Published online June 1, 2007
PEDIATRICS Vol. 119 No. 6 June 2007, pp. 1267-1269 (doi:10.1542/peds.2007-0916)

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LETTER TO THE EDITOR

Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns: In Reply

Edward F. Bell, MD
Department of Pediatrics
University of Iowa Carver College of Medicine
Iowa City, IA 52242

Daniel G. Batton, MD
Department of Pediatrics
William Beaumont Hospital
Royal Oak, MI 48073

Ann R. Stark, MD On behalf of the American Academy of Pediatrics Committee on Fetus and Newborn
Department of Pediatrics
Baylor College of Medicine
Houston, TX 77030

The members of the American Academy of Pediatrics Committee on Fetus and Newborn thank Mr Whittall and the Nuffield Council on Bioethics for their correspondence and for calling attention to the recent Nuffield report, "Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues."¹ As Mr Whittall pointed out, the Nuffield report provides a practical framework to guide decisions based on gestational age for infants born before 25 weeks’ gestation. The American Academy of Pediatrics Neonatal Resuscitation Program (NRP) Steering Committee took a similar approach in its 2005 NRP guidelines.² They cited the infant born before 23 weeks’ gestation as an example of the category of infants for whom resuscitation would not be indicated, and they cited the infant of 25 weeks’ gestation as an example of one for whom resuscitation is nearly always indicated. For infants of 23 and 24 weeks’ gestation, those with uncertain prognosis, they indicated that parental wishes should take precedence.

The Committee on Fetus and Newborn considered such an approach (ie, defining the gestational age below which resuscitation should not be undertaken and another gestational age above which resuscitation should be routine), with decisions in the intermediate range guided primarily by the wishes of informed parents. However, we decided against this categorical approach for several reasons. First, the prognosis for extremely premature infants is influenced by other factors besides gestational age, such as fetal gender and corticosteroid exposure. Second, we avoided proposing gestational-age guidelines because we felt that these demarcation lines are not fixed but have moved over time and may continue to do so. Third, the concept of standard gestational-age cutoffs for active intervention is problematic because there is considerable center-to-center variability in outcome below 25 weeks’ gestation, both in mortality^3–6 and morbidity⁷; ideally, decisions should be based on prognosis. However, much of the variability in outcome among centers results from differences in the attitudes and beliefs of medical staff regarding the potential for intact survival at very early gestation.^8–12 In fact, it is not possible to isolate the impact of the attitudes of medical providers on prognosis from other factors that contribute to center-to-center variability in outcome in the United States and other medically advanced countries.

The worldwide variation in potential outcome at the threshold of viability dwarfs the magnitude of center-to-center variability in the United States and United Kingdom. The guidelines of the Nuffield Council on Bioethics and the NRP Steering Committee may be reasonable for the United States and the United Kingdom in 2007, but these specific gestational-age boundaries would not be appropriate in many parts of the world where maternal-fetal medicine and neonatal intensive care are not as advanced.¹³

To be truly useful, an approach using default gestational-age cutoffs to guide therapy would have to allow for consideration of other factors in addition to completed weeks of gestation. As an example, a female fetus at 24 weeks, 6 days, whose mother received betamethasone has a better prognosis than a male fetus at 24 weeks, 0 days, whose mother did not receive corticosteroid. In addition, the guidelines would need to be reappraised every few years as new outcome information becomes available.

The Nuffield report is a thorough and scholarly document. Insofar as treatment decisions at the threshold of viability are sometimes made primarily on the basis of gestational age, the guidelines proposed in the Nuffield report are valid in medically advanced countries in the early 21st century. We commend the Nuffield Council on Bioethics for their efforts in producing this important document, and we welcome the discussion it has stimulated.

REFERENCES

1. Nuffield Council on Bioethics. Critical care decisions in fetal and neonatal medicine: ethical issues. Available at: www.nuffieldbioethics.org/fileLibrary/pdf/CCD_web_version_8_November.pdf. Accessed April 11, 2007
2. American Heart Association; American Academy of Pediatrics. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: neonatal resuscitation guidelines. Pediatrics. 2006;117(5). Available at: www.pediatrics.org/cgi/content/full/117/5/e1029
3. Lee SK, McMillan DD, Ohlsson A, et al. Variations in practice and outcomes in the Canadian NICU network: 1996–1997. Pediatrics. 2000;106 :1070 –1079[Abstract/Free Full Text]
4. Chien LY, Whyte R, Aziz K, Thiessen P, Matthew D, Lee SK; Canadian Neonatal Network. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol. 2001;98 :247 –252[CrossRef][Web of Science][Medline]
5. Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. Mortality in low birth weight infants according to level of neonatal care at hospital of birth. Pediatrics. 2002;109 :745 –751[Abstract/Free Full Text]
6. Vohr BR, Wright LL, Dusick AM, et al. Center differences and outcomes of extremely low birth weight infants. Pediatrics. 2004;113 :781 –789[Abstract/Free Full Text]
7. Synnes AR, MacNab YC, Qiu Z, et al. Neonatal intensive care unit characteristics affect the incidence of severe intraventricular hemorrhage. Med Care. 2006;44 :754 –759[CrossRef][Web of Science][Medline]
8. Gardner M, Bronstein J, Goldenberg R, Haywood J, Cliver S, Nelson K. Physician opinions of preterm infant outcome and their effect on antenatal corticosteroid use. J Perinatol. 1996;16 :431 –434[Medline]
9. Bottoms S, Paul R, Iams J, et al. Obstetric determinants of neonatal survival: influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol. 1997;176 :960 –966[CrossRef][Web of Science][Medline]
10. Haywood JL, Morse SB, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Estimation of outcome and restriction of interventions in neonates. Pediatrics. 1998;102(2). Available at: www.pediatrics.org/cgi/content/full/102/2/e20
11. de Leeuw R, Cuttini M, Nadai M, et al. Treatment choices for extremely preterm infants: an international perspective. J Pediatr. 2000;137 :608 –615[CrossRef][Web of Science][Medline]
12. Håkansson S, Farooqi A, Holmgren PÅ, 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]
13. Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: when? Where? Why? Lancet. 2005;365 :891 –900[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Bell, E. F. Search for Related Content PubMed Articles by Bell, E. F. Related Collections Emergency Medicine Social Bookmarking                         What's this?