PEDIATRICS Vol. 114 No. 1 July 2004, pp. 264
Proactive Management of Extremely Premature Infants
J. M. Lorenz, MD
Division of Neonatology,
Department of Pediatrics,
College of Physicians and Surgeons,
Columbia University,
New York, NY 10032
Håkansson et al1 report in this issue of Pediatrics a population-based retrospective cohort study of mortality and morbidity during the first year of life in Swedish infants 22 to 27 weeks’ gestation with 2 different perinatal management strategies in the 1990s. In the southern region of the country, active obstetric intervention at 
25 weeks’ gestation for fetal indications was restricted, and the approach to resuscitation of these infants was individualized. In the northern region, the approach to births 25 weeks’ gestation was proactive: a greater proportion of these births were managed in level III perinatal centers and delivered by cesarean section, a smaller proportion of infants had 1- and 5-minute Apgar scores <4, and mortality in the first 24 hours of life was lower. (The philosophy of care was similar for infants 26–27 weeks’ gestation; only the proportion managed in level III centers was greater in the north) This "natural experiment" provides a rare and possibly unique opportunity to compare the outcomes resulting from these different philosophies of care in 2 cohorts that can reasonably assumed to be otherwise similar.
In the north, after the philosophies of care diverged, the survival rate was significantly higher in infants 25 weeks’ gestation in the 1990s. Deaths within the first 24 hours of life accounted for this difference, suggesting that intensive care, when initiated and continued beyond the first day of life, was equally effective in both regions in promoting survival. There was no significant difference in survival rates at 26 to 27 weeks’ gestation. A greater proportion of survivors in the north survived without morbidity (defined as chronic lung disease, intraventricular hemorrhage, or retinopathy of prematurity) in the 1990s at both 25 and 26 to 27 weeks’ gestation. This difference seems to be the result of a higher prevalence of retinopathy of prematurity among survivors in the south. No measures of resource utilization and no neurodevelopmental outcomes were reported.
The authors clearly believe that these data justify a more proactive approach to the care of extremely premature infants. However, their focus on neonatal survival and morbidity to the exclusion of other considerations leaves room for disagreement about the wisdom of the divergent philosophies of care of extremely premature infants that are manifest nationally and internationally.2 The high prevalence of morbidities and disabilities, our frustratingly imperfect ability to estimate an individual extremely premature infant’s prognosis, and the lack of the "holy grail" of neonatology (ie, an intervention or approach to care that will increase survival and decrease the prevalence of disability among survivors) preclude the possibility of a simple solution to reducing the number of extremely premature survivors with disability. Efforts to reduce the number of disabled survivors by the selective application of intensive perinatal care will result in fewer disabled survivors, but infants who would have survived without disability will die. Without a decrease in the prevalence of disability among survivors or even with a modest (compared with the increase in survival rate) decrease in morbidity (and possibly major disability) among survivors as reported in this study, a more uniformly aggressive approach will result in a great absolute number of survivors without disability, but a greater absolute number of infants will survive with disability and more resources will be expended for the perinatal care of these infants and for the often life-long costs of their disabilities. Given the relevant moral values, the different ways in which competing values will be prioritized by different communities and cultures and countries, the variation in available resources, and the different priorities for the distribution of limited resources among worthy endeavors, it is unreasonable to expect that a single philosophy of care of extremely premature infants can be most appropriate for all countries, cultures, or communities.
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FOOTNOTES
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Received for publication Apr 1, 2004; Accepted Apr 1, 2004.
Address correspondence to J. M. Lorenz, MD, Division of Neonatology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY 10032. E-mail: jl1084{at}0040columbia.edu
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REFERENCES
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- Håkansson S, Farooqi A, Holmgren PA, Serenius F, Högberg U. Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal management strategies.
Pediatrics. 2004;114
:58
–64[Abstract/Free Full Text]
- Lorenz JM. Management decisions in extremely premature infants.
Semin Neonatol. 2003;8
:471
–482
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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