The decision as to whether an ELBW neonate should be resuscitated or not is one of the most distressing situations that pediatric care providers have to face. The decision is multifaceted taking into account the ethical, moral, religious and legal views of the parents, the resuscitation team, and the community.
In our case study, the resuscitation of this ELBW infant was accomplished successfully in a community hospital. Given that the technical and personal facilities were relatively limited for such a type of resuscitation, and that the infant’s weight was 650 g and he was 23 weeks gestational age, the decision to resuscitate was a great dilemma. The decision was taken and informed consent obtained from the parents before delivery and after discussion of the possible potential complications, taking into consideration that the baby was precious since the mother had been infertile for 12 years.
Ethically, physicians have a duty to inform the parents of newborns about resuscitation procedures and the potential outcomes for their preterm infants as well as to obtain their consent to proceed with resuscitation and treatment. The process of informing is inherently flawed by the uncertainty of predicting outcomes and is often flawed by the urgency and tension of the potential parents’ situation.8
The other point of critical importance in the decision is that resuscitation should be undertaken urgently and aggressively second by second, because the care administered in the first critical hours of life can have a direct effect on the lifelong outcomes of the ELBW infant. There may be a ‘golden hour’ (GH) of care for ELBW infants that begins with delivery until admission to the NICU.6
The GH initiative goes beyond looking to change one clinical outcome. Instead, it looks at a process for providing care to implement multiple evidence-based practice initiative “bundles” that could improve short and long term outcomes for ELBW infants. During these initial hours, the clinician is faced with complex decisions based on multiple systems that require attention—knowing that a lack of care in these first minutes of life can translate into life-long medical problems.
The promise of the GH in neonatal care lies not only in evidence-based treatment, but also in team structure, communication, and proficiency. Health care providers are faced with a multitude of tasks (cognitive, procedural, communicative, and managerial) that must be completed in a relatively short time. Neonatal resuscitation is complex and takes place in an extremely dynamic and complex environment.6
The pediatric profession has widely acknowledged that there exists a certain ‘grey zone’ of gestational ages, wherein it is not clear whether resuscitation should be attempted, because of the high likelihood of death or disability. Within that grey zone, it has been recommended that informed parents be permitted to choose. There is some variation in opinion regarding the exact location of the margins of the grey zone, but in the United States and the United Kingdom, at least, 23 weeks generally falls within it.9
Literature data confirm that resuscitation should not be indicated for patients aged less than 23 weeks or weighing less than 400 g.4
After this period, if time allows, parents should be informed about the implications of resuscitation procedures, including the possibility of sequelae from diseases associated with a specific gestational age.5
Moreover, the previous outcome of newborns in the neonatal unit should also be included in resuscitation decisions.12
Each clinical case must be analysed separately, always trying to establish adequate communication between parents, obstetricians and paediatricians in order to decide whether resuscitation is appropriate.
Most physicians agree that the delivery room is the proper place for life and death decision.13
Some surveys of parents have indicated that the vast majority of parents prefer resuscitation to be initiated even when there is great uncertainty about the outcome.14
A recent survey of New England neonatologists sought to describe current practices of delivery room decision making and prenatal consultation at the border of viability. Given a hypothetical scenario of impending delivery of a 23.5 to 24.5 week preterm infant of appropriate weight for gestational age, more than three-quarters of neonatologists believed that they and the parents should make the final decision together.6
It seems advisable to recommend that resuscitation should be performed if the diagnosis of gestational age has not been previously established. The “wait and see” strategy before starting resuscitation should be eliminated, since a delay in the procedures can cause cold stress injury, hypoglycemia, hypotension and hypoxaemia in newborn infants, increasing mortality and morbidity.13
The body temperature of premature infants drops precipitously after birth. Hypothermia after admission is a risk factor for mortality in preterm infants and is associated with acid–base abnormalities, respiratory distress, necrotising enterocolitis, and intraventricular haemorrhages. Cold stress in ELBW infants, who are at increased risk for hypothermia, can be significantly reduced by controlling environmental temperature and using wraps.
An early complication of extreme prematurity is respiratory distress caused by surfactant deficiency. The incidence of chronic lung disease can be significantly reduced by standardising practice, ensuring early administration of surfactant, and developing a ventilation protocol.15
Another ethical aspect that should be considered is the time for discontinuation of resuscitation procedures in the delivery room. Literature data reveal that the resuscitation of a newborn after 10 minutes of asystolic cardiac arrest resulting in survival, or survival without severe sequelae, is quite improbable.15
Resuscitation should be suspended after 15 minutes of absent heart rate despite the appropriate use of all resuscitation procedures available.7
Most clinicians agree that some infants are so immature that initiating resuscitation is futile, whereas others think that not initiating resuscitation is unacceptable. Uncertainty exists, however, for infants between these 2 extremes, when it is unclear whether resuscitation is in the infant’s best interest.17
For these infants, selective resuscitation on the basis of parental preference is often considered to be an appropriate option, and general guidelines for decision-making are commonly based on estimated gestational age.7
A recent summary of international guidelines concluded that an individual approach consistent with parents’ wishes should be considered for infants born at 23 to 24 weeks’ gestation.15
Circumstances are important, of course, e.g. additional morbidity, in particular severe malformations.