used as one of multiple factors in assessing prognosis on Web-based tools such as that on the NICHD Web site (www.nichd.nih.gov/neonatalestimates).8
What are the implications of these and other recent outcome studies9–12 for decision-making in the care of extremely preterm fetuses or newborn infants? With the editors’ encouragement, we offer the following thoughts.
Approaches such as the following can be considered.
Table 1 lists probability estimates of outcome and resource use of ventilated infants in the NRN. It is provided to stimulate discussion of the threshold probability estimates that may be considered in designating intensive care as unwarranted, investigational, or optional. Whatever guidelines are developed, they obviously should be reconsidered as new information emerges.
Despite the advances in assessing the prognosis of extremely preterm infants, much additional study is needed to promote better informed parental counseling and treatment decisions for extremely preterm infants. Although beyond the scope of this commentary, promising areas of investigation have been suggested elsewhere.1,23
This work was supported in part by National Institutes of Health grant U10HD021373-22.
Funded by the National Institutes of Health (NIH).
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.