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Active treatment of extremely preterm infants varies

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Data needed to inform decisions

This article raises important questions about what information should be given to parents during counseling about risks after an extremely preterm birth. To give crude data on the survival rate among all such infants, regardless of whether treatment efforts were made, is misleading and helps to make poor survival a self-fulfilling prophecy.

This report underscores the need for unbiased data to inform chances of overall survival and survival without major neurodevelopmental impairment in extremely preterm infants. Information on survival, morbidity, and policies regarding active intervention should be available to assist parents in making an informed choice about transfer to a specialist hospital, if feasible, and the level of intervention provided after birth.

Neil Marlow, D.M., is professor of neonatal medicine at the Garrett Anderson Institute for Women’s Health, University College London. Dr. Marlow reported that he had no relevant financial disclosures related to the study. He has received personal fees from Novartis, Shire, and GlaxoSmithKline outside the submitted work. He is also a member of the Executive Board of the European Foundation for the Care of Newborn Infants. These comments were taken from an accompanying editorial (N. Engl. J. Med. 2015 May 6 [doi:10.1056/NEJMe1502250]).


 

FROM THE NEW ENGLAND JOURNAL OF MEDICINE

References

For extremely preterm infants in the United States, there is considerable variation among hospitals in terms of the gestational age at which they begin active treatment as well as the survival outcomes, according to a study of nearly 5,000 infants born before 27 weeks’ gestation.

The overall rates of active treatment ranged from 22.1% (interquartile range, 7.7-100) among infants born at 22 weeks’ gestation to 99.8% (interquartile range, 100-100) among those born at 26 weeks’ gestation.

Currently, both the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that clinicians and families make individualized decisions about the treatment of extremely preterm infants based on parental preference and the latest available data on survival and morbidity.

Matthew A. Rysavy Courtesy Matthew Rysavy

Matthew A. Rysavy

Matthew A. Rysavy of the University of Iowa College Of Public Health, Iowa City, and his colleagues identified 4,987 infants born between April 1, 2006, and March 31, 2011, at 24 hospitals included in the National Institute of Child Health and Human Development’s Neonatal Research Network.

Overall, 4,329 (86.8%) received active treatment, including surfactant therapy, tracheal intubation, ventilatory support, parenteral nutrition, epinephrine, or chest compressions.

Treatment was administered to 22.1% of infants born at 22 weeks and 71.8% born at 23 weeks. For those born at 24 weeks’ gestation, the overall percentage receiving active treatment was 97.1%, while 99.6% born at 25 weeks received active treatment, and 99.8% born at 26 weeks received active treatment.

“We found that rates of active treatment among infants born at the end of 22 or 23 weeks of gestation were significantly higher than the rates among infants born earlier during the same weeks,” the researchers wrote. “Our findings suggest that physicians and families may ‘round up’ when considering gestational age in the decision to initiate potentially lifesaving treatment.”

The decision to provide active treatment varied widely between hospitals. The interquartile ranges for hospital rates of active treatment stretched from 7.7% to 100% among infants born at 22 weeks’ gestation, from 52.5% to 96.5% among infants born at 23 weeks’ gestation, and from 95.2% to 100% among infants born at 24 weeks’ gestation.

At 25 and 26 weeks’ gestation, most hospitals provided active treatment, but only 5 of the 24 hospitals in the study provided active treatment to all infants born at 22 through 26 weeks’ gestation, Mr. Rysavy and his associates reported.

Overall survival and survival without severe impairment ranged from 5.1% and 3.4%, respectively, among infants born at 22 weeks’ gestation, to 81.4% and 75.6%, respectively, among those born at 26 weeks’ gestation (N. Engl. J. Med. 2015;372:1801-11 [doi:10.1056/NEJMoa1410689]).

The researchers found that hospital rates of active treatment accounted for 78% and 75% of the between-hospital variation in survival and survival without severe impairment, respectively, for infants born at 22 or 23 weeks’ gestation. For infants born at 24 weeks’ gestation, rates of active treatment accounted for 22% of between-hospital variation in survival and 16% of variation in survival without severe impairment.

The rates, however, did not account for the variation in outcomes for infants born at 25 and 26 weeks’ gestation, Mr. Rysavy and his associates noted.

The study was supported by the National Institutes of Health. One of the researchers reported receiving personal fees from MedNax that were unrelated to the submitted work. Another researcher reported receiving a grant from the Bill and Melinda Gates Foundation that was not associated with the study.

mbock@frontlinemedcom.com

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