PEDIATRICS Vol. 97 No. 5 May 1996, pp. 636-643
This Article
Right arrow Full Text (PDF)
Right arrow P3Rs: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when P3Rs are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Meadow, W.
Right arrow Articles by Lantos, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Meadow, W.
Right arrow Articles by Lantos, J.

Birth Weight-specific Mortality for Extremely Low Birth Weight Infants Vanishes by Four Days of Life: Epidemiology and Ethics in the Neonatal Intensive Care Unit

William Meadow MD, PhD1, Tyler Reimshisel BA1, and John Lantos MD1

1 Department of Pediatrics and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago

Background. The persistent differences between those who question the appropriateness of aggressive resuscitative measures for many extremely low birth weight (ELBW) infants (birth weight <1001 g) and those who generally initiate such treatment has been a source of ongoing tension for physicians, parents, judges, and policymakers. We believe that much of this tension may be a result of the way the issue is framed. We began this study with the intuition that although many ELBW infants die, most succumb quickly. Were this true, discussions that considered only survival rates might miss the point. A more relevant statistic might be the degree to which interventions prolong dying, extend suffering, or use resources for infants who will eventually die.

Methods. We determined the survival and nonsurvival for 429 ELBW infants admitted to our neonatal intensive care unit (NICU) for 3 years. We noted particularly the relationship between birth weight, illness seerity (fraction of inspired oxygen [Fio2] requirement for infants requiring mechanical ventilation), and the time course of mortality for nonsurvivors. We next calculated a resource utilization index (NICU bed days occupied by survivors and nonsurvivors) for each patient and for the population as a whole. Finally, we determined how NICU resources were distributed among infants who eventually died and those who survived.

Results. Of the 429 ELBW infants alive on day of life (DOL) 1, 202 (47%) survived to be discharged. On DOL 1, both birth weight and illness severity independently predicted likelihood of survival. Approximately 80% of ELBW deaths occurred in the first 3 days of life—consequently, once an infant had survived to DOL 4, the like-lihood of survival was dramatically enhanced (81% for the 249 patients alive on DOL 4). In addition, although survival for DOL 4 infants continued to depend on illness severity, survival no longer depended on birth weight. These observations on DOL 4 were confirmed in the subpopulation of 212 infants whose birth weight was <750 g. Overall, although 53% of ELBW babies admitted died, only sim13% of all NICU bed-days (a proxy for resource allocation) were devoted to infants who did not survive. This figure did not vary as a function of birth weight.

Conclusions. Generally, when we talk of survival rates to parents, ethics committees, or policy makers, we base our predictions largely on birth weight. The data presented here suggest that predictions should be corrected by including DOL and that, when this is done, the prognostic value of birth weight rapidly diminishes. In addition, birth weight-specific mortality and day of death for nonsurvivors correlated inversely; that is, more of the smaller infants died, but the doomed ones died more quickly. Consequently, medical resources allocated to nonsurvivors remained low, and independent of birth weight. This formulation lends weight both to the reasonableness of physicians in offering NICU care to ELBW infants with unlikely prospects for survival, and of parents and surrogate decision-makers in requesting/assenting to it.

Submitted on December 1, 1994
Accepted on April 28, 1995




This article has been cited by other articles:


Home page
 PediatricsHome page
W. Meadow, J. Lagatta, B. Andrews, L. Caldarelli, A. Keiser, J. Laporte, S. Plesha-Troyke, M. Subramanian, S. Wong, J. Hron, et al.
Just, in Time: Ethical Implications of Serial Predictions of Death and Morbidity for Ventilated Premature Infants
Pediatrics, April 1, 2008; 121(4): 732 - 740.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
N. Ambalavanan, W. A. Carlo, G. Bobashev, E. Mathias, B. Liu, K. Poole, A. A. Fanaroff, B. J. Stoll, R. Ehrenkranz, L. L. Wright, et al.
Prediction of Death for Extremely Low Birth Weight Neonates
Pediatrics, December 1, 2005; 116(6): 1367 - 1373.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
W. Meadow, G. Lee, K. Lin, and J. Lantos
Changes in Mortality for Extremely Low Birth Weight Infants in the 1990s: Implications for Treatment Decisions and Resource Use
Pediatrics, May 1, 2004; 113(5): 1223 - 1229.
[Abstract] [Full Text] [PDF]

Home page
 Obstet GynecolHome page
B. Kahn, L. H. Lumey, P. A. Zybert, J. M. Lorenz, J. Cleary-Goldman, M. E. D'Alton, and J. N. Robinson
Prospective Risk of Fetal Death in Singleton, Twin, and Triplet Gestations: Implications for Practice
Obstet. Gynecol., October 1, 2003; 102(4): 685 - 692.
[Abstract] [Full Text] [PDF]

Home page
 NeoReviewsHome page
W. Meadow and J. Lantos
Ethics at the Limit of Viability: A Premie's Progress
NeoReviews, June 1, 2003; 4(6): e157 - 162.
[Full Text] [PDF]

Home page
 PediatricsHome page
H. MacDonald and Committee on Fetus and Newborn
Perinatal Care at the Threshold of Viability
Pediatrics, November 1, 2002; 110(5): 1024 - 1027.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
W. Meadow, L. Frain, Y. Ren, G. Lee, S. Soneji, and J. Lantos
Serial Assessment of Mortality in the Neonatal Intensive Care Unit by Algorithm and Intuition: Certainty, Uncertainty, and Informed Consent
Pediatrics, May 1, 2002; 109(5): 878 - 886.
[Abstract] [Full Text] [PDF]

Home page
 Ann. N. Y. Acad. Sci.Home page
M.-J. LEE, E. L. CONNER, L. CHARAFEDDINE, J. R. WOODS JR., and G. DEL PRIORE
A Critical Birth Weight and Other Determinants of Survival for Infants with Severe Intrauterine Growth Restriction
Ann. N.Y. Acad. Sci., September 1, 2001; 943(1): 326 - 339.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
V. Tommiska, K. Heinonen, S. Ikonen, P. Kero, M.-L. Pokela, M. Renlund, M. Virtanen, and V. Fellman
A National Short-Term Follow-Up Study of Extremely Low Birth Weight Infants Born in Finland in 1996-1997
Pediatrics, January 1, 2001; 107(1): 2e - 2.
[Abstract] [Full Text]

Home page
 J. Med. EthicsHome page
M. L Gross
Avoiding anomalous newborns: preemptive abortion, treatment thresholds and the case of baby Messenger
J. Med. Ethics, August 1, 2000; 26(4): 242 - 248.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
A. Wilson, M. N. Gardner, M. A. Armstrong, B. F. Folck, and G. J. Escobar
Neonatal Assisted Ventilation: Predictors, Frequency, and Duration in a Mature Managed Care Organization
Pediatrics, April 1, 2000; 105(4): 822 - 830.
[Abstract] [Full Text]

Home page
 PediatricsHome page
J. B. Gould, W. E. Benitz, and H. Liu
Mortality and Time to Death in Very Low Birth Weight Infants: California, 1987 and 1993
Pediatrics, March 1, 2000; 105(3): 37e - 37.
[Abstract] [Full Text]

Home page
 PediatricsHome page
M. W. Doron, K. A. Veness-Meehan, L. H. Margolis, E. M. Holoman, and A. D. Stiles
Delivery Room Resuscitation Decisions for Extremely Premature Infants
Pediatrics, September 1, 1998; 102(3): 574 - 582.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
T. R. Cooper, C. L. Berseth, J. M. Adams, and L. E. Weisman
Actuarial Survival in the Premature Infant Less Than 30 Weeks' Gestation
Pediatrics, June 1, 1998; 101(6): 975 - 978.
[Abstract] [Full Text] [PDF]

Home page
 Arch. Dis. Child. Fetal Neonatal Ed.Home page
P W Fowlie, W O Tarnow-Mordi, C R Gould, and D Strang
Predicting outcome in very low birthweight infants using an objective measure of illness severity and cranial ultrasound scanning
Arch. Dis. Child. Fetal Neonatal Ed., May 1, 1998; 78(3): 175F - 178.
[Abstract] [Full Text]

Home page
 PediatricsHome page
J. W. Stolz and M. C. McCormick
Restricting Access to Neonatal Intensive Care: Effect on Mortality and Economic Savings
Pediatrics, March 1, 1998; 101(3): 344 - 348.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
T. M. O'Shea, K. L. Klinepeter, D. J. Goldstein, B. W. Jackson, and R. G. Dillard
Survival and Developmental Disability in Infants With Birth Weights of 501 to 800 Grams, Born Between 1979 and 1994
Pediatrics, December 1, 1997; 100(6): 982 - 986.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
M. C. McCormick
The Outcomes of Very Low Birth Weight Infants: Are We Asking the Right Questions?
Pediatrics, June 1, 1997; 99(6): 869 - 869.
[Full Text] [PDF]

Home page
 PediatricsHome page
M. Ellington Jr, D. K. Richardson, J. E. Gray, D. M. Pursley;, W. Meadow, J. Lantos, L. Frain, and Y. Ren
Early Deaths in Chicago and New England
Pediatrics, May 1, 1997; 99(5): 753 - 754.
[Full Text]