The nonimpact of gestational age on neurodevelopmental outcome for ventilated survivors born at 23-28 weeks of gestation
ABSTRACT It has long been known that survival of preterm infants strongly depends upon birth weight and gestational age. This study addresses a different question - whether the gestational maturity improves neurodevelopmental outcomes for ventilated infants born at 23-28 weeks who survive to neonatal intensive care unit (NICU) discharge.
We performed a prospective cohort study of 199 ventilated infants born between 23 and 28 weeks of gestation. Neurodevelopmental impairment was determined using the Bayley Scales of Infant Development-II at 24 months.
As expected, when considered as a ratio of all births, both survival and survival without neurodevelopmental impairment were strongly dependent on gestational age. However, the percentage of surviving infants who displayed neurodevelopmental impairment did not vary with gestational age for any level of neurodevelopmental impairment (MDI or PDI <50, <60, <70). Moreover, as a higher percentage of ventilated infants survived to NICU discharge at higher gestational ages, but the percentage of neurodevelopmental impairment in NICU survivors was unaffected by gestational age, the percentage of all ventilated births who survived with neurodevelopmental impairment rose - not fell - with increasing gestation age.
For physicians, parents and policy-makers whose primary concern is the presence of neurodevelopmental impairment in infants who survive the NICU, reliance on gestational age appears to be misplaced.
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ABSTRACT: IMPORTANCE Many centers delivering infants at 22 to 25 weeks' gestation have limited data regarding their outcomes. A meta-analysis of the 4- to 8-year neurodevelopmental outcomes and exploration of the limitations of meta-analysis would aid physicians and parents to plan care for these infants. OBJECTIVES To determine the rate of moderate to severe and severe neurodevelopmental impairment by gestational age in extremely preterm survivors followed up between ages 4 and 8 years, as well as to determine whether there is a significant difference in impairment rates between the successive weeks of gestation of survivors. EVIDENCE REVIEW A peer-reviewed search strategy obtained English-language publications from MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, and EMBASE. Personal files and reference lists from identified articles were searched. Contemporary cohorts were obtained by restriction to those published after 2004. Inclusion criteria were prospective cohort studies, follow-up rate of 65% or more, use of standardized testing or classification for impairment, reporting by gestation, and meeting prespecified definitions of impairment. We excluded randomized clinical trials, highly selective cohorts, consensus statements, and reviews. Of 1771 identified records, 89 full-text publications were assessed for eligibility. Using the full text of each publication, 2 authors independently followed a 2-step procedure. First, they determined that 9 studies met inclusion criteria. Next, they extracted data using a structured data collection form. Investigators were contacted for data clarification. RESULTS All extremely preterm infant survivors have a substantial likelihood of developing moderate to severe impairment. Wide confidence intervals at the lower gestations (eg, at 22 weeks, 43% [95% CI, 21%-69%]; heterogeneity I2, 0%) and high heterogeneity at the higher gestations (eg, at 25 weeks, 24% [95% CI, 17%-32%]; I2, 66%) limit the results. There was a statistically significant absolute decrease in moderate to severe impairment between each week of gestation (6.5% [95% CI, 2%-11%]). CONCLUSIONS AND RELEVANCE Knowledge of these data, including the limitations, should facilitate discussion during the shared decision-making process about care plans for these infants, particularly in centers without their own data. More prospective, high-quality, complete cohorts are needed.08/2013; 167(10). DOI:10.1001/jamapediatrics.2013.2395
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ABSTRACT: Interventions for extremely preterm infants bring up many ethical questions. Guidelines for intervention in the "periviable" period generally divide infants using predefined categories, such as "futile," "beneficial," and "gray zone" based on completed 7-day periods of gestation; however, such definitions often differ among countries. The ethical justification for using gestational age as the determination of the category boundaries is rarely discussed. Rational criteria used to make decisions regarding life-sustaining interventions must incorporate other important prognostic information. Precise guidelines based on imprecise data are not rational. Gestational age-based guidelines include an implicit judgment of what is deemed to be an unacceptably poor chance of "intact" survival but fail to explore the determination of acceptability. Furthermore, unclear definitions of severe disability, the difficulty, or impossibility, of accurately predicting outcome in the prenatal or immediate postnatal period make such simplistic formulae inappropriate. Similarly, if guidelines for intervention for the newborn are based on the "qualitative futility" of survival, it should be explicitly stated and justified according to established ethical guidelines. They should discuss whether newborn infants are morally different to older individuals or explain why thresholds recommended for intervention are different to recommendations for those in older persons. The aim should be to establish individualized goals of care with families while recognizing uncertainty, rather than acting on labels derived from gestational age categories alone.Seminars in perinatology 02/2014; 38(1):31-7. DOI:10.1053/j.semperi.2013.07.006 · 2.42 Impact Factor
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ABSTRACT: This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.Journal of Perinatology advance online publication, 10 April 2014; doi:10.1038/jp.2014.70.Journal of perinatology: official journal of the California Perinatal Association 04/2014; 35(2). DOI:10.1038/jp.2014.70 · 2.35 Impact Factor