Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. 1072-1073 (doi:10.1542/peds.2008-0545)

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 Bassan, H. Articles by du Plessis, A. J. Search for Related Content PubMed Articles by Bassan, H. Articles by du Plessis, A. J. Related Collections Neurology & Psychiatry Social Bookmarking                         What's this?

LETTER TO THE EDITOR

Withdrawing Support for Withdrawing Support From Premature Infants With Severe Intracranial Hemorrhage: In Reply

Haim Bassan, MD
Department of Neurology,
Children's Hospital Boston,
Harvard Medical School,
Boston, MA 02115,
Pediatric Neurology Unit,
Dana Children's Hospital,
Tel Aviv Sourasky Medical Center,
Tel Aviv University,
Tel Aviv 64239, Israel

Adré J. du Plessis, MBChB, MPH
Department of Neurology,
Children's Hospital Boston,
Harvard Medical School,
Boston, MA 02115

We thank Dr Sawyer for his insightful comments regarding the ethical implications of our study.

In the current era, the risk of neonatal death of infants with periventricular hemorrhagic infarction (PVHI) remains high, ranging from 40%^1,2 to 69%.³ Withdrawal of life support currently precedes many of these deaths, as was the case in 95% of the deaths in our cohort.⁴ For this reason, the prognostic accuracy of the outcome of PVHI becomes a very relevant matter in the early neonatal period.

In most PVHI cases that result in death, the infant is critically ill and hemodynamically unstable, with multiple systemic complications. In a minority of PVHI cases, the infant is clinically stable. In these latter cases, measures of expected outcome and quality of life become increasingly relevant to decisions regarding withdrawal of life support.

A pervasive view of PVHI is that of a devastating lesion with uniformly major neurodevelopmental sequelae, including cerebral palsy and mental retardation. This notion is based mainly on earlier studies that reported major sequelae in up to 90% of PVHI survivors. These studies predate the advances in neonatal critical care and the more intensive and widespread rehabilitation practices of recent years. In addition, previous studies focused on global motor and cognitive outcomes without considering daily living and subdomain developmental measures.

In our recent report, one third of PVHI survivors escaped without significant neuromotor and/or cognitive sequelae, and two thirds had relatively spared adaptive and communication skills.⁵ Our data support a reevaluation of the currently held view of PVHI as a lesion with a uniformly poor outcome. To assist with improving prognostic accuracy in the individual infant, we propose a simple, 4-level (0–3) cranial ultrasound severity score of the echogenic PVHI lesion. In our report, outcome of the lowest PVHI score (score 0) was similar to that of grade III intraventricular hemorrhage, whereas higher PVHI scores (scores 2–3) were associated with poor neurodevelopmental outcome.

Prospective studies of PVHI are difficult to undertake given its relatively low prevalence and high mortality rate. Additional studies of this population from other centers are awaited. Until such data are available, our results should be viewed cautiously. Life-support decisions should be made on an individual basis with consideration for the infant's overall clinical condition, the ultrasound severity of PVHI, and informed parental wishes.

REFERENCES

1. Bassan H, Feldman HA, Limperopoulos C, et al. Periventricular hemorrhagic infarction: risk factors and neonatal outcome. Pediatr Neurol. 2006;35 (2):85 –92[Web of Science][Medline]
2. de Vries LS, Van Haastert IL, Rademaker KJ, Koopman C, Groenendaal F. Ultrasound abnormalities preceding cerebral palsy in high-risk preterm infants. J Pediatr. 2004;144 (6):815 –820[Web of Science][Medline]
3. Hamrick SE, Miller SP, Leonard C, et al. Trends in severe brain injury and neurodevelopmental outcome in premature newborn infants: the role of cystic periventricular leukomalacia. J Pediatr. 2004;145 (5):593 –599[CrossRef][Web of Science][Medline]
4. Bassan H, Benson CB, Limperopoulos C, et al. Ultrasonographic features and severity scoring of periventricular hemorrhagic infarction in relation to risk factors and outcome. Pediatrics. 2006;117 (6):2111 –2118[Abstract/Free Full Text]
5. Bassan H, Limperopoulos C, Visconti K, et al. Neurodevelopmental outcome in survivors of periventricular hemorrhagic infarction. Pediatrics. 2007;120 (4):785 –792[Abstract/Free Full Text]

---

PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

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 Bassan, H. Articles by du Plessis, A. J. Search for Related Content PubMed Articles by Bassan, H. Articles by du Plessis, A. J. Related Collections Neurology & Psychiatry Social Bookmarking                         What's this?