Published online February 1, 2007
PEDIATRICS Vol. 119 No. 2 February 2007, pp. 410-411 (doi:10.1542/peds.2006-3079)
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LETTER TO THE EDITOR

Long-term Health Outcomes of Extremely Premature Infants

Joseph W. Kaempf, MD
Mark Tomlinson, MD
Departments of Neonatology and Obstetrics
Providence St Vincent Medical Center
Portland, OR 97225

To the Editor.—

As students of bioethical decision-making, we always look forward to Dr Saigal's sequential follow-up studies that focus on the long-term health and social welfare of the 166 premature infants born in Ontario, Canada, between 1977 and 1982.1 In the course of our work as a neonatologist, perinatologist, and clinical researchers, the debate over the wisdom and compassion of aggressive resuscitation and NICU care of extremely premature infants who are <27 weeks' gestational age continues to yield no simple solutions.

Our obstetrics and neonatology service at Providence St Vincent Medical Center in Portland, Oregon, offers comprehensive periviability counseling to women threatening premature birth that features clear consensus guidelines related to the resuscitation of premature infants.2 After careful discussion and thought, we actually do not recommend aggressive obstetric care and NICU care for infants born <25 weeks' gestation and allow parents to decline NICU care at <26 weeks' gestation if this is their informed choice. When we discuss our program at conferences, rounds, or medical meetings, someone inevitably makes a comment such as, "All extremely premature infants should be resuscitated, because even if they are eventually neurologically impaired, Dr Saigal's research shows they are happy and well adjusted."

We find this particular interpretation of the work by Saigal and her co-workers somewhat mystifying given the considerable demographic, social, and biological differences between their cohort born in 1977–1982 and the population of extremely premature infants cared for in NICUs today. We ask Dr Saigal to please clarify for all of us who are interested in the rational process of ethical decision-making the following features of her study population:

  1. In her original cohort, at each specific gestational age (23, 24, and 25 weeks), how many infants were born alive, how many were resuscitated, how many died in the NICU, how many went home, and how many of these extremely early-gestation infants are now part of her follow-up studies?
  2. Were parents ever offered the option of declining NICU care?
  3. How many of the infants were of lower socioeconomic status, were from single-parent households, did not have health insurance, and/or were not white?
  4. Are the involved subjects and their parents (that have been studied and interviewed now for >20 years) aware of Saigal et al's serial publications related to them? Do they read them? Does this affect the health-related quality-of-life evaluations?

Given all the potential variables, the follow-up literature of infants born at <27 weeks' gestation is remarkably constant: approximately one quarter of survivors are severely neurologically impaired, one quarter are moderately impaired, and one half are assessed to be normal.3,4 Our experience with parents who become reasonably well informed of the risks and benefits of NICU care is that a significant proportion will decline aggressive care. We believe this decision process is ethically just and morally responsible. If Dr Saigal would address the above-listed questions and the accuracy and relevance of extrapolating her follow-up data to modern obstetric and neonatal care, she could add even more to her considerable contributions to this fundamental controversy.

REFERENCES

  1. Saigal S, Stoskopf B, Pinelli J, et al. Self-perceived health-related quality of life of former extremely low birth weight infants at young adulthood. Pediatrics. 2006;118 :1140 –1148[Abstract/Free Full Text]
  2. Kaempf JW, Tomlinson M, Arduza C, et al. Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants. Pediatrics. 2006;117 :22 –29[Abstract/Free Full Text]
  3. Lorenz JM, Wooliever DE, Jetton JR, Paneth N. A quantitative review of mortality and developmental disability in extremely premature newborns. Arch Pediatr Adolesc Med. 1998;152 :425 –435[Abstract/Free Full Text]
  4. Marlow N, Wolke D, Bracewell MA, Samara M; EPICure Study Group. Neurologic and developmental disability at six years of age after extremely premature birth. N Engl J Med. 2005;352 :9 –19[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




This Article
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